Community Health Initiatives Taking HIT to the Next Level

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1 NEW JERSEY Chapter New York State Chapter Community Health Initiatives Taking HIT to the Next Level Elaine Remmlinger Vice President/National Service Director Kurt Salmon Associates 0 Topics Current State Realities Trends Moving Forward What s Next 1 1 1

2 Current State Realities It s a journey and we ve only just begun By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care Within the next 10 years, electronic health records will ensure that complete health care information is available for most Americans at the time and place of care, no matter where it originates. Participation by patients will be voluntary. These electronic health records will be designed to share information privately and securely among and between health care providers when authorized by the patient. President George W. Bush, January 2004, State of the Union Address 3 3 2

3 Definition of Terms Medication Management Vital Signs & I&Os Results Review INPATIENT Clinical Information System (CIS) Data CPOE Clinical Data Repository (CDR) Clinical Decision Support Order Management Clinical Documentation Home Health Personal Health Information Emergency Department Electronic Health Record (EHR) Critical Care Affiliated Providers Specialty Systems Orders & e-prescribing Encounter Documentation OUTPATIENT Electronic Medical Record (EMR) Clinical Decision Support Clinical Data Repository (CDR) Chart/ Results Review Health Maintenance/ Disease Mgmt. Data Phone Notes E&M Coding Support 4 4 Current State: EHR Goals Patient Safety CPOE Clinical decision support Medication administration Medication reconciliation Clinical documentation Ambulatory EMR Streamlined Operations Workflow Productivity Capacity management Patient experience Digital hospital Quality / P4P/ Public Reporting Leapfrog Bridges to Excellence CMS Connecting Communities RHIOs Physician practice EMRs Other providers Patient portals Interoperability Surveillance ADEs Infection control Public reporting 5 5 3

4 Current State: Implementation Realities Product CPOE Clinical Decision Support Medication Reconciliation Medication Administration Evidence based content Clinical Documentation Ambulatory EMR Workflow tools Paperless sites Digital hospital Quality/core measures, public reporting RHIOs and data exchange initiatives Patient portal / personal health records Surveillance Availability High Med Med Med Med High Med Maturity High Med Med High 6 6 Limited EHR Deployment to Date 10-to-25% estimate; conflicting statistics & EHR definitions Hospitals 32% of organizations have a fully operational EHR with 37% implementing 1 6.8% of U.S. hospitals are doing CPOE on commercial software 2 3.2% of U.S. hospitals are actively using CPOE (>50% of patient orders) on commercial software 2 Only 79 inpatient sites have achieved 100% CPOE 2 Ambulatory Practices 25% all medical group practices use EMR % practices with 5 or fewer physicians use EMR 3 Sources: 1. HIMSS 2007 Leadership Survey 2. KLAS Confidential 2007 KLAS Enterprises, LLC, All rights reserved 3. HIMSS 2007 Whitepaper: Ambulatory Paperless Clinics Workgroup 7 7 4

5 EMR Adoption Varies by Specialty survey Number of FR 80% 70% 60% 50% 40% 30% 20% 10% 0% * Obtain Guidelines 57 46* 46* Access Patient Notes * Write Prescriptions 43* 57* Physician Exchange Hospital Exchange PCP MEDICAL (Reference Group) SURGICAL * All Five * Difference from reference group is statistically significant at p <.05. Note: Physicians with access to IT for all five clinical activities were considered to have an electronic medical record (EMR). Source: Community Tracking Study Physician Survey, Center for Studying Health System 8 Change, September Needs not met...yet The early adopters have found that EHRs as they exist now do cost a fair amount and don t give a big boost in [health care] quality So as we go beyond the early adopters and into the mainstream, we are seeing some pushback from the market. Dr. Don Detmer, President and CEO, American Medical Informatics Association 9 9 5

6 Hospital Systems Lacking (Partial List) Medication reconciliation Quality reporting Real time surveillance Meaningful reminders and alerts Data transformed into knowledge Systems and data integration across continuum Usability Intelligent workflow management Capacity management tools Research data mining and clinical trials support Chronic care support Physician Systems Lacking (Partial List) Usability Assistive tools Interactive content Meaningful alerts Efficiency and workflow improvement Less time commitment than current processes Elimination of paper Information for patient care, research, quality Tools to maximize reimbursement

