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Testimony for the Workgroup on Computerbased Patient Records


... Benefits of an Electronic Medical Record in a Family ... Provide recommendations for an electronic medical record. Medicalogic. Practice with Knowledge ... – PowerPoint PPT presentation

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Title: Testimony for the Workgroup on Computerbased Patient Records

Testimony for the Workgroup on Computer-based
Patient Records
    STATISTICS December 9, 1998 Presented by
    Blackford Middleton, MD, MPH, MSc Vice President
    for Clinical Informatics MedicaLogic, Inc.

  • Blackford Middleton, MD, MPH, MSc
  • VP for Clinical Informatics, MedicaLogic
  • Current Affiliations
  • Clinical Assistant Professor of Medical
    Informatics and Outcomes Research, Oregon Health
    Sciences University, 1996-
  • Attending Physician, Department of Medicine
    Faculty Practice, Providence Health System, St.
    Vincents Hospital
  • Chair-person Elect, Computer-based Patient Record
    Institute (CPRI)
  • Thank you for inviting me to testify before you.

Materials Submitted
  • Copy of presentation slides
  • Supporting documentation
  • Informatics standards used in MedicaLogic
    Logician EMR
  • Logician product architecture
  • Case Report Cost and Quality Benefits of an
    Electronic Medical Record in a Family Practice

MedicaLogic Background
  • First generation EMR 1983 - ClinicaLogic
  • MedicaLogic incorporated 1985
  • Second generation EMR 1995 - Logician
  • Open architecture, standards-based EMR
  • Oracle RDBMS, TCP-IP, 2- or 3-tier architecture,
    browser-based or C desktop
  • Informatics Standards
  • Messaging HL-7 (hundreds of system interfaces)
  • Content ICD-9-CM, CPT4, SNOMED, ASTM, LOINC,
  • Inc. 500 in 1995 (262), 1996 (181), 1997 (84),
    1998 (131) - fast growth due to standards-based

Use of Informatics Terminology Standards
  • Support/enhance the doctor-patient relationship
  • Improve healthcare delivery efficiency, quality,
    and service at appropriate cost
  • Empower clinicians with state of the art tools to
    support clinical information access and clinical
    decision making
  • Exchange a longitudinal complex record between
    two disparate EMRs when a patient changes doctors
    or plans
  • Secure access to healthcare information remotely
    when disease occurs away from home

Opportunities for Annual Costs Savings with
HIT (Punk Ziegel)
Macro-economic Benefit Cost Analysis for HIT
  • US Healthcare - 1.0T, 15 of GDP
  • Potential Savings Est. - 250B
  • Even if HIT spending increased to 8 of
    Healthcare operating budgets - only 80B
  • Therefore…
  • Benefit/Cost ratio 250B/80B 3.13
  • Or… for every 1 spent in HIT expect 3.13

Microeconomic Analysis Capital Region Healthcare
- Concord, NH
  • Family Care of Concord - 12 providers and staff
    -gt 1200 visits/month
  • 42 Managed Care (seven companies), 35
    commercial insurance, 15 Medicare, 5 self pay,
    3 Medicaid
  • 87,000 for hardware, software, and
    implementation of EMR with I/Fs
  • Annual support costs, which include software
    maintenance fees, upgrades, information
    technology support staff, and depreciation, are
  • Total Year 1 costs 124,000

Capital Region Healthcare - Benefits per Annum
  • Transcription costs of 53,000 eliminated through
    use of physician data entry tools - net savings
  • Chart Pulls eliminated - 24,500
  • Prescription writing - 71,400
  • Coding research and assignment - 5,950
  • Lab filing - 5,525
  • Referral paperwork - 7,140
  • Total Benefits 158,295

Capital Region Healthcare - Benefits per Annum
  • Qualitative Reporting - Detect true rate of
    preventive care services (discovered practice
    eligible for quality bonus)
  • Drug recalls - Patient letters sent within one
    day of recall alerts
  • Hospital inpatients - EMR available on hospital
  • Patient Satisfaction - Group satisfaction rates

Capital Region Healthcare - Benefits and Costs
  • Operational Costs Annual
  • Total Benefits 158,295
  • Total Expense 37,000
  • Net Benefits 121,295
  • Benefit/Cost Year 1 1.27
  • Benefit/Cost Ongoing 4.27

Q1 How do you interpret the Congressional
  • Goal Administrative Simplification
  • To improve the efficiency effectiveness of the
    health care system by standardizing the
    electronic data interchange of certain
    administrative and financial transactions
  • Establish penalties for non-compliance with the
    legislation and,
  • To protect the security privacy of health care
    information by setting standards.
  • Hopefully, through standardization of electronic
    data interchange, the system will experience a
    net savings potential over six years of 42
    billion as estimated in the 1993 WEDI Report.

HIPAA mandate to HHS
  • Adopt national standards necessary for efficient
    electronic administrative and financial health
    care transactions.
  • All health plans (including government health
    plans), all clearinghouses, and those providers
    who choose to conduct their transactions
    electronically are REQUIRED to implement the
  • Provide privacy legislation.
  • Provide recommendations for an electronic medical

HIPAA mandate to HHS
  • Provide standards for nine EDI administrative
    transactions (claims, encounters, enrollment,
    etc., including code sets.)
  • Provide standards for COB (Coordination of
  • Provide standards for unique identifiers
    (including allowed uses) for individuals,
    employers, health plans, health care providers.
  • Provide standards for security, confidentiality,
    and electronic signatures.

