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Healthcare Informatics Primer

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Neil Kudler

on 29 May 2014

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Transcript of Healthcare Informatics Primer

Health Information Technology
America's Health Care Crisis
and the Triple Aim
Berwick, DM, Nolan, TW, and Whittington, J. "The Triple Aim: Care, Health, And Cost," Health Affairs May 2008 27:3759-769; doi:10.1377/hlthaff.27.3.759
Electronic Health Record
Meaningful Use
Health Information Exchange
Health Care Analytics
Telehealth
The Quadruple Aim
Improving the individual experience of care
Improving the health of populations
Reducing the per capita costs of care for populations
Improving the individual experience of care
Improving the health of populations
Reducing the per capita costs of care for populations.
Inventions, Opportunities and Challenges
Where are
the dollars
going?

What is the
benefit?

Who is winning
the game?
Each country’s input level, on each of eight inputs, is expressed as a percentage of the highest value for that indicator in the group
Highest drug spending
Spending on beds and drugs is comparable
Highest spending on human resources and beds
At or close to the maximum on every input
Documentation
Patient-Oriented Clinical Summary
Enterprise Communications Process
Electronic prescribing
CMS Mandate with upfront incentives followed by penalties if non-compliant
Legible prescriptions are directly sent to the pharmacy
Interaction and Allergy checking at the time of entry
Patient satisfaction with fewer errors and less waiting time
Improved formulary compliance decreasing direct cost to patients and overall cost of healthcare
Automated retrieval of “external Rx history”
Formulary and insurance eligibility checking at the point of service
Order sets based on Clinical Practice Guidelines
Computerized Provider Order Entry
EMR’s are very different from other electronic applications.
No common standards
No common vocabulary
Development driven by vendors
Large institutions favor systems that enable data sharing across the enterprise (one size fits all; enterprise solutions)
Small clinics favor systems that maximize their particular workflow (silos of information; "best of breed" solution)
Electronic Medical Records
Databank of patient health information
Narrative history
Laboratory and test results
Menagerie of notes, messages, letters, old records, etc.
Means of clinical communication
Patient-to-physician, physician-to-physician, staff-to-physician
Memory aid
“How did you remember that, doc?”
Way to satisfy billing needs
Diagnostic coding and documentation support
Medicolegal document
“if it’s not in the medical record, it never happened…”
What is a medical record?
Documentation
Patient Education
Condition-specific
results flowsheets
Results management
Electronic prescribing
Electronic prescribing
Evaluate orders for errors and provide alerts for:
Drug-drug interaction
Computerized Provider Order Entry
Summary Data
Problem Lists
Medications
Allergies
Immunization records
Social History
Family History
Procedure History
Access to Longitudinal Data
Summary Data
Problem Lists
Medications
Allergies
Immunization records
Social History
Family History
Procedure History
Access to Longitudinal Data
Access to Longitudinal Data
Summary Data
Problem Lists
Medications
Allergies
Immunization records
Social History
Family History
Procedure History
Summary Data
Problem Lists
Medications
Allergies
Immunization records
Social History
Family History
Procedure History
Access to Longitudinal Data
Summary Data
Problem Lists
Medications
Allergies
Immunization records
Social History
Family History
Procedure History
Access to Longitudinal Data
Increase revenue (improve code capture, bolster documentation)
Reduce costs (record storage, copy expense, decrease duplication of services )
Facilitate referrals within the IDN
Reduce hospital admissions by creating point of service access to patient record
Improve access to patient records
Ensure legibility
Provide access to information (encounters, results, references)
Enhance quality & safety (medication management, practice guidelines, disease- and population-based care, etc)
The Electronic Medical Record: Why?
Why abandon a time-proven tradition?
Difficult to access over multiple sites
Hand-written documents are often illegible
The paper chart is difficult to organize and even more difficult to search
The Paper-Based Medical Record
Why abandon a time-proven tradition?
Difficult to access across multiple sites
A prerequisite for admission to medical school?…
The Paper-Based Medical Record
Graphics for
results trending
Results management
Electronic delivery of lab, radiology,
ancillary testing results with visual alerts
for abnormal and critical values
Results management
Electronic prescribing
Evaluate orders for errors and provide alerts for:
Dose range checking
Specifically: Single dose limits, daily dose limits, age and kidney function appropriateness
Computerized Provider Order Entry
Evaluate orders for errors and provide alerts for:
Drug-allergy checking
Computerized Provider Order Entry
Pre-configured orders and order sentences for ease and accuracy of entry
Computerized Provider Order Entry
Summary Data
Problem Lists
Medications
Allergies
Immunization records
Social History
Family History
Procedure History
Access to Longitudinal Data
Influenza incidence
Why abandon a time-proven tradition?
Difficult to access over multiple sites
Hand-written documents are often illegible
Not easily searched or organized
The paper chart is not amenable to population assessments or event surveillance
The Paper-Based Medical Record
Why abandon a time-proven tradition?
The paper chart is difficult to access over multiple sites (ED, consultants, satellite clinics, home)
The Paper-Based Medical Record
Electronic prescribing
Summary Data
Problem Lists
Medications
Allergies
Immunization records
Social History
Family History
Procedure History
Access to Longitudinal Data
Eligible Providers must attest to CMS that:
A certified EHR system is used
The EHR achieves functionality requirements and associated measures
EPs must also attest on quality reporting requirements
Data were generated from EHR
Results are reported in the aggregate (numerators, denominators, and exclusions) to CMS (or states for Medicaid project)
Results are accurate
Data include all patients to whom the measure applies

