VA Health Informatics 101 Industry Expert Perspective Series Ernie Hood Senior Research Director Advisory Board Company Funded by the Office of the National Coordinator for Health IT U.S. Department of Health and Human Services ARRA Grant # 90CC07701

Why are we here?

Some Health Care Basic Numbers What percent of the U.S. population accounts for what % of health care costs? 80% of population generates 20% of the cost 10% of population generates 70% of the cost 1% of population generates 30% of the cost

Physician population aging & overwhelmed Health Care? “Inconsistent practices & inconsistent results” (Berwick) 55% of diabetics receive inadequate care (Rand study NEJM June 2003) Half of America’s heart attack victims do not receive proper follow-up care (IOM, Crossing the Quality Chasm, 2001) Nearly 55% of older women with a fracture did not receive osteoporosis meds after diagnosis (Journal of Bone & joint Surgery 12/03) 135 doctors diagnosed the same patient and recommended 82 different treatments (Strong Medicine, 1993) Physician population aging & overwhelmed There are more than 20,000 medical journals and nearly 10,000 articles on clinical trials published annually (National Library of Medicine 2001) Some scary stuff here – especially the idea that the same patient would have so much variation in Dx and Treatment! …and why is that? Well certainly a contributing factor is the over whelming amount of information that physicians are expected to master. I would postulate that it is extremely difficult – if not flat out impossible – for a single person to stay on top of everything needed to keep a human healthy. We may have reached a point where high quality care actually requires a “village” or a team rather than a soloist.

How can IT help Health Care? Electronic Records Physician Decision Support Patient Safety Research Quality Improved Coordination

How Users Adapt to New Technology

Clinician Use of EHR Technology – the Reality

EHR History 1960-1999

EHR History 2000-2010

Electronic Health Records Components Medical Records Database Clinical Documentation Diagnosis Problem List Medication List Allergy List Demographics Vitals (Ht, Wt, BP) Immunizations Test Results Drug Formulary Links to other Record Systems e.g. PACS, Document Imaging, etc Work Flow Documentation Support Work Flow Management Order Entry (CPOE) Safety Checks (drug/drug, drug/allergy, etc) Clinical Decision Support (Alerts, Order Sets, Practice Guidelines, etc) Registry Support Clinical Quality Reporting

1Q11 Percent of Hospitals At Stage 2Q11 Percent of Hospitals At Stage Stages of EMR Adoption HIMSS Analytics EMR Adoption Model Stage Description 1Q11 Percent of Hospitals At Stage 2Q11 Percent of Hospitals At Stage 7 Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with Emergency Dept, ambulatory, Outpatient venues 1.0% 1.1% 6 Physician documentation (structured templates) on one inpatient unit, full clinical decision support (variance and compliance), full radiology PACS 3.5% 4.0% 5 Closed loop medication administration fully implemented on one inpatient unit 5.9% 6.1% 4 CPOE and clinical decision support implemented in at least one inpatient unit 10.7% 12.3% 3 Nursing/clinical documentation (flow sheets) on one inpatient unit, clinical decision support (error checking in pharmacy), image access outside radiology dept. 48.4% 46.3% 2 Clinical data repository, controlled medical vocabulary, clinical decision support capability, may have document imaging; HIE capability 14.1% 13.7% 1 All three ancillary systems installed 6.7% 6.9% Not all ancillary systems (lab, radiology, pharmacy) installed 9.6% 10.0%

Questions?

Data Standards

Billing & Reimbursement

Data Standards - Websites Handy Sources CPT4, HCPS, ICD-9: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page ICD-10: https://www.cms.gov/icd10/ and http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036866.hcsp?dDocName=bok1_036866 SNOMED: http://www.nlm.nih.gov/research/umls/Snomed/core_subset.html LOINC: http://loinc.org/ NDC: http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm

Technical Data Standards Handy Sources HL7: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page X12: https://www.cms.gov/icd10/ SNOMED: http://www.nlm.nih.gov/research/umls/Snomed/core_subset.html LOINC: http://loinc.org/ NDC: http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm

Questions? (Data Standards)

Patient Portals/PHRs

Patient Access to Records Sneaking a Peak? OR Ironically, after all these years as a semi-autonomous vertically integrated IDN – we find that to progress, we really need the rest of the community. The transitions in care – where a patient moves in and out of our system – is where we have the biggest opportunity for improvement. As one of our physicians that works at a nursing home told me – “Every week I get a patient delivered by ambulance from a hospital with no records! I have to resort to interviewing the patient. What did they do to you in the hospital? Why were you there? What drugs are you taking?” – talk about opportunities for improvement! Several years ago now, we closed our hospitals. In a closed system where we were aggressively pursuing preventative care our success led to 50% of our beds being empty and lead to closure. This means we now rely on community hospitals and we put hospitalists in each facility to take care of our patients. We have discovered that simple techniques like ensuring that the patient follows their care plan on discharge enables us to half our re-hospitalization rate! Managing these transitions better means that we have to do a better job of connecting to the community. Hence my current mission. Prying it out of your Provider?

Sample Patient Portal Features Clinical Features Email your Care Team Get your Lab Results Fill your Prescriptions View your Medical Record View your child’s record Online Appointing Fill out a Health Risk Assessment Access a Health Care knowledgebase Interact with other patients “like me” Health Plan Features Email Customer Service View your co-pays View your deductable status Pay your bills These are most of the significant features we landed on as part of the portal. I took the vision we had and the features listed here to a broad group of technical staff in our IT department and we brainstormed how we would go about accomplishing these things. After much discussion we came up with a way to deliver on email, discussion boards, the knowledgebase and the HRA and an idea about how to do prescription refills. We decided to buy our knowledgebase from Healthwise – a vendor we had an existing relationship with and to partner with WellMed on the HRA. The rest we would build ourselves starting with Secure messaging.

Tethered Portal This created a world where the patient and care team were able to connect over the medical record – a world where the patient and care giver were looking at the same record but through a context designed for them and where both could contribute information (the patient through an HRA)

Online Test Results & Clinical Information For example, physicians do not need to have an explanation of what a Creatin level means or what a total Cholesterol level of 200 with a HDL of 50 means – but patients do

Information Therapy (lx) “Ix” is effective, more affordable, and with less side effects than “Rx” The same information, from the exam room to the living room The clinical knowledgebase can be accessed in the context of a lab result or prescription as see before or directly in search of information. The Clinician can also “prescribe” links to the patient that help them understand and deal with their situation.

Personal Health Records From the Online Journal of Nursing

Personal Health Record From e-caremanagement.com

Questions? (Patient Portals)

Health Information Exchange

Health Information Exchange (HIE)

HIE Components

NHIN

Advice for Students Be Curious Go to the Source Trust, but Verify Ask why Go to the Source Go to where the work takes place Trust, but Verify Don’t be afraid to go to the source documents

Questions? (HIE)