7 Community Collaboration is Complex Pharmacies Retail Clinics Labs Payors/ Regulatory Agencies Single Enterprise Patient Number Medical Group Hospital-based Services Inpatient Outpatient ED CIS PACS Registration Scheduling Interfaces Filtered Access Consumer Exchange of/ Access to Patient Information RHIO MD Office MD Office Exchange of/ Access to Patient Information MD Office MD Office Physician to Physician Communication Active Collaboration Prescriptions and Refills Physician to Physician Communication Orders and Results Referrals/Authorizations/Reporting Community Physicians MD Office MD Office MD Office MD Office MD Office MD Office 12 Physician to Physician Communication 12 Retail Clinics Add To Fragmentation Trend You're Sick, We're Quick 1 consumer focus Often hosted by Wal-Mart, Walgreens, supermarket, or malls Focus on the simple-to-treat maladies Some health systems are piloting their own retail medicine sites HIT Status Many have their own electronic medical record systems Potential future Integration with retail pharmacy systems and PBMs Addition of PHR in the works Challenges Critical to extend information sharing with other providers 1. The Minute Clinic Movement: Model for the Future or 60 Seconds of Fame?, available at (last accessed 25 September 2007)

8 How Much Data Sharing is Really Needed? Hospital CIS Demographics Lab Results Dictated Reports Physician EMR Demographics Medication List Allergies Problem List Advance Directives Image (Reference) Schedule Medication List Allergies Problem List Advance Directives Office Notes* Vital Signs Available from source system Available Planned for future Not in current development plans * Unstructured form Trends 8

9 Consumer Involvement Is Limited EARLY (Late 90s-2000) PRESENT (2007) FUTURE ( ) Static content Education Information on classes Appointment request Clinical trials information Personal web pages Interactive health tools Information on quality RX refills Online bill payment Online registration Appointment scheduling Disease management Personal Health Record Patient editing evisits Second opinions Clinical trial registration PHR evolution Available & Utilized Available, Partially Utilized Future Functions Substantially Future Functions Personal Health Records Today No universally accepted definition Perhaps 200 different products on the market (estimate) Different architectures, format, functions, business models, orientation Provider-based: View available data, add personal health status and preferences Secure messaging to physicians, scheduling, prescription refills Payor-sponsored Claims data, prescriptions, health risk assessments, disease management Employer-sponsored Health risk assessments, wellness, disease management Internet companies, benefits consultants, financial services, etc Consumer participation limited

10 Employer Sponsored PHR DOSSIA-enabled personal health information technologies Vendor PHR Health Plan PHR Finance App Provider PHR Disease Mgmt App Custom PHR API DOSSIA Authentication Amb Hosp Imaged Drugs Claims EMR EMR Paper Labs Personal Health Records Challenges Who pays, business model, and incentives Completeness Fragmentation Lack of standards Technology and meaningful data integration Static, not interactive Privacy and security Data integrity Consumer participation and confidence

11 Consumer Directed PHR HMOs/ Insurance Companies Hospitals Physician Offices Health Data Custodian Ambulatory Clinics Patients Labs Physicians Retail Clinics RHIOs: Current State Few successes, many failures NHIN prototypes, 200+ unique initiatives Many targeted initiatives Clinical affiliations, PBM / medication reconciliation, emergency departments, state sponsored, independent providers Imported lessons learned Focus on issues Need for a realistic business plan Start-up funding and sustainability Stakeholder consensus Participation Interoperability standards Privacy policy and law

12 RHIOs: The Next Wave RHIO 2.0 will not be this orderly version of communitybased exchanges that are united by a NHIN. Rather, RHIO 2.0 may be this form of chaotic convergence of diverse and often disconnected connectivity interests. John Glaser, VP and CIO, Partners HealthCare Source: JHIM, September Quality and P4P Presidential Commission Report: Quality First: Better Health Care for All Americans IOM Report To Err is Human: Building a Safer Health System National Quality Forum constituted Presidential Commission Report: Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact Hospitals begin data collection for JCAHO core measures IOM Report Crossing the Quality Chasm Medicare Modernization Act ties CMS Nursing home Compare launched CMS Home Health Compare launched Deficit Reduction Act IOM Report Performance Measurement Accelerating Improvement CMS Roadmap to Quality launched Creation of Bridges to Excellence Pharmacy Quality Alliance launched JCAHO launches the ORYX Intiative Creation of The Leapfrog Group Hospital Quality Alliance launched Ambulatory Quality Alliance launched Source: Envisioning the Roadmap for a National Hospital Quality Reporting (June ) 23 12