Quality reporting is not focused on performance or
other outcomes, but rather on the ability to utilize the
EHR to provide accurate and comprehensive data
Attesting To Meaningful Use
Defining Meaningful Use
The HITECH Act does not award partial payments
The EHR reporting period is any continuous 90 day period of demonstration in 2011
Full incentive payment will be awarded for this 90 day period
Subsequent payment will require the entire year of meaningful use
Defining Meaningful Use
Eligible Hospital: Incentive payments for eligible hospitals would be calculated based on the provider number used for cost reporting purposes, which is the CMS Certification Number (CCN) of the main provider
Eligible Hospitals and CAHs may participate in both the Medicare programs and the Medicaid program
Defining Meaningful Use
HITECH (Health Information Technology for Economic and Clinical Health) Act created 3 incentives programs for Meaningful Use:

Medicare Fee-for-Service
Medicare Advantage
Medicaid programs

Three categories of eligibility:
Eligible hospitals (EH)
Critical access hospitals (CAH)
Eligible providers (EP)
American Recovery and Reinvestment Act (ARRA) authorizes CMS to provide incentive reimbursement to physician and hospital providers for becoming “meaningful users” of a certified electronic health record
Stage 1 of 3 began in 2011 with project culmination in 2015
Penalties are incurred for non-compliance in 2016
Defining Meaningful Use
Defining Meaningful Use
Criteria is divided into Core and Menu sets
Must satisfy all 15 Core measures and 5 of 10 Menu measures
Emergency Department explicit participant in the EH project
Aggressive quality reporting programs for both ambulatory and hospital projects
Eligible Professionals (EPs) can receive either Medicare or Medicaid incentive payments:
EP must provide >10% of services in ambulatory setting (including observation status patients; excludes all POS 21 & 23)
Hospital-based clinic providers are eligible as EPs
Medicare: MD, DO, DDS, DMD, DPM, DC, OD
Medicaid: 30% Medicaid volume (20% for pediatrics)
Physicians, NPs, CNMs, PAs in health centers
Defining Meaningful Use
Eligible Hospitals and Critical Access Hospitals are eligible for
both Medicare and Medicaid incentive payments
Medicare and Medicaid programs have minor variations in eligibility and reimbursement planning
Incentive payments for eligible hospitals would be calculated based on the provider number used for cost reporting purposes
CMS Certification Number (CCN)
Defining Meaningful Use
Interim Final Rule released 12-31-09
Public comment to 3-10
Reformulation and response released as Final Rule on July 13, 2010
The Electronic Health Record
Incentive Payment Program:
Meaningful Use
In 2008, the National Quality Forum identified a set of
national priorities for healthcare improvement

Patient engagement
Reducing racial disparities
Improved safety
Increased efficiency
Coordination of care
Improved population health



Privacy and security have since been built into the framework
Defining Meaningful Use
CORE
Protecting Patient
Health Information!

