1. 1 HIT Return on Investment: Evaluating Progress in a Sea of Change John Hsu, MD, MBA, MSCE AHRQ Conference 27 September 2007

2. 2 HIT Background  Great potential for transforming clinical care, especially for patients with chronic diseases  Adoption of HIT across the U.S. is limited but growing  Actual benefits of HIT unclear:  Initial benefits of HIT depend on how routinely and systematically clinicians use the HIT tools and resulting information  Little information on HIT effects in the ambulatory setting with commercially-available systems  Actual benefits and costs of HIT are difficult to quantify  Comprehensive identification  Methodological challenges

3. 3 Preliminary Results - IMPACT Study Impact of Information Technology on Clinical Care: An Evaluation of the Technology on Quality, Safety and Efficiency of Chronic Disease Care John Hsu, MD, MBA, MSCE (KP DOR) Ilana Graetz (KP DOR) Huihui Wang (KP DOR) Jie Huang, PhD (KP DOR) Mary Reed, DrPh (KP DOR) Bruce Fireman, MA (KP DOR) Joseph Selby, MD, MPH (KP DOR) Yvonne Zhou, PhD (KP) Jim Bellows, PhD (KP CMI) Naomi Bardach, MD (UCSF) Julian Wimbush (UCB) Tom Rundall, PhD (UCB) Robert Miller, PhD (UCSF) Richard Brand, PhD (UCSF) Funding: AHRQ R01HS015280

4. 4 Design: –Longitudinal study with quasi-experimental changes in exposure to HIT, and using a pre-post analytic design with concurrent controls Study Period: 2004-2008 Population: IDS Members with any of five chronic diseases in January 2004 (Asthma, CAD, DM, HF, Htn) Data: -Automated databases -Annual surveys Overview

5. 5 Basic HIT Tools CIPSeCharteRx/eRefilleConsult First Available: 1995March 2004 Functions: Data-Review  Documentation  Order-Entry  Communication  Paper-alternative:NoYes Integrated:Not integrated with other applications (i.e., need log onto each application separately) Description: Viewing lab results Viewing medication list Writing free-text visit notes Using standard note templates Viewing medication list Viewing medication allergies Entering orders for new prescription or refills Requesting referrals or consultations Sending messages to other providers

6. 6 First Available: Staggered implementation (2005-2008) Functions: Data-Review  Documentation  Order-Entry  Communication  Paper-alternative:No Integrated: Fully Integrated Description: Viewing medication list, allergies, lab results Using standard note templates & writing free-text visit notes Order new prescription or refills with decision support Ordering Disease-specific sets (drugs and labs) Sending messages to other providers & requesting referrals or consultations Sending and receiving messages from patients Point-of-care access to decision-support tools– including: –Online references and resources for current treatment guidelines –Care Management Institute protocols, and standard tests/screens KP HealthConnect Ambulatory Suite

7. 7 Potential Benefits of HIT Improved information availability (value of information) Clinical benefits Financial benefits: e.g., greater efficiency, lower administrative costs, better coding Benefits predicated on clinician use of HIT tools

8. HIT Use

9. 9 HIT Implementation and Use * Among office visits in department of Medicine or Family Practice

10. 10 CPOE Implementation and Use * New prescriptions are defined as new prescriptions doctor wrote, can be refills for existing drugs or completely new drugs

11. 11 HIT Use Implementation ≠ use Use of one type of HIT ≠ use of all HIT tools

12. Information Quality

13. 13 Data Availability: Diagnoses Completed on Visit Date * Among office visits in department of Medicine or Family Practice

14. Clinical Benefits

15. 15 Methodological Challenges for Assessing Clinical Benefits Measures of use Temporal trends - concurrent control groups Patient- and physician-level differences Reliable pre-implementation clinical data - differentiating documentation vs. care Multi-level effects Adequate power

16. 16 Methods Study Period: 04/2004-12/2006 Study Population –Active KPNC members who continuously enrolled during the study period –18 years and older as of 04/01/2004 –In diabetes registry as of 1st quarter of 2004 –Members in 5 medical centers where KPHC implemented before 07/2006 during the study period –In teams which existed all the time during the study period –With at least one LDL measurement in pre-HIT period and one in post-HIT period Predictor Measures: Presence of HIT (HealthConnect) Model: Mixed model with random effects at PCP and Patient level, adjusted for patient age, gender, race/ethnicity, neighborhood SES, time of measurement and Medical centers

17. 17 Definitions of Presence of HIT Definition 1: Medical center level KPHC rollout schedule –HIT=0: before KPHC was implemented at the first team in the medical center –HIT=1: within six months after KPHC was implemented at the first team in the medical center –HIT=2: six months after KPHC was implemented at the first team in the medical center Definition 2: Primary care team level actual use –HIT = 0: low use (<80% at team level) of eChart or KPHC –HIT = 1: starting from the first month when eChart used >=80% –HIT = 2: starting from the first month when KPHC used >=80%

18. 18 Mean LDL in Each Month in KPNC

19. 19 Association between HIT and LDL Estimate95% CI 1. Implementation at Medical Center (roll- out schedule) Before KPHC1.00ref. group First 6 months of KPHC-0.50-1.150.15 6+ months of KPHC-0.64-1.580.30 2. Actual use by Primary Care Team (% of total visits) Low HIT use (<80% of visits)1.00ref. group EChart used in >80% of visits-0.89-1.55-0.23 KPHC used in >80% of visits-1.72-2.68-0.76

20. Costs

21. 21 Investment Investment costs –Equipment –Personnel/productivity –Training Maintenance costs –IT support staff –Future upgrades –Continued training

22. Other Relevant Features

23. 23 Dynamic Environment Changes in HIT –Decision support –Information use Changes in Care Delivery –Clinical coordination –Delivery system Changes in Medical Therapy –Information on effectiveness –Dissemination of new knowledge Changes in the Market –Payment features, e.g., risk adjustment, reporting, performance incentives –Payment mix

24. 24 Conclusions Benefits –Some potential clinical benefits related to better information at the point-of-care –Unclear benefits associated with improvements in clinical information at the system level –Transaction benefits perhaps easiest to quantify –Financial benefits depend market and reimbursement mix Costs –Investment costs beyond equipment costs can be difficult to quantify –Maintenance costs also important Dynamic/changing systems and markets....

25. 25 Summary: Need for Better Empirical Studies

26. 26 HIT as Basic Infrastructure