13 Manual Effort Overwhelming The real impact on human health will only occur when the hospitals, physicians, and health plans have aligned usable measures and consumers have easy access to meaningful information. Current Effort Ideal Effort Data Collection Data Reporting Data Analysis Clinical Performance Improvement Source: Envisioning the Roadmap for a National Hospital Quality Reporting (June ) 24 Quality Requires Consensus The biggest challenge to realizing the vision of a national quality reporting system that enables hospitals and other care settings to collect and transmit data once, and have that data serve the diverse quality reporting requirements of all stakeholders, is gaining consensus on what to measure, when to measure, and how to report the results. Source: Envisioning the Roadmap for a National Hospital Quality Reporting (June ) 25 13

14 Advancing The Quality Agenda National consensus on what to measure Payors [likely] require detailed records to support treatment decisions before reimbursing the caregiver EHR deployment Foundation systems Intelligent EHRs Common Medical Vocabularies, Natural Language Processing Automated extraction of information from the data Consistent data quality Data aggregation from multiple sources Business intelligence tools oriented for health care Personalized Medicine Background Information-based health care Culmination of biotechnical and medical advances Shift to predictive/proactive treatment Prerequisites Genetic and molecular research Translational research New product development processes and relationships HIT and knowledge management Source: Personalized Health Care: Opportunities, Pathways, Resources (September 2007) available at (last accessed 24 September ) 27 14

15 Personalized Medicine Benefits Predict individual susceptibility to disease Provide person-specific tools for preventing disease Detect onset of disease earlier Preempt the progression of disease Target medicines and dosages more precisely and safely Accelerate treatment and alerts Leverage medical evidence Source: Personalized Health Care: Opportunities, Pathways, Resources (September 2007) available at (last accessed 24 September ) 28 Personalized Medicine HIT Elements Standards and policies Genetic information in EHRs Confidentiality, privacy, and security Clinical decision support Learning health care (intelligence) Informatics and nomenclature Integration into clinical practice; dynamic EBM Knowledge management and decision support tools De-identified data customized to specific inquiries Source: Personalized Health Care: Opportunities, Pathways, Resources (September 2007) available at (last accessed 24 September ) 29 15

16 Moving Forward Requirements for Advancing EHR Meet diverse business objectives er total cost of ownership Allay stakeholder fears about loss of control Align incentives Encourage public-private partnerships Evolve EHR offerings with current/advanced technology Advance legal, regulatory, and standards frameworks Hope political distraction does not delay further Further human cultural shift and change management

17 HIT Vendor Progress Needed No one vendor offers all the pieces Products need to advance to meet market demand Next generation technology essential Implementation takes too long and costs too much Change management approaches ineffective R&D: Clinical trials Research analytics Workflow Sub-specialties Personal health records Bio-surveillance Intelligent tools International Data exchange Evidence-based content Personalized medicine Getting Ready Commit to capital and operating funds Proceed with advanced CIS and ambulatory EMR projects Optimize clinical decision support and alerts Work with vendors to address unmet needs Organize internal quality initiatives for efficiency Implement business intelligence tools Participate in community data exchange projects Implement change management to foster clinical adoption Learn from others and own experience

18 What s Next The Future: No Boundaries Clinical Research Education

19 The Future: Active Convergence Infrastructure Utility Computing Self Organizing Networks Smart Buildings Applications Advanced Clinical Systems Standards Mature PHRs Advance Intelligent EHRs Enabling Technology RFID VoIP Voice/Handwriting Recognition Remote Monitoring Smart Cards Disruptive Clinical Practice Changes Next Frontier: Gradual evolution to Intelligent EHRs Technology advances enable digital health care Leveraging research Advancing IT skills and blurring organizational lines Community data exchange evolves Role of consumer

20 Evolutionary, not Revolutionary EHRs are not the panacea that will miraculously appear and solve the complexities of healthcare. EHRs will continue to evolve over time to better meet the needs of clinicians, patients, payors, and government. Trial and error continue in the free market economy. Just like watching your children grow, progress will only be evident when looking back over a long time horizon Imagine 39 20

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