Meaningful
Use
Ensure Privacy
& Security
Protections
CORE
Exchange key clinical information

MENU
Summary of care
Medication Reconciliation

Meaningful
Use
Improve Care
Coordination
CORE
Electronic Summary
DC Summary
ED & EP visit
Visit Summary

MENU
Patient Portal

Meaningful
Use

Engage Patients
and
Families
MENU
Public Health Objectives:
Immunizations reports
Labs submission to DPH
Outbreak surveillance

Meaningful
Use
Improve
Population
&
Public Health
CORE
Demographics
Problem List
Vital Signs
Medication List
Allergy List
ePrescribing
CPOE
Drug Checking
CDS Rule
Smoking Status
Quality Reporting

MENU
Patient Reminders
Lab Results
Registries

Meaningful
Use

Improve Quality
Safety
& Efficiency
Medicare and Medicaid EHR Incentive Payment Basics
Eligible providers must be meaningful users of certified
EHR systems beginning in 2015 to avoid Medicare
payment reductions (no Medicaid penalties)
They are eligible to receive temporary EHR incentive payments:
Hospitals: Medicare AND Medicaid
Physicians: Medicare OR Medicaid
These providers qualify to receive incentives if they are:
A meaningful user of certified (EHR) system
PPS Hospitals and CAHs, along with physicians providing care
in OPDs, hospital clinics, and private practices are eligible
for the program

Meaningful Use
Improve
Population
&
Public Health
Ensure Privacy
& Security
Protections
Improve Care
Coordination

Improve Quality
Safety
& Efficiency

Engage Patients
and
Families
In accordance with these pre-established priorities,
Meaningful Use requirements will increase over time

Meaningful
Use
Improve
Population
&
Public Health
Ensure Privacy
& Security
Protections
Improve Care
Coordination

Improve Quality
Safety
& Efficiency

Engage Patients
and
Families
Priorities for US health care reform…
Automation
Infrastructure for health care delivery has not kept pace with the electronic innovations of other industries.
Many institutions still rely on systems that are not automated and allow opportunities for human error, even though technology exists to minimize errors and improve efficiency.
Health Care Reform
Priorities for US health care reform…
Access
Lack of insurance is a major reason for not obtaining access to needed care.
The 40 million Americans without insurance coverage are less likely to obtain needed medical care and preventive tests
Even with insurance, barriers to care still exist:
Lack of an established relationship with a doctor
Language and Cultural barriers
Social Determinants of Health
Transportation issues
Geography
High out-of-pockets costs even for those with insurance ie: high deductibles, underinsured, etc.

Health Care Reform
Priorities for US health care reform…
Cost
The U.S. spends more on health care per capita than any other nation.
The U.S. spends more on health care as a proportion of GDP (Gross Domestic Product) than any other nation.

Patient-friendly
Public confidence in hospitals and personal doctors remains relatively high.
While individuals report generally positive experience with medical care, public confidence and trust in the
system at large is eroding.

*Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002. The Commonwealth Foundation.
Health Care Reform
Priorities for US health care reform…

Quality-WHO (World Health Organization) identifies the US health care system as the “most individually responsive”
WHO ranks US health care 37th overall (among 191 countries)

Efficiency
People with acute and chronic medical conditions receive only about two-thirds of the health care that they need.
Between 20 and 30% of tests and procedures provided to patients are neither needed nor beneficial.

*Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002. The Commonwealth Fund
*Schuster, McGlynn, and Brook.
Health Care Reform
A personal physician who coordinates all care for patients and leads the team.
Physician-directed medical practice – a coordinated team of professionals who work together to care for patients.
Whole person orientation – this approach is key to providing comprehensive care.
Coordinated care that incorporates all components of the complex health care system.
Quality and safety – medical practices voluntarily engage in quality improvement activities to ensure patient safety is always being met.
Enhanced access to care – such as through open-access scheduling and communication mechanisms.
Payment – a system of reimbursement reflective of the true value of coordinated care and innovation.
“Joint Principles” of the Patient-Centered Medical Home
[AAFP, AAP, ACP, AOA]
Convenient Access
A recent survey cited in Health Affairs indicated that 70% of hospitals plan to invest in HIE
The number of private HIE entities increased from 52 in 2009 to 200+ in 2011
Where is the industry going?
HIE: Health Information Exchange is the reliable and secure transmission of, access to and retrieval of healthcare-related data among facilities, healthcare organizations and government agencies.
Enterprise/Private HIE: ownership by a hospital or health system, which bears its cost, controls its governance, and determines its membership. Ideally able to facilitate point-to-point transactions, such as lab/ancillary/radiology ordering and tracking.

