1. Role of the EHR in Healthcare Reform of Integrated Health Care Systems Blackford Middleton, MD, MPH, MSc Partners HealthCare System, Harvard Medical School

2. Agenda  Principal components of healthcare reform  Partners’ High Performance Medicine  Current Research & Development  Smart use of EMR: Clinical Decision Support  Quality Dashboards  Patient Activation  Clinical Decision Support Consortium

3. Principal Components of Healthcare Reform  President Obama’s FY 2010 Budget overview:  Reduce long-term growth of health care costs for businesses and government.  Protect families from bankruptcy or debt because of health care costs.  Guarantee choice of doctors and health plans.  Invest in prevention and wellness.  Improve patient safety and quality care.  Assure affordable, quality health coverage for all Americans.  Maintain coverage when you change or lose your job.  End barriers to coverage for people with pre-existing medical conditions.  The New Healthcare Policy “ABCDE”  Access  Best Quality  Cost  Disparities  (Comparative) Effectiveness

4. Partners HealthCare System  Eleven hospitals, 7000 physicians  $6.4B in revenues  4M outpatient visits and 160,000 admissions/year  $1B in biomedical research annually  Teaching affiliate of the Harvard Medical School  Founded by the Brigham and Women’s Hospital and the Massachusetts General Hospital

5. Information Systems Descriptive Numbers  Operating budget (FY07) = $158M  Capital budget (FY08) = $45M  Number of users = 54,000  Devices on the network = 71,000  Locations on the Partners network = 140  Electronic Medical Record physician users = 4,000 (> 100% of AMC PCPs; ~ 75% of Specialists)  Patients with data in the clinical data repository = 4,000,000  Medical images on line = 450,000,000  Orders entered hourly through Computerized Provider Order Entry (across Partners) = 1,000  LMR (ambulatory EMR) transactions per day = 1M  Calls to the Help Desk each month = 18,000

6. Major Information Systems Initiatives  Provision of electronic medical records, computerized provider order entry, electronic medication administration records and clinical decision support to further the goals of High Performance Medicine  Implementation of COMPASS to standardize and improve revenue cycle processes across Partners  Creation of the next generation of healthcare information systems architecture through the Service Oriented Architecture (SOA) initiative

7. HPM comprises five System-wide projects with one common goal: To deliver better care to patients. Care that is:  Safer  Better coordinated  More reliable in delivering proven interventions Systems that support providers in “doing the right thing.” To deliver better care to patients. Care that is:  Safer  Better coordinated  More reliable in delivering proven interventions Systems that support providers in “doing the right thing.” What is High Performance Medicine? http://www.partners.org/about/hpm.htm Dr. Jim Mongan

8. 1.Investing in quality and utilization infrastructure  Information systems applications  Informatics Infrastructure (data, knowledge, services) 2.Enhancing patient safety by reducing medication errors system-wide 3.Enhancing uniform high quality by measuring performance to benchmark for select inpatient and outpatient conditions 4.Expanding disease management programs by supporting activities for certain patients with chronic illnesses 5.Improving cost effectiveness through managing utilization trends and analysis of variance Quality Efficiency Initiative Focus Infrastructure What are the High Performance Medicine Initiatives?

10. Clinical Systems Goals  To ensure comparability of clinical data across the enterprise common data  To facilitate enterprise clinical decision support common logic  To facilitate enterprise reporting and data mining common reports, business intelligence  To facilitate enterprise standard clinical practice for providers and patients common workflow – reduced unwarranted variation – where appropriate  To enhance our development agility by creating re-usable application components and services common infrastructure, 1-4 above