Q2 What factors or issues are preventing or
delaying the development and widespread
implementation of uniform standards for patient
medical record information and its electronic
  • Scope
  • Its a BIG and COMPLICATED problem
  • Numerous stakeholders
  • Unaligned incentives
  • Uncoordinated healthcare standards setting
  • Poorly or un-coordinated implementation of
    vendor, or home-grown, systems
  • Uncoordinated healthcare professional society
    data standardization efforts

Q3 Is the private sector able to address these
problems? What is the role of government for
assisting the private sector in the guidance,
development, coordination, and implementation of
standards for patient medical record data and
their electronic transmission? How might the
government help to improve the standards
  • Why cant vendors (private sector) solve these
  • Why cant providers solve these problems?
  • Why the government should assume an expanded
    leadership role in this field?

Why cant vendors (private sector) solve these
  • Healthcare standards are DIFFERENT in character
    and scope
  • tangled web of interrelated standard setting
    efforts makes broad based progress slow
  • One-off solutions, or worse site-specific
  • Vendors are rewarded for successful enterprise
    implementations with little regard for
    inter-enterprise data sharing
  • Possible for hard standards such as ISO stack
    protocols, HL-7
  • Difficult or impossible for soft standards such
    as terminology and reference model

Why cant providers solve these problems?
  • They are not SDOs, or software developers - we
    have yet to see successful commercialization of
    home grown system.
  • With rare exception provider organizations have
    little concern for data-sharing issues beyond
    their enterprise
  • Often limited scope or relevance to their
    business mission (few provider organizations
    cover ALL of healthcare delivery needs)

Why the government should assume an expanded
leadership role in this field?
  • BIG problem
  • Healthcare informatics standards as a public good
  • Many stakeholders, unaligned incentives,
    potentially forever at odds
  • Critical to the health and well being of the
    American People, and the American economy
  • Leadership void identified in the 1993 GAO report
    remains unfilled

Q 4a Which standards related to patient medical
record information and its electronic
transmission would Add the most value for
improving the quality and efficiency of health
care for the nation? Why?
  • First -
  • Simplify the goals to the bare minimum with
    respect to identifiers, terminology, data sets
    and models, interoperability, connectivity,
    security and confidentiality
  • Second -
  • Establish a framework for comprehensive health
    terminology systems, and a trusted agency to act
    as responsible party for coordinating the
    essential health information technology standards
    development process
  • (Chute C, Cohn S, Campbell J et al. JAMIA

Critical Informatics Standards and Issues
  • 1. Education and training
  • Public, Providers, Payers, Employers, Feds
  • 2. Documentation requirements for paper and
    electronic records
  • Minimal documentation requirements
  • By specialty or domain
  • By location of care
  • 3. Minimal data sets
  • Essential terminology standards for clinical
    findings pertinent to 2, and to clinical
    decision support, and outcomes assessment
  • Support uniform and consistent quality measures

Critical Informatics Standards and Issues
  • 4. Interoperability standards for EMRs
  • Identifiers person, provider, place, plan, EIN
  • Enterprises already implementing MPIs
  • Facilitates integration and exchange of clinical
  • Reference terminology and information model
  • Support consistency of usage
  • Support interoperability and clinical information
    exchange and machine interpretation
  • Messaging - HL-7, X12, NCPDP
  • NHII, secure national healthcare networks
  • 5. NEW - Mandated drug interaction assessment at
    the point of care
  • 6. NEW - Mandated quality standards

Q 4b Which standards related to patient medical
record information and its electronic
transmission would Be most important to the
business or goals of your organization? Why?
  • Documentation requirements (money)
  • Interoperability standards - (implementation)
  • Outcomes reporting -report cards (fear)
  • Clinical Decision support - (quality)

Q 4c What is the business case for more rapid
standards development and implementation?
  • From whose perspective?
  • FFS Provider - wait and see
  • At Risk Provider Organization - Now!
  • Health Plan (without owned providers) - Depends
    on local market
  • Employer - ditto
  • Consumer - about to explode
  • Cost - Speed adoption of clinical information
    management technology to experience process
    improvements and savings
  • Case study demonstrates savings utilizing fairly
    rudimentary standards
  • Quality secondarily improve clinical decision
    making, and resultant outcomes

  • Epidemiologist William Farr, 1848
  • nomenclature is of as much importance… in this
    inquiry… as weights and measures in the physical
    sciences, and should be settled without delay
  • Chute, et al
  • Failure to achieve common goals and standards
    will preclude efficient comparison of practice
    patterns and outcomes, and we will therefore have
    great difficulty identifying best practices and
    sharing among institutions or nations. Nor would
    be be able to consistently implement identified
    best practices across institutions as health care
    deliverers begin to develop decision support

Q5 Do you agree with our emphasis the four focus
areas listed above? Explain.
  • Four focus areas
  • standards for administrative clinical messages
  • standards for patient clinical information (data
    element definitions, data models, and code sets).
  • enhance the coordination and maintenance of both
    administrative and clinically-specific code sets
    (data-dictionary and data-set registry)
  • address the business case issues regarding the
    implementation of uniform data standards for
    patient medical record information.
  • Yes - with additional focus on public-private
    mechanisms for production, support, and
    maintenance of informatics standards
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