Community/State HIE: healthcare information exchange among stakeholders within a defined geographic area within a federated, but shared services environment. It considered better positioned to deliver public health services, such as disease surveillance. State model.
What is HIE?
Care Collaboration in Support of Accountable Care
Secondary Uses – research, quality improvement
Patient Matching – do I have the right John Smith?
Connecting Exchange Nodes – avoiding walled gardens
Tracking Sources of Information
Filtering and Searching – judging the accuracy of information
Provider Workflow – not another system to use – please!
Liability – relying on information that is inaccurate or incomplete
Future Challenges for HIE
Private HIE advantages
Fewer stakeholders to developed a shared vision
Funding does not rely on grants that leave sustainability issues
“healthcare is local” and local physician engagement is important
Quality reporting is enabled through a centralized database
HIE will be a network-of-networks, so it isn’t really isn’t a private vs. public decision (do both!)
Private HIE vs. MA Public HIE
ePrescribing
Retrieve Medication History for Reconciliation
Care Coordination
Public Health Reporting
Consumer Empowerment
Query Patient History
Health Information Exchange:
EOHHS Topical Perspective
HIE Conceptualization
Auto-faxing
EMR Messaging
Uni- & Bidirectional Interfacing
Community EMR
Webpage and Secure eMail
ePrescribing
Clinically-driven Data Exchange
DATA
Integration &
Aggregation
Data Aggregation
Patient Centric Disease-State View (PCMH)
Clinical Data Repository
Augment Practice/Physician
Alignment
Accountable Care
Risk Analysis and
Predictive Modeling
Integrated
Care Management
Facilitate Sharing of
Composite Data
EHR-Agnostic for
Capture of PHI
Population
Management
Data Analytics
Health Information Delivery and Exchange
Data Aggregation
Electronic Health Records
?
?
?
?
Augment Practice/Physician
Alignment
Facilitate Sharing of
Composite Data
EHR-Agnostic for
Capture of PHI
Health Information Delivery and Exchange
Clinical Data Repository
Data Aggregation
Electronic Health Records
Clinical Data Repository
Augment Practice/Physician
Alignment
Improve the health of the patient & population
Increase the value of healthcare resources
Enhance patient and provider experience
Accountable Care
Risk Analysis and
Predictive Modeling
Integrated
Care Management
Facilitate Sharing of
Composite Data
EHR-Agnostic for
Capture of PHI
Population
Management
Data Analytics
Health Information Delivery and Exchange
Data Aggregation
Electronic Health Records
Rapidly Changing Technologies
Niche Platforms
Multiple Platforms
Payer
Goal: Clinical Integration & ACO Enablement Funding: Private
Governance: Enterprise
Healthcare
Organization
Physician
Practice
(Owned)
Physician
Practice
(Affiliated)
Hospital 1
Hospital 2
Exchange
Goal: Meaningful Use & Patient Safety
Funding: State/Federal/Other
Governance: HIO (State)
HIE N
Public Health
HIE 1
HIE 2
HIE 3
Exchange
HIE Network
Connects several independent HIEs, creating an HIE network. Exchange networks are typically found at the State or Federal level.
Exchange
Network
Goal: Workflow Efficiency and Connectivity
Funding: State/Other
Governance: HIO
HIE connects all the healthcare organizations in a given region/area as well as national data providers, local public health organizations, etc.
Labs, Rx,
Etc.
Public
Health
Health
Systems
& Hospitals
Payers
Physicians
Exchange
Regional HIE
HIEs can be created at many levels of scope and purpose
HIE Deployment Models
Private
Exchange
Exchange is created by a healthcare organization (e.g., Health System) in order to connect constituents in the region/area and align to organization-specific business goals.
Regional
Exchange
Analytics is the discovery and communication of meaningful patterns in data. Especially valuable in areas rich with recorded information, analytics relies on the simultaneous application of statistics, computer programming and operations research to quantify performance. Analytics often favors data visualization to communicate insight.
Patient to Provider
Remote Radiology
Remote ICU
Improving the experience of the physician

Fewer than 20% of graduating medical
students enter into primary care

Who will take care of us?
Full transcript