Health IT, Quality, and Health Care Transformation in California

Transcription

1 Health IT, Quality, and Health Care Transformation in California Jonah Frohlich, MPH July 9, 2010 Redwood MedNet 4th Annual HIE Conference Connecting California to Improve Patient Care

2 2 U.S. health care is broken. Although other industries have transformed themselves using tools such as performance measurement, and transparent reporting of quality, the application of these tools to health care is controversial, evoking fears of cookbook medicine The application of improvement tools is not only essential to modernizing care delivery but also the key to preserving the values to which our current system aspires. - Stephen Swensen et al., NEJM, February

3 3 U.S. health care is broken. Although other industries have transformed themselves using tools such as performance measurement, and transparent reporting of quality, the application of these tools to health care is controversial, evoking fears of cookbook medicine The application of improvement tools is not only essential to modernizing care delivery but also the key to preserving the values to which our current system aspires. - Stephen Swensen et al., NEJM, February

4 4 Variation in Recommended Care Percentage of Recommended Care Received Breast Cancer Prenatal Care 73% 76% Low Back Pain Coronary Artery Disease Hypertension Congestive Heart Failure 69% 68% 65% 64% Depression Orthopedic Conditions Colorectal Cancer Asthma Benign Prostatic Hyperplasia 58% 57% 54% 54% 53% Hyperlipidemia Diabetes Mellitus Headache 45% 45% 49% Urinary Tract Infection 41% Ulcers 33% Sources: The World Factbook (ISSN ; also known as the CIA World Factbook). Wal-Mart 2006 Annual Report. Hip Fracture 23% Alcohol Dependence 4 11%

5 5 Variation in Recommended Care Percentage of Recommended Care Received Breast Cancer Prenatal Care 73% 76% Low Back Pain Coronary Artery Disease Hypertension Congestive Heart Failure 69% 68% 65% 64% Depression Orthopedic Conditions Colorectal Cancer Asthma Benign Prostatic Hyperplasia 58% 57% 54% 54% 53% Hyperlipidemia Diabetes Mellitus Headache 45% 45% 49% Urinary Tract Infection 41% Ulcers 33% Sources: The World Factbook (ISSN ; also known as the CIA World Factbook). Wal-Mart 2006 Annual Report. Hip Fracture 23% Alcohol Dependence 5 11%

6 Variation of Procedures in CA per 100,000 Population, Data: OSHPD

7 Variation of Procedures in CA per 100,000 Population, Data: OSHPD

8 Variation of Procedures in CA per 100,000 Population, Data: OSHPD

9 9 What Health IT Can (and Can t) Do Broad adoption of EMR systems and connectivity are necessary but not sufficient steps toward real health care transformation adoption of EMR systems and valid comparative performance reporting would enable the development of value-based competition and quality improvement to drive transformation. - Richard Hillestad et al., Health Affairs, October

10 10 What Health IT Can (and Can t) Do Broad adoption of EMR systems and connectivity are necessary but not sufficient steps toward real health care transformation adoption of EMR systems and valid comparative performance reporting would enable the development of value-based competition and quality improvement to drive transformation. - Richard Hillestad et al., Health Affairs, October

11 11 HITECH Incentives - Driving EHR Adoption Entitlement Incentives in California (Up to $4 billion may be expected for California s eligible hospitals and providers) Program Medicare Payment Incentives Distribution Agency* CMS Use of Funds Incentive Payments through Carriers Acute Care and Children s Hospitals Medi-Cal EHR Incentive Program DHCS Incentive Payments through Medi-Cal Physicians and Dentists Meaningful Use Nurse Practitioners and Midwives FQHC

12 12 Meaningful Use Stages Stage 1 - eprescribing - Lab results into EHRs - Send clinical summary to providers and patient - Public health reporting - Quality reporting (2012) Stage 2 Proposed - Patient PHR access - eprescribing refills - Electronic summary record - Receive health alerts - Immunization information Stage 3 Proposed - Access comprehensive patient data - Automated real-time surveillance

13 13 Supporting Programs Program Health Information Exchange Recipient CHHS Funds $38.8 million States Cal econnect Health IT Extension Program LA Care, CalHIPSO $46.6 million Workforce Training Grants Los Rios $5.4 million Nonprofits Priority Primacy Care Providers California Telehealth Network UCOP $22.1 million Higher Education Medical/ Graduate Schools Beacon Communities UCSD $15.3 million

14 California s ehealth Landscape

15 15... Some Coordination Required $1.4 billion in Medi-Cal EHR incentives + ~ $25-$30M Overall EHR Medicaid admin, plan, promotion, payment, consumer education, quality reporting, oversight California ehealth Coordinating Committee Up to Rural $4 billion Regional Extension Centers available Workforce $38.8M Support and infrastructure to make information exchange between sectors faster, more efficient and more secure $46M+ On the ground implementation support to physicians, hospitals and community health centers

16 16 Programs altering the landscape HITECH: First checks for incentive programs will issued in 2011 Health Reform: 7.3 million CA residents who do not currently have insurance could begin to get affordable coverage HIPAA 5010 transactions required by January 1, 2011 Prerequisite for ICD-10; required by October 2013 for payment

17 International Comparison of Health Spending Average spending on health per capita ($U.S. PPP) 17 $7,290 $3,895 Source: OECD Health Data 2007.

