Care with Healthcare Information Technology Promises and Peril

Transcription

1 09 Re engineering engineering U.S. Health Care with Healthcare Information Technology Promises and Peril Blackford Middleton, MD, MPH, MSc Corporate Director, Clinical Informatics Research & Development Chairman, Center for Information Technology Leadership Partners Healthcare System Harvard Medical School

2 Systems In Healthcare A Simple Clinical Encounter in the US Healthcare Delivery System Three Dilemmas: Patient, Provider, Purchaser Information Technology Systems The Promise and the Peril Discussion, Q&A

3

4 Clinical Encounter Lab Order Medical Group Order Exam notes Imaging Center

5 Lab Diagnosis: Mild Pneumonia Results Order Medical Group Order Imaging Center Results Exam notes

6 Lab Treatment: Amoxycillin, fluids & rest Results Order Pharmacy Imaging Center Order Results Pick-up script Exam Notes Order

7 Claims and Billings Primary Care Group Administrator Aggregated billing Aggregated claims Lab Third Party Administrator or PBM Aggregated billing Encounter Report Results Order Claim Order Order Imaging Center Results Pick-up script Pharmacy

8 EOB & Payment Primary Care Group Administrator Aggregated billing EOB / payment Aggregated billing Salary & Bonus Encounter Report Order Results Aggregated claims EOB / payment Order Lab Third Party Administrator or PBM Claim EOB / payment Imaging Center Results Pick-up script Order Pharmacy Copayment Co-payment

9 HMO Consumer satisfaction survey Aggregate Encounter data Capitation payments Enrollment data Primary Care Group Administrator Aggregated billing EOB / payment Imaging Center Health Plan Transactions Encounter Report Aggregated billing Salary & Bonus Order Results Pick-up script Results Aggregated claims EOB / payment Order Lab Order Third Party Administrator or PBM Claim EOB / payment Pharmacy Copayment Health Plan Brochure Co-payment

10 HMO Consumer satisfaction survey Aggregate Encounter data Capitation payments Enrollment data JCAHO DOC State Insurance Board Primary Care Group Administrator Aggregated billing EOB / payment Imaging Center Aggregated billing Encounter Report Salary & Bonus Order Results Pick-up script Oversight & Quality Results Aggregated claims EOB / payment Order Lab Third Party Administrator or PBM Claim EOB / payment Pharmacy Copayment NCQA Co-payment Health Plan Brochure

11 HMO Consumer satisfaction survey Aggregate Encounter data Capitation payments Enrollment data JCAHO DOC State Insurance Board Primary Care Group Administrator Aggregated billing EOB / payment Encounter Report Imaging Center Aggregated billing Salary & Bonus Order Results Pick-up script Administrative Databases Results Aggregated claims EOB / payment Order Lab Third Party Administrator or PBM Claim EOB / payment Pharmacy Copayment NCQA Health Plan Brochure Co-payment Pharmacy Wholesaler

12 Employer Public Insurance & Health Care Prig. Other Public Agencies. e.g. INS, Soc. Svcs Public Health & Research Payment Enrollment HMO Consumer satisfaction survey Capitation payments Enrollment data JCAHO DOC State Insurance Board NCQA Health Plan Brochure Research Institutions Aggregate Primary Care Group Encounter data Administrator Aggregated billing EOB / payment Imaging Center Co-payment Aggregated billing Salary & Bonus Encounter Report Aggregated claims Order Results Pick-up script Enrollment & Eligibility Lab Clinical trials / biomedical studies Public Health Dept. Third Party Administrator or PBM Claim EOB / payment Utilization Pharmacy Pharmacy Wholesaler Drug Co.s Sales / Orders

13 Employer Public Insurance & Health Care Prog. Simple Data Flow Payment Other Public Agencies. e.g. INS, Soc. Svcs Enrollment HMO Consumer satisfaction survey Capitation payments Enrollment data JCAHO DOC State Insurance Board NCQA Health Plan Brochure Research Institutions Aggregate Primary Care Group Encounter data Administrator Aggregated billing EOB / payment Imaging Center Co-payment Aggregated billing Salary & Bonus Encounter Report Aggregated claims Order Results Pick-up script Enrollment & Eligibility Lab Clinical trials / biomedical studies Public Health Dept. Third Party Administrator or PBM Claim EOB / payment Utilization Pharmacy Pharmacy Wholesaler Drug Co.s Sales / Orders

14 The Patient s s Dilemma Average American consumers $6240/yr of healthcare, or $12,200 for the ave. family Health premiums rising 4x faster than salary over past 6 yrs 50% of personal bankruptcy due to healthcare costs 42% of the public have experienced medical error themselves or in their family (24% with serious consequences) 45M Americans lack Healthcare insurance 80M lack at some time during each year Increasing exposure to tiered pharmacy plans, consumer directed care, define contribution plans without transparency Absent reliable quality data No value based choices

