1. Health Information Technology: EHRs and Beyond Thomas Sequist, MD MPH

2. The Structure of Our Discussion What is Health IT and how is it used to improve care? What are the health policy strategies around Health IT?

3. The Structure of Our Discussion What is Health IT and how is it used to improve care? What are the health policy strategies around Health IT?

4. What is Health IT? “Health information technology (IT) refers to technologies and tools that allow health care professionals and patients to store, share, and analyze health information” - Office of the National Coordinator for Health IT

5. Is This The Role of Health IT?

6. Health IT and Healthcare Innovation Health Information Technology Advanced Data Analytics Patient Engagement New Approaches to Care Delivery Value- Oriented Financing

7. What do Consumers Want From Health IT? Only 56% feel US healthcare uses the most up-to-date IT Deloitte Survey of Healthcare Consumers, 2012

8. Practical Applications of Health IT Provider-facing ▫Electronic health record ▫Health Information Exchange Patient-facing ▫Personal health records ▫Virtual visits and telemedicine ▫Internet ▫Text messaging ▫Mobile apps ▫Self monitoring devices

9. Provider-Facing Health IT

10. A Common View of EHR Implementation

11. But Perhaps This is the Truth…

12. Physician Perceptions of EHR Implementation

13. It Was Not All Positive!

14. Have EHR tools Been Beneficial? Overall, the answer is yes ▫Focus on EHR decision support ▫Less robust on health information exchange, patient reminders and patient portals Focus is on clinical quality ---- preventive care Cost data are not conclusive 20% - 25% of studies come from 4 institutions ▫More recently, >50% of studies on commercial systems Chaudhry B. et al, Ann Intern Med 2006 Buntin, M. et al, Health Aff 2011 Jones, S. et al, Ann Intern Med 2014

15. Can Health IT Improve Patient Safety? Increase accessibility of information Communication Standardize operations (e.g. prescriptions) Real-time calculations (e.g. dosing) Decision support Bates and Gawande, NEJM 2003

16. Does Health IT Improve Patient Safety? EHRs and decision support effective in reducing adverse drug events ▫Bar coding ▫Drug-disease checking ▫Drug-allergy checking No data on errors in diagnosis ▫Leading cause of ambulatory malpractice Are there unintended consequences?

17. Health Information Exchange Promote care coordination Reduce inefficiency Improve safety Nearly 2/3 of hospitals and ½ of physicians participating Lack of rigorous data to demonstrate above benefits Rahurkar S et al. Health Aff 2015

18. Patient-Facing Health IT

19. What is a Personal Health Record? “An electronic record of an individual’s health information by which the individual controls access to the information and may have the ability to manage, track, and participate in his or her own health care” - Dept of Health and Human Services, Office of Civil Rights

20. How do Patients Use Patient Portals? View laboratory results (53%) Request medication refills (38%) Email messages (37%) Appointment scheduling (15%) Relatively consistent finding that lower SES and minority patients less likely to use portals Sarkar, et al. JAMIA 2011

21. Patient Access to Physician Notes Delbanco T, et al. Ann Intern Med 2012

22. Patient Access to Physician Notes Delbanco T, et al. Ann Intern Med 2012

23. Virtual Visits and Telemedicine Pearl R. Health Aff 2014

24. The Internet

25. Current Use of the Internet General use ▫59% of adults look online for health information Diagnosis ▫35% of adults go online to diagnose a medical condition Social connection ▫16% searched to find others with similar condition Pew Internet 2013

26. Topic% Specific disease/condition55 Certain treatment/procedure43 Weight loss27 Health insurance25 Food safety/recall19 Drug safety/recall16 Drug seen in advertisement16 Medical test results15 How to reduce your health care costs11 Pew Internet 2013

27. Leading Health-related Google Searches 2013 1.Flu 2.Cold 3.Labor 4.Diarrhea 5.Balance 6.Diet 7.Back pain 8.Allergies 9.Rash 10.Lupus Zeitgeist Google 2013 1.Pregnancy 2.Influenza 3.Diabetes 4.Anxiety 5.Thyroid 6.HIV 7.Mono 8.Lupus 9.Herpes 10.Pneumonia Health Issues Symptoms

28. The Internet as Health IT What we know ▫The most ubiquitous form of health IT ▫Diagnosis is a common reason for use ▫Information is variable, not trusted, and not free What we don’t know (…a lot) ▫Impact on health care outcomes ▫Impact of patient experiences ▫Impact on health utilization

29. What’s Next: The Promise of Text? Stockwell MS, et al. JAMA 2012 Urban, low SES population Weekly text message x 5 weeks

30. What’s Next: Activity Monitoring? Ability to monitor health-critical lifestyle features What will this mean for health improvement?

31. The Structure of Our Discussion What is Health IT and how is it used to improve care? What are the health policy strategies around Health IT?

32. EHR Adoption in 2008 DesRoches et al NEJM 2008, Jha et al NEJM, 2009

33. Major Barriers to Adoption Jha et al NEJM, 2009

34. The Policy Response HITECH ▫Meaningful Use of Health IT ▫Target incentives to Hospitals and Physicians ▫Implemented via CMS Define Meaningful Use ▫Stage 1 – data capture and sharing (2011-2012) ▫Stage 2 – advance clinical processes (2014-2015) ▫Stage 3 – improved outcomes (2017-)

35. Increasing Use of Ambulatory EHR Furukawa MF et al. Health Aff 2014 Incentives Begin

36. Increasing Use of Hospital EHR Incentives Begin Adler-Milstein, et al. Health Aff 2014

37. And Meaningful Use? Adler-Milstein, et al. Health Aff 2014

38. The Structure of Our Discussion What is Health IT and how is it used to improve care? ▫It is more than an EHR ▫Care has improved in focused areas ▫We have much to learn and leverage What are the health policy strategies around Health IT? ▫HITECH has dramatically improved adoption ▫What is ‘meaningful use’ of the EHR ▫Adoption and use are all in the details