18 Source: Commonwealth Fund 2010, OECD Health Data

19 Overall Health System Performance 19 Source: Commonwealth Fund 2010, OECD Health Data 2007

20 Long, Healthy, Productive Lives 20 Source: Commonwealth Fund 2010, OECD Health Data 2007

21 EHR Adoption Primary Care Providers 21 Source: Commonwealth Fund 2010, OECD Health Data 2007

22 22 Technologies should support people Adoption of new technology must support your people, process and values... New technology is introduced only after it is proven out through direct experimentation with the involvement of a broad cross-section of people Often it is best to work out a process manually before adding technology to support the process. - Jeffrey Liker, The Toyota Way, 2004

23 23 EHR Vendor Landscape ABELSoft n Allscripts Benchmark Systems CareData Solutions Cerner Community Service Conceptual MindWorks digichart Doctations ecast eclinicalworks e-mds Eclipsys EHS Epic GE Healthcare glostream gmed Greenway Medical Technologies Healthland HealthPort HIT Services Group imedica Indian Health Service Ingenix Integritas Integrity On Site Intivia LSS Data Systems McKesson MedAppz MedcomSoft MediNotes NextGen Nightingale Noteworthy Medical Systems Ochsner Clinic Foundation PracticeOne Purkinje Sage SOAPware SRSsoft SSIMED STI Computer Services TransMed Network Wellogic

24 24 EHR Vendor Landscape ABELSoft n Allscripts Benchmark Systems CareData Solutions Cerner Community Service Conceptual MindWorks digichart Doctations ecast eclinicalworks e-mds Eclipsys EHS Epic GE Healthcare glostream gmed Greenway Medical Technologies Healthland HealthPort HIT Services Group imedica Indian Health Service Ingenix Integritas Integrity On Site Intivia LSS Data Systems McKesson MedAppz MedcomSoft MediNotes NextGen Nightingale Noteworthy Medical Systems Ochsner Clinic Foundation PracticeOne Purkinje Sage SOAPware SRSsoft SSIMED STI Computer Services TransMed Network Wellogic

25 25 It s like going to the supermarket and standing in front of cereal boxes, having not eaten cereal before. - Anonymous physician, California 25

26 26 The fundamental problem with the quality of American medicine is that we ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is ensuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It s viewed as the art of medicine. That s a mistake, a huge mistake. And from a taxpayer s perspective it s outrageous Peter Pronovost, M.D., December 2007

27 27 Data driven approaches to health care delivery improvement Four Case Studies: One integrated delivery system Two clinics One physician practice

28 28 Kaiser HealthConnect Hawaii Health Connect Implementation (2007): Age/sex-adjusted total office visit rate decreased 26.2 percent Scheduled telephone visits increased more than eightfold Secure messaging, which began in late 2005, increased nearly six-fold by 2007 The most visited feature on the Web site was viewing lab test results. Consistently in the site's top six visited features were prescription refill requests and online appointment transactions By 2007, 62 percent of members registered on kp.org accessed the site two or more times in a six-month period Nationally (2009): 21.5 million test results viewed online 8.5 million s to physicians by members

29 29 Kaiser HealthConnect and Clinical Quality Study of 35,423 patients with diabetes, hypertension, or both The use of secure patient-physician messaging was associated with statistically significant improvements in HEDIS scores: 2 to 6.5 percentage point improvements in glycemic, cholesterol and blood pressure screening and control More than 630,000 messages were logged throughout the study - 85 percent were initiated by patients Health Affairs, 29, no. 7 (2010):

30 Columbia Basin Health Association 30

31 31 Demographics 24,991 Patients 75% Hispanic or Latino 57% of Patients Best Served in a Language other than English 47% Migrant/Seasonal Agricultural Workers

32 Patient Income 32

33 Payer Mix 33

34 Outcomes Measurement 34

35 Outcomes Measurement 35 EMR Go Live

36 Outcomes Measurement th Percentile EMR Go Live

37 Outcome Measures, Continued 37

38 38 Outcome Measures, Continued EMR Go Live

39 39 If we can measure it, we can manage it. - Greg Brandenberg, CEO, Columbia Basin Health Association 39

40 40 Family HealthCare Network Sites: 11 Clinical + 2 Admin Annual patients: 101,967* Annual encounters: 492,683* Clinical Support Staff: 450 Clinicians: 88 Dentists: 14 Ancillary Support Services: 3 Nutritionist, 1 Registered Dietician, 5 Behavioral Health Providers, 1 Chiropractor, 8 Radiology Technicians *2009 UDS Report

41 41 Lean Team Goal: Preserving Value with Less Work Front Line Staff selected Experienced, Vocal, with initiative, global thinking Exposed to Lean Concepts with early project in April Brought in their expertise Helped evaluate current workflows Key input for future EHR workflows Became part of the Build and Design Team for IC-Chart

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43 43 Go-Live Numbers for March 3/3 3/16 Visit For the Day: 1,891 2,017 Labs Ordered: Prescriptions: Referrals to Specialists Ordered: In-house Radiology Ordered: Telemedicine Services Ordered: 5 9 Super Users at All Sites providing Support Communication Sessions 2 times per day during Go-Live week Compare 03/3/09, Visits for the Day: 1,936

44 44 Pediatric Partners Medical Group - Temecula 44

45 45 Data-Driven Processes Revenue cycle management services in 2001 Significantly reduced days in A/R Payor dashboard allows deep level of analysis EHR implemented in 2006 Productivity reports: By provider By staff No more faxes Electronic lab results and e-prescribing

46 Pediatric Partners Growth 46 Staff M.D.s Employees Revenue ,800,000 1,800, ,000, ,000,000 Revenue 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000-46

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