15 Americans Spend More Out of of Pocket on Health Care Expenses, 2004 Total health care spending per capita $7,000 $6,000 United States $5,000 $4,000 $3,000 $2,000 $1,000 France a Germany Canada Netherlands OECD Median New Zealand Japan a Australia b $0 $0 $100 $200 $300 $400 $500 $600 $700 $800 $900 a 2003 b 2003 Total Health Care Spending, 2002 OOP Spending Out-of-pocket spending per capita Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

16 Majority of Americans Say Health Care System Needs Fundamental Change or Complete Rebuilding Percent reporting: Only minor changes needed Fundamental changes needed Rebuild completely Total Annual income <$35, $35,000 $49, $50,000 $74, $75,000 or more Insurance status Insured all year Uninsured during year U.S. region Northeast North Central South West Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.

17 The Provider s s Dilemma Unexplained variation, disparities in access and utilization, medical error, patient safety, and quality issues vex US Healthcare 18% of medical errors are estimated to be due to inadequate availability of patient information. Patient data unavailable in 81% of cases in one clinic, with an average of 4 missing items per case. Medical error the 8th leading cause of death 1 in 4 prescriptions taken by a patient are not known to the treating physician 1 in 5 lab and x ray tests ordered because originals can not be found 40% of outpatient prescriptions unnecessary Patients receive only 54.9% of recommended care

18 Unwarranted Variation in Care

19 60% Variation In Medicare Resource Use Intensity For Equivalent Populations SOURCE: Wennberg et. al. Annals Of Internal Medicine 2/18/03

20 Little Impact Of Spending On Quality

21 The Cost Conundrum: Atul Gawande, MD El Paso 790 mi., 1271 km driven primarily by local norms TEXAS that tend towards heavier use of discretionary services such as diagnostic testing and surgical versus less invasive interventions for which there are no clear clinical guidelines. Peter Orszag, OMB Blog /blog/ McAllen

22 Physician Information Needs Medical literature doubling every 19 years Doubles every 22 months for AIDS care 2 Million facts needed to practice Covell study of LA Internists: 2 unanswered clinical questions for every 3 pts 40% were described as questions of fact, 44% were questions of medical opinion, 16% were questions of non medical information. Covell DG, Uman GC, Manning PR. Ann Intern Med Oct;103(4):596-9

23 Measuring Information Needs Generally, with direct observation, or interview immediately after clinical encounters, physicians have approximately one question for every 1 2 patients Independent estimates: 0.6, and 0.62 Q/pt Holds across PCP and specialty care Holds across urban and rural Gorman, 1995 Gorman and Helfand 1995

24 Converting evidence to care Negative results Negative results Lack of numbers Inconsistent indexing 50% 18% Dickersin, % 46% Submission Publication variable 0.5 year 17 Koren, years 1989 Acceptance to apply 14% of Balas, 1995 Poynard, 1985 Original research 0.6 year 0.3 year Bibliographic databases years Reviews, guidelines, textbook 9.3 years Kumar, years to apply 14% of research knowledge to patient care! Patient Care Kumar, :14 Poyer, 1982 Antman, 1992 Expert opinion Balas Yearbook Medical Informatics 2000gtre4, courtesy M Overhage

25 Herbert A. Simon, Nobel Laureate Economics, 1978 What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention, and a need to allocate that attention efficiently among the overabundance of information sources that might consume it. Changing clinician roles: From Omniscient Oracle to Knowledge Broker.

26 Flexner Report "...The curse of medical education is the excessive number of schools. The situation can improve only as weaker and superfluous schools are extinguished." Society reaps at this moment but a small fraction of the advantage which current knowledge has the power to confer. Abraham Flexner, Medical Education in the United States and Canada. Boston: Merrymount Press, 1910

27 Paper based Medicine Prone to error Lots of information but no data Limited decision support, or measurement Does not integrate with ehealthcare Will not transform healthcare

28 The Purchaser s s Dilemma US healthcare is $1.7T, 16% GDP 5% in 1963; Industrialized societies average less than 10% Costs rising 7 9%/yr, expected to double in 10yr 25% of premium is for administrative overhead (limited value) Public expenditure on healthcare now 43% of total (up 10% in past decade) GM healthcare costs now $1500/automobile, most expensive component Where will additional value be found in, or costs taken out of, the system?

29

30

31 Determinants of Health and Their Contribution to Premature Death Purchasers are paying into a disease system rather than a wellness system 4% of health care dollar is spent on prevention and public health Schroeder S. N Engl J Med 2007;357:

32 Health Care Costs Concentrated in Sick Few Distribution of Health Expenditures for the U.S. Population, By Magnitude of Expenditure, % 5% 10% 27% Expenditure Threshold (1997 Dollars) $27,914 50% 55% 69% $7,995 $4,115 97% $351 Source: A.C. Monheit, Persistence in Health Expenditures in the Short Run: Prevalence and Consequences, Medical Care 41, supplement 7 (2003): III53 III64.

