Re engineering U.S. Health Care with Healthcare … · Re‐engineering U.S. Health Care with Healthcare ... Blackford Middleton, MD, MPH, MSc ... script Order Order Claim Pharmacy

ReRe‐‐engineering U.S. Health engineering U.S. Health Care with Healthcare Care with Healthcare 

Information Technology Information Technology ––Promises and PerilPromises and Peril

Blackford Middleton, MD, MPH, MScCorporate Director, Clinical Informatics Research & Development

Chairman, Center for Information Technology LeadershipPartners Healthcare SystemHarvard Medical School

‘09

Systems In HealthcareSystems In Healthcare

A Simple Clinical Encounter in the US Healthcare Delivery SystemThree Dilemmas: Patient, Provider, PurchaserInformation Technology SystemsThe Promise and the PerilDiscussion, Q&A

ClinicalEncounter

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“Simple” Data Flow

The PatientThe Patient’’s Dilemmas Dilemma

Average American consumers $6240/yr of healthcare, or $12,200 for the ave. family

Health premiums rising 4x faster than salary over past 6 yrs50% of personal bankruptcy due to healthcare costs42% of the public have experienced medical error themselves or in their family (24% with serious consequences)

45M Americans lack Healthcare insurance80M lack at some time during each year

Increasing exposure to tiered pharmacy plans, consumer directed care, define contribution plans… without transparency

Absent reliable quality dataNo value‐based choices

Americans Spend More OutAmericans Spend More Out‐‐ofof‐‐Pocket Pocket on Health Care Expenses, 2004on Health Care Expenses, 2004

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$0 $100 $200 $300 $400 $500 $600 $700 $800 $900

a2003b2003 Total Health Care Spending, 2002 OOP Spending

ba

United States

OECD Median

New Zealand

Netherlands

Japan

GermanyFrance Canada Australia

a

Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

Total health care spending per capita

Out-of-pocket spending per capita

Percent reporting:

Only minorchanges needed

Fundamentalchanges needed

Rebuild completely

Total 16 50 32

Annual income<$35,000 11 51 38$35,000–$49,999 13 50 36$50,000–$74,999 16 51 31$75,000 or more 19 52 28

Insurance statusInsured all year 18 52 29Uninsured during year 10 44 45

U.S. regionNortheast 13 51 35North Central 16 50 32South 15 51 33West 21 48 29

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.

Majority of Americans Say Health Care Majority of Americans Say Health Care System Needs Fundamental Change or System Needs Fundamental Change or

Complete RebuildingComplete Rebuilding

The ProviderThe Provider’’s Dilemmas Dilemma

Unexplained variation, disparities in access and utilization, medical error, patient safety, and quality issues vex US Healthcare 

18% of medical errors are estimated to be due to inadequate availability of patient information.Patient data unavailable in 81% of cases in one clinic, with an average of 4 missing items per case.  Medical error the 8th leading cause of death1 in 4 prescriptions taken by a patient are not known to the treating physician1 in 5 lab and x‐ray tests ordered because originals can not be found40% of outpatient prescriptions unnecessary Patients receive only 54.9% of recommended care

Unwarranted Variation in CareUnwarranted Variation in Care

60% Variation In Medicare Resource Use Intensity For Equivalent

Populations

SOURCE: Wennberg et. al. Annals Of Internal Medicine 2/18/03

Little Impact Of Spending On QualityLittle Impact Of Spending On Quality

The Cost Conundrum: The Cost Conundrum: Atul Gawande, MDAtul Gawande, MD

http://tr.im/sVLA

“…driven primarily by local norms that tend towards heavier use of discretionary services –such as diagnostic testing and surgical versus less invasive interventions – for which there are no clear clinical guidelines.”Peter Orszag, OMB Bloghttp://www.whitehouse.gov/omb/blog/

El Paso

McAllen

TEXAS

790 mi., 1271 km

Physician Information NeedsPhysician Information Needs

Medical literature doubling every 19 yearsDoubles every 22 months for AIDS care

2 Million facts needed to practiceCovell study of LA Internists:2 unanswered clinical questions for every 3 pts• 40% were described as questions of fact, • 44% were questions of medical opinion, • 16% were questions of non‐medical information. 

