1. Adoption of Electronic Healthcare Records
Alexander Flores
Arin Halicki
Tiangan Lian
Damien Mar Chong
Mahesh Seethraman

2. Solution: What can EHR do for you?
Introduction
State of US Healthcare
Rising Costs
Quality of Care
Recent Legislation
Public good, Damien will talk about it later
Solution: What can EHR do for you?

3. Network Good
EHR is a Network good with it’s own delicate eco-system….
Benefits
Insurance
Companies
Patients
Medical Groups
EHR
(platform)
EHR is a Network good (talk about what benfits they derive) describe as eco-system….
Patient
Doctors (can have flexibility, who afflilate with and how run practice)
Hospitals (labs, billing, emergencies)
Payers ( insurance companies, claims management)
Government – no “benefit” – relatively new player but doesn’t’ derive true value
Insurance companies authorize the different procedures, in that sense, they are more closely associated with the patients and doctors than they are with medical groups themselves
* Government supports the network/platform w/ subsidies - but the benefits derived from the network is questionable. (Govt. is the largest provider of medicare and medicaid, so they derive a big benefit from the network)
Doctors
Hospitals
Government
Benefits

4. Interoperability and Scalability Can Drive EHR Success
EHR Platforms
Different versions
Formats
Language
Service offerings
Different pricing models
Size
Bundles
Incentives
EHR as a concept/platform provides benfefits to rest of network.
Platforms
Different versions
Formats
Language (CCHIT, HL7)
Service offerings
Different pricing models
Size Based - Scalability
Wide Variety of Schemes (Take Cost links/data from Wiki page)
Interoperability and Scalability Can Drive EHR Success

5. Language/ Interoperability
Products
Scalability / Cost
Language/ Interoperability
EPIC Systems Corporation
Ambulatory & Inpatient
Specialties / Departments / Ancillaries
Health Information Management (HIM)
Medical Groups to Practices or Organizations of any Size
Health Level Seven (HL7 )
ANSI X12
XML
Allscripts-Misys Healthcare Solutions, Inc.
Practice Mgmt Systems
Electronic Prescribing
Document Imaging
Patient Access
Individual Practices to Practices or Organizations of any size
CCHIT Certified
Open Source Connect written in Java
Cerner Corporation
Hospitals /Health Systems
Private Practice
Pharmacy
Employers
Home Care
Services & Devices
The Digital Imaging and Communications in Medicine (DICOM)
GE Healthcare
Peer Vision
Processing & Planning
Integrating the Healthcare Enterprise (IHE™)

6. What’s driving EHR adoption?
American Recovery and Reinvestment Act of 2009
2011 – 2015 scaled payment incentives to hospitals and physicians
By 2015 scaled reimbursement penalties from Medicare plus escalation
Reporting treatment outcomes and other metrics
Physician Quality Reporting Incentives (PQRI)
State Reporting Requirements eg. CA DMHC/OPA/OSHPD
Pay for performance
Improved Quality – error reductions
Cost reduction
We spend more than OECD nations in healthcare as a percent of GDP but with lesser doctors, professionals, hospitals etc…Per capita we spend more and we are measured last in quality by Commonwealthfund.
$80billion savings.

7. Top Motivating Factors for EHR Adoption (75% of Hospitals)
Share patient-record info among healthcare practitioners and professionals
Improve clinical processes or workflow efficiency
Reduce medical errors; improve patient safety
Improve quality of care
State and Pattern of HIT Adoption, RAND, 2005

8. Factors Influencing EHR Adoption
System-level factors
Regional factors
Hospital type
Hospital-bed-size
Medicare and Medicaid
Physician practice and size

9. By System-Level Factors
Importance of Network Externalities in the decision to adopt HIT.
Network Externalities – the value of technology investment for the provider depends on whether other providers have adopted this technology.
The majority of community hospitals belong to multi-hospital systems; thus, their adoption behavior is related to their system’s adoption behavior.
MSA – Metropolitan Service Area
EMR – Electronic Medical Records
CPOE – Computerized Physician Order Entry
PACS – Picture Archiving Communications System (e.g., Radiology)

10. By Regional Factors
Key takeaway: Systems with up to 5 hospitals is likely to adopt HIT than systems with more than 5 hospitals.
Why? - The investment might become more difficult to coordinate as the hospital system gets larger.