11. Quality Matters: Diabetes Measures 2006-2008 2006 Diabetes2007 Diabetes2008 Diabetes Payer 1HbA1c Screening (2x) LDL Screening $2.8M Diabetes Composite Care (4 HEDIS tests: HbA1c screening, LDL screening, Eye Exam, Nephropathy) $1.87M Develop BP baseline $935K 7 POINT SCALE 1. Diabetes Composite Care (4 HEDIS tests) 2. HbA1c Outcomes </= 9 3. HbA1c Outcomes < 7 4. LDL Outcomes < 130 5. LDL Outcomes < 100 6. BP Outcomes < 140/90 7. BP Outcomes <130/80 ~$3.15M (6,000 patients) Payer 2HbA1c Outcomes </= 9 LDL Outcomes < 130 $2.1M HbA1c Outcomes </= 9 $1.25M LDL Outcomes < 100 $1.25M HbA1c Outcomes < 7 ~$1.32M (3,100 patients) LDL Outcomes < 100 ~$1.32M (3,100 patients) Payer 3HbA1c Screening (1X) $2.1M HbA1c Screening (1X) $1.6M (TAHP targets in negotiation) HbA1c Outcomes </= 9* LDL Outcomes < 100* ~$1.75M (2,600 patients)

12. Quality Measures and Requirements: Why is EMR Data Necessary? Contractual measures are moving away from claims based measures to outcomes measures, which require clinical data elements E.G. Diagnoses, Lab results, Blood pressure, Weight, Medications, Eye exam, Ejection Fraction Tracking of performance and management of patients will be dependent upon data in EMRs Settlement of 2008 contractual measures will no longer be dependant upon claims; we will need measure specific clinical values for all patients 12 In the longer term, there will be a move to derive quality measures directly from the EMR, rather than from clinically enriched administrative data.

13. Discrete vs. Shared: Data, Knowledge, Logic Many Partners’ applications utilize discrete data, logic and knowledge or rules; most are not integrated across sites – creating islands of information and supporting varying levels of functionality.

14. The Future: Shared Data, Knowledge, and Logic – Partners SOA Strategy Common ‘Shell’ or Clinical Portal Shared Logic, Dictionaries, and Rules ( Enterprise Clinical Services, Medication Services and Knowledge Management) LOGIC (Services) Enterprise Repository (s) Problems, Meds, Allergies, Labs, Orders, Notes, etc. Dictionaries And Rules Data (Knowledgebases ) Dictionaries And Rules Data (Knowledgebases ) MGH OEBWH OELMR Future clinical applications will take advantage of shared repositories of enterprise data, knowledge, and logic, in a services-oriented architecture

15. Current Research & Development  Smart use of EMR: Clinical Decision Support  Quality Dashboards  Patient Activation  The Clinical Decision Support Consortium

16. Adoption Get an EMR and use it Adoption Get an EMR and use it Effective Use Use key EMR features fully Effective Use Use key EMR features fully Smart Use Leverage EMR decision support Smart Use Leverage EMR decision support We are here How can an EHR make a difference? Meaningful Use StructureProcessOutcome

17. Secure Clinical Communication And Notification of Results Intuitive Chart Summary Automatic Reminders Summary Flowsheets Coded Clinical Data Customizable Desktop

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

19. Preliminary Results: Smart Form On Treatment Analysis <0.001 0.05 0.004 0.006

20. CAD Quality Dashboard Targets are 90 th percentile for HEDIS or for Partners providers Zero defect care: Aspirin Beta-blockers Blood pressure Lipids Zero defect care: Aspirin Beta-blockers Blood pressure Lipids Red, yellow, and green indicators show adherence with targets

21. Discrepancy Details

22. Provider Activation Grant RW et al. Practice-linked Online Personal Health Records for Type 2 Diabetes: A Randomized Controlled Trial. Arch Int Med 2007, in press. More medication changes in visits after diabetes journal submission:

23. CDS Consortium Goal To assess, define, demonstrate, and evaluate best practices for knowledge management and clinical decision support in healthcare information technology at scale – across multiple ambulatory care settings and EHR technology platforms. http://www.partners.org/cird/cdsc

24. Six Specific Research Objectives 1. Knowledge Management Life Cycle 2. Knowledge Specification 3. Knowledge Portal and Repository 4. CDS Public Services and Content 5. Evaluation Process for each CDS Assessment and Research Area 6. Dissemination Process for each Assessment and Research Area  Knowledge management lifecycle  Knowledge specification  Knowledge Portal and Repository  CDS Knowledge Content and Public Web Services  Evaluation  Dissemination

25. Thank you! Blackford Middleton, MD bmiddleton1@partners.org