33 "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care." President George W. Bush State of the Union Address January 20, 2004

34 US Motivation for Healthcare Information Technology Medical error, patient safety, and quality issues 98,000 deaths related to medical error 40% of outpatient prescriptions unnecessary Patients receive only 54.9% of recommended care Fractured healthcare delivery system Medicare beneficiaries see unique providers annually, on average 6.4 different providers/yr Patient s multiple records do not interoperate An unwired system 90% of the 30B healthcare transactions in the US every year are conducted via mail, fax, or phone

35

36 VA s s Success with Healthcare Information Technology Data Source: Thomson TG, Brailer DJ. The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care. Washington, DC: US Department of Health and Human Services; 2004.

37 The evidence for and against HIT 55 83% decrease in hospital non intercepted serious ADEs using CPOE 73% of outpatient drug interaction alerts led to change in prescriptions 22 78% increased adherence to preventive health reminders Fewer medical errors through computerized physician order entry and clinical decision support systems Savings of approximately $5000 using CPOE in hospital Reduced length of stay in critical care, and overall LOS with CPOE 15% overall reduced hospital fatality with HIT CDS in hospitals resulted in 16% fewer complications, and $538 less expense Bates, JAMA 1998 Gandhi, JGIM 2001 Kaushal R, et al. Arch Intern Med Amarasingham R Arch Int Med 2009

38 CPOE: Unintended Consequences 5 mature CPOE sites surveyed, Frequency (%) work for clinicians 19.8 unfavorable workflow issues 17.6 never ending system demands 14.8 problems related to paper persistence 10.8 untoward changes in communication patterns 10.1 and practices negative emotions 7.7 generation of new kinds of errors 7.1 unexpected changes in the power structure 6.8 overdependence on the technology 5.2 Campbell EM, Sittig DS et al., JAMIA 2006

39 How Does HIT Save Money? EHR Effects Completeness, correctness, decision support, formulary, brand to generic, duplicate/redundant meds and tests, charge display Workflow support, messaging (pt/provider), referral, A/R, team CPOE Effects Reduction in hospitalization/los due to ADEs, clinical decision support HIEI Effects Reduction in unnecessary and redundant tests and procedures Labor cost savings Telehealth Effects Reduction in patient transport, utilization of hospitals, and physician office visits PHR Effects Administrative time savings Reduction in hospitalizations and physician visit utilization Improved medication safety Reduction in redundant laboratory tests

40 CITL HIT Value Assessments Net US could save $150B with HIT adoption, or approximately 7.5% or US Healthcare Expenditure The Value of Ambulatory Computerized Order Entry (ACPOE) $44B US nationally; $29K per provider, per year The Value of HealthCare Information Exchange and Interoperability (HIEI) $78B/yr The Value of IT enabled Chronic Diabetes Management (ITDM) $8.3B Disease Registries; Advanced EHR $17B The Value of Physician Physician Tele healthcare >$20B* The Value of Personal Health Records Approx. $20B

41 Rates of Positive Survey Responses on the Effect of Adoption of EMRs, % of physicians use fully functional electronic health records 13% use some form of basic electronic records DesRoches CM et al. N Engl J Med 2008;359:50-60

42 CAD/DM Smart Form Smart View: Smart Data Data Display Documentation Assessment and and recommendations generated from from rules engine Smart Assessment, Orders, and and Plan Plan Lipids Anti platelet therapy Blood pressure Glucose control Microalbuminuria Immunizations Smoking Weight Eye Eye and and foot foot examinations

43 CAD/DM Smart Form Medication Orders Lab Lab Orders Referrals Handouts/Education

44 CAD Quality Dashboard Red, Red, yellow, yellow, and and green green indicators show show adherence with with targets targets Targets Targets are are th th percentile for for HEDIS HEDIS or or for for Partners providers Zero Zero defect care: care: Aspirin Beta blockers Blood pressure Lipids

45

46 Discrepancy Details

47 Patient Journal Causes Provider Activation More medication changes in visits after diabetes journal submission: Grant RW et al. Practice-linked Online Personal Health Records for Type 2 Diabetes: A Randomized Controlled Trial. Arch Intern Med Sep 8;168(16):

48 The Peril? HIT Workforce HIT Technologies Applications Platforms Interfaces Knowledge Management Failure of ARRA HITECH Stimulus to achieve HIT sustainability Others?

49

50 Where are we? I conclude that though the individual physician is not perfectible, the system of care is, and that the computer will play a major part in the perfection of future care systems. Clem McDonald, MD NEJM 1976 Thank you! Blackford Middleton, MD bmiddleton1@partners.org