11. By Hospital Type Academic and Pediatrician hospitals – why?
Academics – easy
Pediatrics – Higher benefits of EMR and CPOE while caring for children (i.e., children are not as reliable a source of their medical histories, medications, etc., as adults)
Critical Access – tiny size and rural location; offer limited range of services
Long-term – small size; exempt from Medicare payment system which is a drive in increasing adoption of HIT

12. By Hospital-Bed-Size Category

13. By Medicare
Hospitals with majority of patients’ claims paid by Medicare are less likely to adopt EMR.
Why? Lower reimbursement rates of Medicare compared with other insurers explains, at least in part, its negative effect on hospital investment in HIT.

14. By Medicaid
Hospitals with a large share of Medicaid patients are generally considered disadvantaged and often receive grants and other financial help, which could be devoted to HIT investment.

15. By Practice and Size
Size effect is very important in the ambulatory clinics.
Practices with over 30 physicians are 3 times as likely to adopt an EMR system as is a solo practitioner.
Leaders in EMR adoption in ambulatory practice are multi-specialty clinics. They are larger organization and have financial resources; and there is greater organizational value to be derived in exchanging info among doctors in multi-specialty clinics.

16. Barriers to EHR Adoption
Older Records
Costs of conversion
Ownership
Other challenges (Tech/Human)
Patient rights & Privacy
HIPAA regulations
Digital security
Theft of information
Significant investment needed to convert old paper records to ehr
How do we do it ? Scan them in ? Type ‘em in anually ? What about human / machine errors that may be introduced during this process
Whose responsibility is it to upload all this info from the past into an Ehr
Whose responsibility is it to payfor the capacity needed to store all the past information ?
HIPAA rights – even if the patient is not part of your network.
How can you provide 24x7 access, if you don’t invest in infrastructure
How long do you have to keep the data if the patient is not part of your network ?
How do you ensure that the only authorized personnel view patients’ records
How do you validate authentication to a requestor, that the patient authorized it ?
What legal consequences / preventive mechanisms does a hospital/clinic need to put in place ?
What do you do when the info is available 24x7, with a higher probablity of theft due to hacking ?

17. Barriers to EHR Adoption
Other reasons
Lack of support from medical staff
Resistance to change
One system does not fit all needs
Fragmentation & customization
ROI impact
Why this lack of progress in ehr, even though it was proposed in the 60s
Technological back seat?
Resistance to change,
Customization – costly process, exposes inefficiencies in the existing process,
Hospitals have to change their routine – retraining, reduction in productivity in the earlier stages of adoption
State and Pattern of HIT Adoption, RAND, 2005

18. Barriers to EHR Adoption
Interoperability
Synchronization
Hardware
Costs
Who pays for it
Startup costs
Maintenance costs
Hardware – High fixed costs
Process change
Many systems for EHR, billings, admissions, discharges, prescribing. For example, there’s EPIC, Eclipsys, GE, AllScripts systems. And then on top of that someone might EPIC for billings but Eclipsys for EMR. Cannot communicate across other systems in other hospitals or clinics. So hospitals and doctors may hesitate to invest if their systems may not communicate with one another. Hardware compatibility, if moving systems.
There are many players and many health plan payers. How to get them to pay in?
Big startup costs. $10,000’s to $millions.
Ongoing maintenance costs for small facilities might be high.
High fixed costs. 18

19. Recommendations Single payer system Create interoperability standard
Public-private ownership for patient information
Financial incentives for EHR Adoption
Leasing of EHR solutions or SaaS
Pay for performance
Free/Subsidized basic System
Train new healthcare practioners about EHR.
At Medical schools
Single payer system
Federal gov’t subsidizes a basic system
ViSTA
Create interoperability standard
CCHIT certification with HITSP standard
Government oversight
Public-private partnership/RHIOs
California eHealth Collaborative
Public-private ownership that addresses who owns the patient information
Leasing of EHR solutions
Lower Setup costs.
SaaS - NextGen
Providing financial incentives to hospitals, clinics, etc..
Go into academia and train new physicians about EHR.