Covell DG, Uman GC, Manning PR. Ann Intern Med. 1985 Oct;103(4):596-9

Measuring Information Needs Measuring Information Needs 

Generally, with direct observation, or interview immediately after clinical encounters, physicians have approximately one question for every 1‐2 patients Independent estimates: 0.6, and 0.62 Q/ptHolds across PCP and specialty careHolds across urban and rural

Gorman, 1995Gorman and Helfand 1995

Publication

Bibliographic databases

Submission

Reviews, guidelines, textbook

Negative        results

variable

0.3 year

6. 0 ­ 13.0 years50%

46%

18%

35%

0.6 year

0.5 year

9.3 years

Dickersin, 1987

Koren, 1989

Balas, 1995

Poynard, 1985

Kumar, 1992

Kumar, 1992

Poyer, 1982

Antman, 1992

Negative        results

Lack of        numbers

ExpertExpertopinionopinion

Inconsistentindexing

17:14

Original research

Acceptance

Patient Care

Converting evidence to careConverting evidence to care

17 years to apply 14% of research knowledge

to patient care!

17 years to apply 14% of research knowledge

to patient care!

Balas Yearbook Medical Informatics 2000gtre4, courtesy M Overhage

Herbert A. Simon, Herbert A. Simon, Nobel Laureate Economics, 1978Nobel Laureate Economics, 1978

“What information consumes is rather obvious: it consumes the attention of its recipients. 

Hence a wealth of information creates a poverty of attention, and a need to allocate that attention efficiently among the overabundance of information sources that might consume it.”

Changing clinician roles:From Omniscient Oracle… to Knowledge Broker.

Flexner ReportFlexner Report

Abraham Flexner, Medical Education in the United States and Canada.

Boston: Merrymount Press, 1910

"...The curse of medical education is the excessive number of schools. The situation can improve only as weaker and superfluous schools are extinguished."“Society reaps at this moment but a small fraction of the advantage which current knowledge has the power to confer.”

PaperPaper‐‐based Medicinebased Medicine

Prone to errorLots of information but no dataLimited decision support, or measurementDoes not integrate with eHealthcare…Will not transform healthcare

The PurchaserThe Purchaser’’s Dilemmas Dilemma

US healthcare is $1.7T, 16% GDP • 5% in 1963; Industrialized societies average less than 10%

• Costs rising 7‐9%/yr, expected to double in 10yr• 25% of premium is for administrative overhead (limited value)

Public expenditure on healthcare now 43% of total (up 10% in past decade)GM healthcare costs now $1500/automobile, most expensive componentWhere will additional value be found in, or costs taken out of, the system?

http://ucatlas.ucsc.edu/spend.php

Schroeder S. N Engl J Med 2007;357:1221-1228

Determinants of Health and Their Determinants of Health and Their Contribution to Premature DeathContribution to Premature Death

• Purchasers are paying into a disease system rather than a wellness system

• 4% of health care dollar is spent on prevention and public health

Health Care Costs Concentrated Health Care Costs Concentrated in Sick Fewin Sick Few

Source: A.C. Monheit, “Persistence in Health Expenditures in the Short Run: Prevalence and Consequences,” Medical Care 41, supplement 7 (2003): III53–III64.

Distribution of Health Expenditures for the U.S. Population, By Magnitude of Expenditure, 1997

1%5%

10%

55%

69%

27%

50%

97%

$27,914

$7,995

$4,115

$351

Expenditure Threshold (1997

Dollars)

www.cmwf.org

"By computerizing health "By computerizing health records, we can avoid records, we can avoid dangerous medical mistakes, dangerous medical mistakes, reduce costs, and improve reduce costs, and improve care."care."

President George W. BushState of the Union Address

January 20, 2004

US Motivation for Healthcare US Motivation for Healthcare Information TechnologyInformation Technology

Medical error, patient safety, and quality issues98,000 deaths related to medical error40% of outpatient prescriptions unnecessary Patients receive only 54.9% of recommended care

Fractured healthcare delivery systemMedicare beneficiaries see 1.3 – 13.8 unique providers annually, on average 6.4 different providers/yrPatient’s multiple records do not interoperate

An ‘unwired’ system90% of the 30B healthcare transactions in the US every year are conducted via mail, fax, or phone 

VAVA’’s Success with Healthcare s Success with Healthcare Information TechnologyInformation Technology

Data Source: Thomson TG, Brailer DJ. The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care. Washington, DC: US Department of Health and Human Services; 2004.

