1. Emerging HIT Incentive Programs: Physician Responses Health Information Technology Summit March 8, 2005 Peter Basch, MDDavid Kibbe, MD Medical Director, eHealthDirector, AAFP’s Center for MedStar HealthHealth Information Technology

2. Slide 2Discussion Document Page 2 Bio’s Peter Basch, MD General internist Medical Director, eHealth – MedStar Health Co-Chair PEHRC Co-Chair of the Small Practice Workgroup of eHI David C. Kibbe, MD, MBA Family physician Director, Center for Health Information Technology Co-Chair PEHRC Co-Chair of the Small Practice Workgroup of eHI

3. Slide 3Discussion Document Page 3 Overview Barriers to HIT adoption Why are incentives necessary? Responses to key HIT incentive programs

4. Slide 4Discussion Document Page 4 Risks / barriers to HIT adoption? Physicians are not computer phobic Physician culture is pro-quality / safety Computers are affordable / reliable Connectivity is affordable / reliable Software is reliable, and often affordable Why haven’t physicians accelerated adoption of HIT? –Risks / barriers to adoption –Risks / barriers to “interconnectivity” –“Questionable” (negative to very negative) business case

5. Slide 5Discussion Document Page 5 Lowering Risks / Barriers to EHR Adoption BarrierSolutionCurrent Work Confusion about product and company EHR product certificationCertification Commission on HIT (CCHIT) Not knowing which EHR is best for which type of practice Trusted specialty-specific EHR guidance AAFP, ACP, other medical specialty societies; KLAS, HIMSS, others High pricesAffordability and transparency Buying collaboratives - Medical professional and specialty societies Risk of implementation failure Trusted technical adviceAAFP’s CHiT, ACP’s PMC, QIOs Wide variability in contracting and business practices Standard contracting language, RFP guidance AAFP’s Partners for Patients, ACP’s PMC eHealth Initiative Difficult and expensive access to external information Standards-based solutions for labs, imaging centers, etc California Health Care Foundation, eHealth Initiative

6. Slide 6Discussion Document Page 6 Lowering Risks / Barriers to EHR Adoption BarrierSolutionCurrent Work Confusion about product and company EHR product certificationCertification Commission on HIT (CCHIT) Not knowing which EHR is best for which type of practice Trusted specialty-specific EHR guidance AAFP, ACP, other medical specialty societies; KLAS, HIMSS, others High pricesAffordability and transparency Buying collaboratives - medical professional and specialty societies Risk of implementation failure Trusted technical adviceAAFP’s CHiT, ACP’s PMC, QIOs Wide variability in contracting and business practices Standard contracting language, RFP guidance AAFP’s Partners for Patients, ACP’s PMC eHealth Initiative Difficult and expensive access to external information Standards-based solutions for labs, imaging centers, etc California Health Care Foundation, eHealth Initiative

7. Slide 7Discussion Document Page 7 Lowering Barriers to Interconnectivity BarrierSolutionCurrent Work  Information overload  Information out of context  Care confusion Potential for ↑duty and risk in an interconnected environment Potential for ↑duty and risk with use of clinical decision support

8. Slide 8Discussion Document Page 8 Lowering Barriers to Interconnectivity BarrierSolutionCurrent Work  Information overload  Information out of context  Care confusion New clinical protocols for interconnectivity Potential for ↑duty and risk in an interconnected environment Dialog and clarity with legal / policy communities Potential for ↑duty and risk with use of clinical decision support Dialog and clarity with legal / policy communities

9. Slide 9Discussion Document Page 9 Lowering Barriers to Interconnectivity BarrierSolutionCurrent Work  Information overload  Information out of context  Care confusion New clinical protocols for interconnectivity CCR Potential for ↑duty and risk in an interconnected environment Dialog and clarity with legal / policy communities ??? Potential for ↑duty and risk with use of clinical decision support Dialog and clarity with legal / policy communities ???

10. Slide 10Discussion Document Page 10 Creating the Business Case BarrierSolutionCurrent Work No money available for IT investment Access to capitaleHealth Initiative Financing Working Group Questionable business case for IT adoption Pay-for-IT useNational Group for the Advancement of HIT Negative business case for quality Pay-for-performanceNational Group for the Advancement of HIT, eHI, DOQ-IT, BTE, Leapfrog Negative business case for information management Pay-for-activities of information management National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB

11. Slide 11Discussion Document Page 11 Creating the Business Case BarrierSolutionCurrent Work No money available for IT investment Access to capitaleHealth Initiative Financing Working Group Questionable business case for IT adoption Pay-for-IT useNational Group for the Advancement of HIT, ACP Negative business case for quality Pay-for-performanceNational Group for the Advancement of HIT, eHI, DOQ-IT, BTE, Leapfrog Negative business case for information management Pay-for-activities of information management National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB

12. Slide 12Discussion Document Page 12 Creating the Business Case BarrierSolutionCurrent Work No money available for IT investment Access to capitaleHealth Initiative Financing Working Group Questionable business case for IT adoption Pay-for-IT useNational Group for the Advancement of HIT, ACP Negative business case for quality Pay-for-performanceNational Group for the Advancement of HIT, ACP, eHI, DOQ-IT, BTE, Leapfrog Negative business case for information management Pay-for-activities of information management National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB

13. Slide 13Discussion Document Page 13 Creating the Business Case BarrierSolutionCurrent Work No money available for IT investment Access to capitaleHealth Initiative Financing Working Group Questionable business case for IT adoption Pay-for-IT useNational Group for the Advancement of HIT, ACP Negative business case for quality Pay-for-performanceNational Group for the Advancement of HIT, ACP, eHI, DOQ-IT, BTE, Leapfrog Very negative business case for information management Pay-for-activities of information management National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB

14. Slide 14Discussion Document Page 14 No money available… For physicians – access to loans is not a problem… But willingness to borrow money for an uncertain ROI is. Nevertheless – may be important for some doctors

15. Slide 15Discussion Document Page 15 Case for IT adoption (per se) Successful IT adoption by itself has not been shown conclusively to improve quality or safety (except where quality has been specifically incented) Without further specifying process / outcomes measures as a requirement of reimbursement – it is clear that HIT will be used to further the existing business case = ↑ volume and “right coding”

16. Slide 16Discussion Document Page 16 The business case for quality and information management Computers are affordable Networking is affordable Broadband is affordable EHR software is affordable Interconnecting to all necessary sources of information is affordable

17. Slide 17Discussion Document Page 17 The business case for quality and information management Computers are affordable Networking is affordable Broadband is affordable EHR software is becoming more affordable Interconnecting to all necessary sources of information will hopefully become affordable (perhaps free) – and may (if we are lucky) improve quality and safety, and not result in information overload, “cookbook medicine,” and/or care confusion Quality care = (information) (knowledge) (context) Quality care = “micro-tasking” Quality care = ↑ time, cost, complexity Activities of quality care = the above, and population and disease management, non-visit based care, and care coordination

18. Slide 18Discussion Document Page 18 Basic EHR

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26. Slide 26Discussion Document Page 26 Decision support for patient

27. Slide 27Discussion Document Page 27 Integrated registry – proactive use by clinicians and staff

28. Slide 28Discussion Document Page 28 Advanced EHR + Registry + eVisits

29. Slide 29Discussion Document Page 29 Advanced EHR + Registry + eVisits + HIE CDE Security / MPI Decentralized model Imaging Centers Labs Community Hospitals Tertiary Care Hospitals PBMs Payors Public Health PCPs and Specialists Patients Patient info Visit list Prob list Med list Allergy list CCR Patient info Visit list Prob list Med list Allergy List Discharge Sum ED Reports CCR Reports Images Med lists Formulary Bio-surveillance Safety, quality, efficiency indicators Diagnosis Claims History Eligibility Referrals Authorizations Claim Submission Claim Status Claim Remittance Personal Health Record Long-term Care Home Health Outcomes Measures

30. Slide 30Discussion Document Page 30 The business case for quality and information management Computers are affordable Networking is affordable Broadband is affordable EHR software is becoming more affordable Interconnecting to all necessary sources of information will hopefully become affordable (perhaps free) – and may (if we are lucky) improve quality and safety, and not result in information overload, “cookbook medicine,” and/or care confusion Quality care = (information) (knowledge) (context) Quality care = “micro-tasking” Quality care = ↑ time, cost, complexity Activities of quality care = the above, and population and disease management, non face-to-face care, and care coordination

31. Slide 31Discussion Document Page 31 Existing P4P initiatives ProsCons Free software / devices Paid eCare Use of administrative data for P4P Use of administrative + clinical data for P4P = bad, to = completely meets goals

32. Slide 32Discussion Document Page 32 Preferred P4P initiatives = bad, to = completely meets goals ProsCons Care coordination / management fee Paid eCare* Staged pay-for-use → data submission → performance

33. Slide 33Discussion Document Page 33 Summary There are many risks and barriers to HIT adoption that can and should be lowered Interoperability only sets the stage – meaningful clinical interconnectivity will determine its value Payers must create a sustainable positive business case for adoption and optimal use (recognizing the implications to the practice) HIT adoption per se may add little or no net cost to a practice, and may produce little or no net value for the patient – may require a “jump-start,” but will not require ongoing incentives Integration of HIT into some practice settings can lead to ↑ quality/safety/efficacy/access (↑ HIT value), and doing so will ↑ provider time/cost/complexity (↑ practice costs) – requires ongoing structural reimbursement changes Incentives should not just be based on numerical targets, as healthcare transformation enabled thru HIT includes other key elements, such as meaningful care coordination / management, collaboration with patients, and optimal use of non face-to-face care (none of which will occur without fundamental reimbursement reform)