Health Information Technology 101: Basics for Hospitals John

Health Information Technology 101: Basics for Hospitals John

Health Information Technology 101: Basics for Hospitals John Glaser, Ph.D. Vice President & Chief Information Officer Robert M. Kolodner, MD Acting Deputing CIO for Health & Acting Chief Health Informatics Officer Partners Healthcare System Veterans Health Administration Department of Veterans Affairs A Brief Agenda Setting the Stage Information Technology (IT) & the health care system A Little Perspective Electronic Health Records It really can work now Does it make any difference?

Some additional features and capabilities The Next Frontier: Personal Health Records The Concept of HealthePeople HIT Summit OCTOBER 2004 Page 2 2004: Who is VA? Veterans Health Administration VHA is an Agency of the Department of Veterans Affairs Locations & Affiliations ~ 1,300 Sites-of-Care Including 158 medical centers, ~ 850 clinics, long-term care, domiciliaries, home-care programs Affiliations with 107 Academic Health Systems Additional 25,000 affiliated MDs Almost 80,000 trainees each year 60% (70% MDs) US health professionals have some training in VA

HIT Summit OCTOBER 2004 Page 3 2004: Who is VA? Veterans Health Administration Budget, Staff, & Patients ~193,000 Employees (~15,000 Doctors, 56,000 Nurses, 33,000 AHP) 6% decrease since 1995 13,000 fewer employees than 1995 ~ $27.4 Billion budget 42% increase since 1995 Flat at ~ $19B from 1995 - 1999 5.1 million patients, ~ 7.5 million enrollees 104% increase in patients treated since 1995 From 2.5 million patients / enrollees in 1995 HIT Summit

OCTOBER 2004 Page 4 VAs Patient Satisfaction Index External American Customer Satisfaction Index (University of Michigan) 2000: 79 of 100 on Outpatient Care 2001: 82/100 Inpatient & 83/100 Pharmacy Significantly better than private health sector average of 68 Loyalty Score of 90 & Customer Service Score of 87 were healthcare benchmarks! 2002: Repeat Performance - Outpatient (79) & Inpatient (81) 2003: Repeat Performance - Outpatient (80) & Inpatient (81) HIT Summit OCTOBER 2004 Page 5 Health Information Technology as a

Lever for Change Health information technology provides a mechanism for refocusing care delivery around consumers without substantial regulation and industry upheaval. Information technology can result in better care (care that is higher in quality, safer, and more consumer responsive) and at the same time, more efficient (care that is appropriate, available, and less wasteful). There are very few other alternatives that can achieve both of these goals in a balanced and timely manner. The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care July 21, 2004 US Department of Health and Human Services HIT Summit OCTOBER 2004 Page 6 Improved Health & PAPERLESS

Standards Data Communications --------------------- Health Info Systems Electronic Health Records Systems (EHRs) Personal Health Record Systems (PHRs) Info Exchange Adoption by health organizations & persons of affordable, high quality & standardsbased EHRs, PHRs & Health Info Exchange Improved Health

Paperless (IOM) 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 * This graphic inspired by discussions at a Kaiser-Permanente and IOM sponsored meeting in October 2001. HIT Summit OCTOBER 2004 Page 7 Toward a Virtual Health System Electronic Health Records (EHRs) Robust, Widespread Use of High Performance Electronic Health Records (EHRs) Personal Health Records (PHRs) Full copy of ones own health information along with personalized services based on that information Standards Health Data & Communication Standards Health Information Exchange

Connectivity Among the EHRs, PHRs, and related health entities HIT Summit OCTOBER 2004 Page 8 Safety is Not Enough Patients dont seek care just to be safe, Safety is Fundamental Goal: Avoid Getting It Wrong Safety & Effectiveness, To Close to Chasm Expect effectiveness in maintaining & improving health, managing disease & distress Goal: Getting It Right . . . Consistently Patient-Centered, Coordinated Care Patient is locus of control Seamless across environments To Err is Human: 98,000 Patients Integrates disease-specific, general health and social needs

Anticipates health trajectory and modifies risks, even before traditional risk factors manifest Goal: Care that is safe, effective & predictive and delivered in the time, place & manner that the patient prefers The Quality Chasm: Every Patient Crossing the Quality Chasm 2001: IOM Information Technologies & Care Coordination in Supporting These Goals HIT Summit OCTOBER 2004 Page 9 Medical Computing Status . . . Given the huge increase in personal computer and Internet use, as well as the dramatic changes in other industries, most

consumers assume that healthcare is highly electronic and computerized. The reality, however, is that 90 percent of the business of healthcare remains paper-based. . . . Because healthcare (in the U.S.) is Why? a trillion-dollar cottage industry! Rx 2000 Institute HIT Summit OCTOBER 2004 Page 10 Shortcomings of a Cottage Industry: Dual Challenges Information:

1 in 7 hospital admissions occurs because care providers do not have access to previous medical records. 12% of physician orders are not executed as written 20% of laboratory tests are requested because previous studies are not accessible. 1 in 6.5 hospitalizations complicated by drug error Effectiveness: 98,000 Americans die each year from medical errors Virtually every patient experiences a gap in care from best evidence Health care inflation accelerating without commensurate value Uninsured & pharm uninsured Administrative costs

American health care is reactive; Safety net after catastrophe Marginal Prevention Unable to systematically anticipate needs that will predictably arise 1 in 20 outpatient prescriptions HIT Summit Patient / Payors / Providers OCTOBER 2004increasingly dissatisfied Page 11 Except in VA ! Every VA Medical Center has Electronic Health Records !

HIT Summit OCTOBER 2004 Page 12 EHR Electronic Health Records Praise for VistA VHAs integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation. Institute of Medicine (IOM) Report, Leadership by Example: Coordinating Government Roles in Improving Health Care Quality (2002) HIT Summit OCTOBER 2004 Page 14

VistAs Contribution to VA Creating a Culture of Quality: The Remarkable Transformation of the Department of Veterans Affairs Health Care System What was largely an inpatient, subspecialty-based system became a full-service, integrated delivery system committed to a new model of health promotion, disease prevention, and coordination of care. The culture of quality depended on the successful implementation of several innovations: a uniform data collection system facilitated by nationwide implementation of an electronic medical record system, systematic application of quality standards, and externally monitored local area networks to monitor quality. Annals of Internal Medicine, Editorial, August 17, 2004 HIT Summit OCTOBER 2004 Page 15 HIT Summit OCTOBER 2004

Page 16 Chart Metaphor, Combining Text and Images HIT Summit OCTOBER 2004 Page 17 So. . . . What Else Can an EHR Do? HIT Summit OCTOBER 2004 Page 18 Clinical Reminders

Contemporary Expression of Practice Guidelines Time & Context Sensitive Reduce Negative Variation Create Standard Data Acquire health data beyond care delivered in VA HIT Summit OCTOBER 2004 Page 19 HIT Summit OCTOBER 2004 Page 20

HIT Summit OCTOBER 2004 Page 21 HIT Summit OCTOBER 2004 Page 22 HIT Summit OCTOBER 2004 Page 23 Some National VistA Statistics (Total / Daily) Number of orders 1.14 Billion / >860,000

Number of Documents (Progress Notes, Discharge Summaries, Reports) 533,000,000 / >510,000 Number of Medications Administered with BCMA 500,000,000 / >580,000 Number of Images 197,000,000 / ~340,000 HIT Summit OCTOBER 2004 Page 24 Performance Measurement Setting the U.S. Benchmark for 18 Comparable Indicators Clinical Indicator VA 2003 Medicare 03

Best Not VA or Medicare Advised Tobacco Cessation (VA x3, others x1) 75 62 68 (NCQA 2002) Beta Blocker after MI 98 93 94 (NCQA 2002) Breast Cancer Screening 84 75

75 (NCQA 2002) Cervical Cancer Screening 90 62 81 (NCQA 2002) Cholesterol Screening (all pts) 91 NA 73 (BRFSS 2001) Cholesterol Screening (post MI) 94 78

79 (NCQA 2002) LDL Cholesterol <130 post MI 78 62 61 (NCQA 2002) Colorectal Cancer Screening 67 NA 49 (BRFSS 2002) Diabetes Hgb A1c checked past year 94 85

83 (NCQA 2002) Diabetes Hgb A1c > 9.5 (lower is better) 15 NA 34 (NCQA 2002) Diabetes LDL Measured 95 88 85 (NCQA 2002) Diabetes LDL < 130 77 63

55 (NCQA 2002) Diabetes Eye Exam 75 68 52 (NCQA 2002) Diabetes Kidney Function 70 57 52 (NCQA 2002) Hypertension: BP < 140/90 68 57

58 (NCQA 2002) Influenza Immunization 76 P 68 (BRFSS 2002) Pneumocooccal Immunization 90 P 63 (BRFSS 2002) Mental Health F/U 30 D post D/C 77 61

74 (NCQA 2002) HIT Summit OCTOBER 2004 Page 25 And yet a few more features . . . . HIT Summit OCTOBER 2004 Page 26 HIT Summit OCTOBER 2004 Page 27

