October 25, 2005 Robert M. Kolodner, MD Chief Health Informatics Officer, VHA Department of Veterans Affairs Realizing the Financial Benefits of Electronic Health Records: What do the Data Show? The VA Experience

AMIA - S49 (Kolodner)October 25, Cost Savings and EHRs in VA 20+ year history of computer use to support care in the Veterans Health Administration (VHA) Sometimes challenging to tease out effects of the Electronic Health Record from other major changes in VHA, especially since 1995 –Shift from Inpatient to Outpatient care –Reorganization to 22 (now 21) regional networks –Implementation of performance measures –Shift from facility-centric to veteran-centric

AMIA - S49 (Kolodner)October 25, Transformational Strategies for VA Health Care “In summary, electronic health records, performance management, and a patient-centric focus have been critical transformational strategies for the VA. They have been utilized to support achievement and are associated with measurable progress in each of the VA’s value domains.” The American Journal of Managed Care, November 2004

AMIA - S49 (Kolodner)October 25, : Who is “VHA”... Veterans Health Administration 5.2 million patients, ~ 7.6 million enrollees ~ $30 Billion budget ~ 1,300 Sites-of-Care –Including 171 medical centers or hospitals ~ 870 clinics –207 counseling centers & –long-term care programs ~ 197,500 Employees (~14,000 MD, 56,000 Nurses, 33,000 AHP) ~ 150,000 volunteers Affiliations with 107 Academic Health Systems –1,500 Health Professions Training Affiliations –Additional 25,000 affiliated MD’s; +35,000 residents & fellows in 14,000 slots ~ 89,000 trainees in all disciplines –Nearly half US health professionals (>65% MDs) have some training in VA ~ $1.7B Research: Rehabilitation, Health Services, Clinical, Basic

AMIA - S49 (Kolodner)October 25, VA’s Health Information System is VistA “CPRS” is the integrated EHR application VA runs 128 VistA systems these sites –Down from 172 VistA systems 10 years ago –~180,000 PCs and thin clients Delivers a complete hospital information system, electronic health record, imaging, Bar Code Medication Administration –Hardware, software, maintenance, upgrades, staffing For FY2004: –Cost per enrollee  $78 / enrollee –Average cost per hospital (n=158)  $3.6 million

AMIA - S49 (Kolodner)October 25, And VistA Is Actively Used... Some National VistA Statistics (Total…Daily) Documents (Progress Notes, Discharge Summaries, Reports) –742,000,000…… ,000 each workday Orders –1.48 Billion…… ,000 each workday Images –385,000,000……… +587,000 each workday Vital Sign Measurements –915,000,000……… +676,000 each workday Medications Administered with the Bar Code Medication Administration (BCMA) system –716,000,000……… +607,000 each workday Statistics as of September 2005

AMIA - S49 (Kolodner)October 25, VistA Data Trend – Rate of Increase

AMIA - S49 (Kolodner)October 25, Financial Benefits of EHR in VA Unable to provide overall benefits for the system since DHCP/VistA implemented and matured over 20 years and baselines were not taken HOWEVER Many local examples with costs Some local examples with implications without exact costs Some speculations …not counting savings by not repeating tests / or avoiding hospital admissions

AMIA - S49 (Kolodner)October 25, Myths: VA’s Different... “VA’s Command & Control” –Truth: Yes, 17,000 staff physicians, but 25,000 affiliated faculty & 35,000 housestaff through affiliations with 107 academic health systems “VA has an appropriated budget” –True, but VA $1.5 of $25 B (FY03) was revenue from billing, increased from $300 M, 3 years prior “VA’s patients are former military, thus overall healthier & follow instructions” –VA patients define adverse selection Think of VA as “Living Laboratory”

AMIA - S49 (Kolodner)October 25, Examples Medications – Inpatient –Bar Code Medication Administration Medications – Outpatient (local initiatives) –Drug Cost feedback Disease Management - Diabetes –HgB A1c –Outcomes Impact of Vaccinations –Pneumovax Not having to pull charts or maintain a chart room

Bar Code Med Administration (BCMA) INFORMATION TECHNOLOGY – SAFETY

AMIA - S49 (Kolodner)October 25, What is the Associated Cost Avoidance or Cost Savings?

INFORMATION TECHNOLOGY – EFFICIENCY Drug Costs are listed in the order menu Using Technology to Manage Drug Costs

INFORMATION TECHNOLOGY – EFFICIENCY Using Technology to Manage Drug Costs Here Fluoxetine is listed as the preferred drug, costs are also listed

INFORMATION TECHNOLOGY – EFFICIENCY Using Technology to Manage Drug Costs Conversion from Citalopram to Fluoxetine

AMIA - S49 (Kolodner)October 25, Diabetes Mellitus (DM) Prevalence of DM among VA patients is 20% –Substantially higher than in the general population –More than 1 million patients per year –Nearly all are male (2.4% women) –Largest group is >65 years old