The evidence for and against HITThe evidence for and against HIT

55‐83% decrease in hospital non‐intercepted serious ADEs using CPOE73% of outpatient drug interaction alerts led to change in prescriptions22‐78% increased adherence to preventive health remindersFewer medical errors through computerized physician order entry and clinical decision support systemsSavings of approximately $5000 using CPOE in hospitalReduced length of stay in critical care, and overall LOS with CPOE15% overall reduced hospital fatality with HITCDS in hospitals resulted in 16% fewer complications, and $538 less expense

Bates, JAMA 1998Gandhi, JGIM 2001

Kaushal R, et al. Arch Intern Med. 2003 Amarasingham R Arch Int Med 2009

CPOE: Unintended ConsequencesCPOE: Unintended Consequences

5 mature CPOE sites surveyed, 2004‐5Frequency (%)

work for clinicians  19.8unfavorable workflow issues  17.6never ending system demands  14.8problems related to paper persistence  10.8untoward changes in communication patterns  10.1and practices 

negative emotions  7.7generation of new kinds of errors  7.1unexpected changes in the power structure 6.8overdependence on the technology  5.2

Campbell EM, Sittig DS et al., JAMIA 2006

How Does HIT Save Money? How Does HIT Save Money? 

EHR EffectsCompleteness, correctness, decision support, formulary, brand to generic, duplicate/redundant meds and tests, charge displayWorkflow support, messaging (pt/provider), referral, A/R, team

CPOE EffectsReduction in hospitalization/LOS due to ADEs, clinical decision support

HIEI EffectsReduction in unnecessary and redundant tests and proceduresLabor cost savings

Telehealth EffectsReduction in patient transport, utilization of hospitals, and physician office visits

PHR EffectsAdministrative time savingsReduction in hospitalizations and physician visit utilizationImproved medication safetyReduction in redundant laboratory tests

www.citl.org

CITL HIT Value AssessmentsCITL HIT Value Assessments

Net US could save $150B with HIT adoption, or approximately 7.5% or US Healthcare Expenditure 

The Value of Ambulatory Computerized Order Entry (ACPOE)• $44B US nationally; $29K per provider, per year

The Value of HealthCare Information Exchange and Interoperability (HIEI)• $78B/yr

The Value of IT‐enabled Chronic Diabetes Management (ITDM)• $8.3B Disease Registries; Advanced EHR $17B

The Value of Physician‐Physician Tele‐healthcare• >$20B*

The Value of Personal Health Records– Approx. $20B

www.citl.org

DesRoches CM et al. N Engl J Med 2008;359:50-60

Rates of Positive Survey Responses Rates of Positive Survey Responses on the Effect of Adoption of EMRs, on the Effect of Adoption of EMRs, 

200820084% of physicians use fully functional electronic health records13% use some form of basic electronic records

CAD/DM Smart FormCAD/DM Smart Form

Smart View: Data DisplaySmart View: Data Display

Smart Assessment, Orders, and Plan

Smart Assessment, Orders, and Plan

Assessment and recommendations generated from rules engine

Assessment and recommendations generated from rules engine

Smart DocumentationSmart Documentation

• Lipids• Anti‐platelet therapy• Blood pressure• Glucose control• Microalbuminuria• Immunizations• Smoking • Weight• Eye and foot examinations

• Lipids• Anti‐platelet therapy• Blood pressure• Glucose control• Microalbuminuria• Immunizations• Smoking • Weight• Eye and foot examinations

CAD/DM Smart FormCAD/DM Smart Form

Medication OrdersMedication Orders

Lab OrdersLab Orders

ReferralsReferrals

Handouts/EducationHandouts/Education

CAD Quality DashboardCAD Quality Dashboard

Targets are 90th percentile for HEDIS or for Partners providersTargets are 90th percentile for HEDIS or for Partners providers

Zero defect care: • Aspirin• Beta‐blockers• Blood pressure• Lipids

Zero defect care: • Aspirin• Beta‐blockers• Blood pressure• Lipids

Red, yellow, and green indicators show adherence with targetsRed, yellow, and green indicators show adherence with targets

Discrepancy

Details

Patient Journal CausesPatient Journal CausesProvider Activation Provider Activation 

Grant RW et al. Practice-linked Online Personal Health Records for Type 2 Diabetes: A Randomized Controlled Trial. Arch Intern Med. 2008 Sep 8;168(16):1776-82. .

More medication changes in visits after diabetes journal submission:

The Peril?The Peril?

HIT WorkforceHIT TechnologiesApplicationsPlatforms

InterfacesKnowledge ManagementFailure of ARRA‐HITECH Stimulus to achieve HIT sustainabilityOthers?

“I conclude that though the individual physician is not perfectible, the system of care is, and that the computer will play a major part in the perfection of future care systems.”

Clem McDonald, MD NEJM 1976

Thank you!Blackford Middleton, [email protected]/cirdwww.citl.org

Where are we?Where are we?