Bar-Coded Medication Administration (BCMA) Virtually Eliminates Errors at the Point of Administration HIT Summit OCTOBER 2004 Page 28 PHR Personal Health Record The Opportunity of the Web: 2 million new Internet users/month 45% of the population uses email on a regular basis 35% of internet users are searching for health information National Survey of Veterans in 2001: 62% of veterans reported internet access Those who have been the least traditional users people of lower income levels, lower education levels, or the elderly are among the fastest adopters of this

technology. A NATION ONLINE: How Americans Are Expanding Their Use of the Internet U.S. DEPARTMENT OF COMMERCE February 2002 HIT Summit OCTOBER 2004 Page 30 What Is My HealtheVet ? My HealtheVet is a new ehealth portal where veterans, family, and clinicians may come together to optimize veterans health care. Web technology will combine essential patient record information and online health resources to enable and encourage patient/clinician collaboration. Veterans will be provided with information on benefits, services, and special programs, and can request services online. HIT Summit OCTOBER 2004

Page 31 Principles: The veteran "owns" his/her My HealtheVet Personal Health Record My HealtheVet (Phase 1) Veterans Day 2003 The VistA Computerized Patient Record System (CPRS) is the authoritative VA medical record The veteran can request that a copy of his/her VistA record be electronically extracted and sent to the My HealtheVet system HIT Summit OCTOBER 2004

Page 32 HIT Summit OCTOBER 2004 Page 33 HealthePeople Initiative: Toward a Virtual Health System EHRs Provide financial incentives Strongly encourage private sector vendors to make available affordable, high quality, standards-based EHRs Strongly encourage provider-based efforts like AAFP Continue to improve HealthePeople-VistA & make available Standards Consolidated Health Informatics as federal leadership Strongly encourage public/private development/adoption of national standards PHRs Strongly encourage public/private sector to work together to develop & make

available PHRs for persons EHR/PHR Info Exchange (IE) Strongly encourage public & private sector to work together to develop & make available national exchange solution HIT Summit OCTOBER 2004 Page 34 HealthePeople Virtual Health System EHRs, PHRs, Health Info Exchange (IE) & Standards (S) Population Electronic Health Record System (EHR) /Community Primary R H E health provider Hospital

Nursing Home Clinic S IE Clinic Hospital Care in Community Nursing Home Care in Community Public health Public Health

Info Systems S Research Other health org IE S HIT Summit IE ElectronicR Health Record EH Systems (EHR) Research a

d an s d S r SSt IE Research IE Person S Information IE Exchange OCTOBER 2004

S IE IE S Person Personal R Health Record PHSystem (PHR) Page 35 What Causes Value? Brown and Hagel. Harvard Business Review, July, 2003

Innovation in business practices Economic value results from incremental innovations rather than big bang initiatives Strategic value results from the cumulative effect of sustained initiatives to innovate business practices 36 HIT Summit Studies of Sustained IT Excellence McKenney, Copeland and Mason. Waves of Change: Business Evolution Through Information Technology. Harvard Business School Press (1995)

Sambamurthy and Zmud. Information technology and Innovation: Strategies for Success. Financial Executives Research Foundation (1996) Ross, Beath and Goodhue. Develop Long-Term Competitiveness Through IT Assets. MIT Sloan Management Review (1996) Weill and Broadbent. Leveraging the New Infrastructure: How Market Leaders Capitalize on Information Technology. Harvard Business School Press (1998) 37 HIT Summit Achieving and Sustaining IT Excellence Strong, sustained and clear themes often provided the basis for IT decisions We must continuously improve the care we deliver We must improve the professional lives of our providers We must engage the patient as an active participant in their care

Individuals and leadership matter Leaders who are smart, honest, seasoned, committed and value the healthy exchange of ideas Leadership engages in the information systems conversation and once committed has the strength to stay the course Leadership asks hard questions and is pragmatic but it never loses sight of its beliefs and value Leadership has focus and stamina and endures 38 HIT Summit Achieving and Sustaining IT Excellence Relationships between IT and organization individuals and teams are crucial CIO/CEO/COO/CFO/CMO/CNO Project teams and project managers Various mechanisms to integrate physicians into the IT agenda and activities

Technical infrastructure both enables and hinders Possesses characteristics of agility, potency, supportability, reliability and efficiency Provides critical capabilities, e.g., enables the extension of applications to anywhere on the globe or allows delivery of applications to any form factor 39 HIT Summit Achieving and Sustaining IT Excellence Innovation is encouraged and is recognized to take time Supports experimentation and creativity Encouragement is practical, goal-directed, bounded and managed Evaluation of IT opportunities is thoughtful Folds the IT agenda into the strategy conversation and the budget

discussion Applies disciplined upfront and post-implementation review Allows instinct and raw beliefs Processes, data and differentiation forms the focus of impact Referral, order entry or patient access Quality measures, referral patterns or financial status Patient-physician communication or referring physician booking of specialist appointment 40 HIT Summit

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