AMIA - S49 (Kolodner)October 25, Performance Measurement Setting the U.S. Benchmark for 18 Comparable Indicators Clinical IndicatorVA 2003Medicare 03Best Not VA or Medicare Advised Tobacco Cessation (VA x3, others x1) (NCQA 2002) Beta Blocker after MI (NCQA 2002) Breast Cancer Screening (NCQA 2002) Cervical Cancer Screening (NCQA 2002) Cholesterol Screening (all pts)91NA73 (BRFSS 2001) Cholesterol Screening (post MI) (NCQA 2002) LDL Cholesterol <130 post MI (NCQA 2002) Colorectal Cancer Screening67NA49 (BRFSS 2002) Diabetes Hgb A1c checked past year (NCQA 2002) Diabetes Hgb A1c > 9.5 (lower is better)15NA34 (NCQA 2002) Diabetes LDL Measured (NCQA 2002) Diabetes LDL < (NCQA 2002) Diabetes Eye Exam (NCQA 2002) Diabetes Kidney Function (NCQA 2002) Hypertension: BP < 140/ (NCQA 2002) Influenza Immunization76P68 (BRFSS 2002) Pneumocooccal Immunization90P63 (BRFSS 2002) Mental Health F/U 30 D post D/C (NCQA 2002)

INFORMATION TECHNOLOGY – QUALITY CLINICAL REMINDERS

INFORMATION TECHNOLOGY – QUALITY Effect of Clinical Reminders at 1 VAMC

INFORMATION TECHNOLOGY – QUALITY Effect of Clinical Reminders at 1 VAMC

AMIA - S49 (Kolodner)October 25, Highest Quality of Care For Patients with Diabetes in VA “Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care.” Annals of Internal Medicine, August 17, 2004

AMIA - S49 (Kolodner)October 25, VA-TRIAD Adjusted Intermediate Outcomes VA, %CMC, % A 1 C level (proportion <8.5%) * 8365 A 1 C level (proportion <9.5%) * 9280 LDL level (proportion <100) * 5236 LDL level (proportion <130) * 8672 BP level (proportion <130/80)2829 BP level (proportion <140/90)5352 *P<0.001 Kerr et al – Annals of Internal Medicine 2004

October 25, 2005AMIA - S49 (Kolodner)23 FY99-04 Changes in Total, Major and Minor Age-Adjusted Amputation Rates Among Patients With Diabetes Amputations per 1000 patients

AMIA - S49 (Kolodner)October 25, What is the Associated Cost Avoidance or Cost Savings?

AMIA - S49 (Kolodner)October 25, Pneumococcal Vaccination Rates in VHA Iowa: Petersen, Med Care 1999;37: >65/ch dz HHS: National Health Interview Survey, >64 --BRFSS-- --BRFSS 90th--

AMIA - S49 (Kolodner)October 25, Pneumonia: Acute Inpatient Improving Efficiency by Reducing Excess Health Care Utilization 9,500 fewer bed days 8,000 fewer discharges DRG89-90; Unadjusted for Pt. Population (up 20%, FY99-01)

AMIA - S49 (Kolodner)October 25, Vaccine Cuts Pneumonia Risk in High-Risk Patients* 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine. –VA Medical Center study of 1,900 elderly patients with chronic lung disease; 2/3 vaccinated against pneumonia. Pneumococcal vaccination: –43% reduction in hospitalizations for pneumonia and influenza, and a 29% reduction in the risk of death. Pneumonia and Influenza vaccination: –72% reduction in hospitalizations for these two diseases and an 82% reduction in deaths from all causes. Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period. *Archives of Internal Medicine 1999;159: Dr. Kristin Nichol, VAMC / Minneapolis

AMIA - S49 (Kolodner)October 25, Extrapolating from Dr. Nichol’s Study: Between 1996 and 1998, Increased Rates of Pneumococcal Vaccination Averted 3914 Excess Deaths Nationally in VHA Patients with Chronic Lung Disease… Today, over 6,000 lives have been saved.

AMIA - S49 (Kolodner)October 25, What is the Associated Cost Avoidance or Cost Savings?

AMIA - S49 (Kolodner)October 25, Priceless

AMIA - S49 (Kolodner)October 25,

AMIA - S49 (Kolodner)October 25,

AMIA - S49 (Kolodner)October 25, Paper versus Electronic – Elimination of Processes Without an EHR –Paper charts were pulled & delivered to clinic locations for scheduled appointments –Also involved re-filing –Resulted in a 60% average chart availability rate One VA Medical Center –Budget of 1% of the entire VHA –Closed file room - cost avoidance estimated at $600,000 VERY Conservative estimate –$1 per pull, delivery and re-file  Some estimates in private sector as high as $10/pull –Eliminating this for VA’s 50 million outpatient encounters  estimated $50 million cost avoidance in staff resources

AMIA - S49 (Kolodner)October 25, Home Telehealth And what savings might we see from Home Telehealth?

October 25, 2005AMIA - S49 (Kolodner)35 Home-Telehealth Technologies

October 25, 2005AMIA - S49 (Kolodner)36

AMIA - S49 (Kolodner)October 25, What is the Associated Cost Avoidance or Cost Savings?

AMIA - S49 (Kolodner)October 25, This presentation is available on the VHA internet at: Select “Office of Information Document Library” on the left hand bar Presentation is Titled “AMIA Presentation by Robert M. Kolodner M.D.”