Transcript The HITECH Initiative: Implementation in Boston and Local

Lessons from Meaningful Use:
Implications for the UK
London, 2013
David W. Bates, MD, MSc
CQO, and Chief, General Internal Medicine, Brigham and
Women’s Hospital
Medical Director of Clinical and Quality Analysis, Partners
Healthcare
Overview
• Where U.S. is starting
– Quality/Safety/Efficiency
– Health care reform
• HIT policy in the U.S.
– How important is this to organizations
• Evidence about HIT in the U.S. and electronic
prescribing
• Conclusions
Question
• What are the chances of getting injured by the
care you receive during hospitalization?
– 1 in 100
– 5 in 100
– 10 in 100
– 25 in 100
Harm is Ubiquitous: Rates of Adverse
Events Around the World
• 3.7% of hospitalizations in New York
– 58% preventable
• 2.8% Colorado-Utah
• 16.6% in Quality in Australian Health Care study
• Near 10% in Canada, New Zealand, Denmark
among others
– Approximately 10% in UK
• Rate in most developed countries appears to be
at least 10%
– Recent study by Classen found adverse events in a
third of admissions in U.S. using trigger tool
Adverse Events are Expensive:
Costs of Safety Issues in the U.S.
Event Type
•Preventable
JJJ ADEs
Annual Costs (Billions)
$3.8
All hospital-acquired infections
$5.8
Thromboembolic disease
$3.1
Other adverse events
$3.3
Total Preventable Adverse Events
$16
Jha et al, Health Affairs 2009
Health Care Reform
• Affordable Care Act
– Provides access to all patients
– Incentives to improve costs, quality, efficiency
• “Accountable care organizations”
• Bundling
• Many have questioned whether pressure on
costs will be sufficient
• Still politically contentious
• No strong movement to single payer
Electronic Medical Record Adoption by Country
Zimlichman, CMAJ 2011
Adoption in Hospitals: Jha et al. NEJM 2009
• By panel
definition:
– 1.5% have
comprehensive
system
– 10.9% have basic
system
– Installed across
major clinical
units
Another View of the Hospital Data
Percent of hospitals fully implementing:
• Laboratory and radiology reports: 77%-78%
• Drug allergy/interaction alerts: 45%-46%
• Medication lists: 45%
President Obama’s First Weekly Address
Saturday, January 24th, 2009
“To lower health care costs,
cut medical errors, and
improve care, we’ll
computerize the nation’s
health records in five years,
saving billions of dollars in
health care costs and
countless lives.”
HITECH will Advance the “Tipping
Point”
Technology Adoption
2004
National
Coordination
Grant
Programs
Enhanced
Trust
Payment
Incentives
2012
TIME
Meaningful Use is Being Defined and Will
Follow an “Ascension Path”
2009
2011
2013
2015
HIT-Enabled Health Reform
HITECH Policies
2011 Meaningful
Use Criteria
(Capture/share
data)
*Report of sub-committee of
Health IT Policy Committee
2013 Meaningful Use
Criteria
(Advanced care
processes with
decision support)
2015 Meaningful
Use Criteria
(Improved
Outcomes)
14
Three Key Components for HigherPerforming Healthcare System
• Better information on what works and what
doesn’t
• Ability to rapidly apply knowledge to practice
• Changes in the financing and organization of
care that reward physicians for considering
cost and quality in decision-making
Blumenthal, ONCHIT coordinator
Health IT Policy Committee
• Required to make recommendations to the National
Coordinator on:
• A policy framework for the development and adoption
of a nationwide health IT infrastructure
• The areas in which standards, implementation
specifications, and certification criteria are needed
• Working groups
– Meaningful Use
– Certification/Adoption
– Interoperability and information exchange
Observations from HIT Policy
 Everything has been conducted in open
 Stakeholders on group from many perspectives
 Regulations have gotten much better after public
commentary, response
 Sometimes has been significant time pressure
 Can’t keep everyone happy, but highly successful
overall
◦ Lately vendors and providers are asking to slow down,
consumer groups and insurers to keep going/move
faster
◦ Has been consensus about direction
Health System IT Priorities
Percent
Meaningful Use
Focus on Clinical Systems
Optimizing Current Systems
Leveraging Information
Focus on Ambulatory Systems
2%
Interoperability
0%
Integration of IT Medical Devices
0
10
20
30
40
50
2011 HIMMS Leadership Survey
60
Health IT Standards Committee
• Required to make recommendations to the National
Coordinator on standards, implementation
specifications, and certification criteria for adoption
by the Secretary.
• Three workgroups:
– Clinical quality
– Clinical operations
– Privacy and security
Payment Incentives and Meaningful
Use
•
•
•
A hospital or eligible provider must be a meaningful
user to receive payment incentives
Changes the focus from technology potential to
clinician behavior
By law, a “meaningful user” must:
1. Use a certified EHR
2. Exchange health information
3. Report quality measures
Issues in Setting Up Criteria
• Primary care vs. specialty
– Superspecialty
• Big practices vs. small
• Big hospitals vs. small
• What do you include/exclude?
– Emergency departments
– Psychiatric hospital
Stage 2 Hospital Core Objectives
Eligible hospitals must meet all 16 core objectives:
Core Objective
Measure
1. CPOE
Use CPOE for more than 60% of medication, 30% of
laboratory, and 30% of radiology
2. Demographics
Record demographics for more than 80%
3. Vital Signs
Record vital signs for more than 80%
4. Smoking Status
Record smoking status for more than 80%
5. Interventions
Implement 5 clinical decision support interventions +
drug/drug and drug/allergy
6. Labs
Incorporate lab results for more than 55%
7. Patient List
Generate patient list by specific condition
8. eMAR
eMAR is implemented and used for more than 10% of
medication orders
22
Stage 2 Hospital Core Objectives
Eligible hospitals must meet all 16 core objectives:
Core Objective
Measure
9. Patient Access
Provide online access to health information for more than
50% with more than 5% actually accessing
10. Education Resources
Use EHR to identify and provide education resources
more than 10%
11. Rx Reconciliation
Medication reconciliation at more than 50% of transitions
of care
12. Summary of Care
Provide summary of care document for more than 50% of
transitions of care and referrals with 10% sent
electronically and at least one sent to a recipient with a
different EHR vendor or successfully testing with CMS
test EHR
13. Immunizations
Successful ongoing transmission of immunization data
14. Labs
Successful ongoing submission of reportable laboratory
results
15. Syndromic Surveillance
Successful ongoing submission of electronic syndromic
surveillance data
16. Security Analysis
Conduct or review security analysis and incorporate in
risk management process
23
Stage 2 Hospital Menu Objectives
Eligible Hospitals must select 3 out of the 6:
Menu Objective
Measure
1. Progress Notes
Enter an electronic progress note for more than 30% of
unique patients
2. E-Rx
More than 10% electronic prescribing (eRx) of discharge
medication orders
3. Imaging Results
More than 10% of imaging results are accessible through
Certified EHR Technology
4. Family History
Record family health history for more than 20%
5. Advanced Directives
Record advanced directives for more than 50% of patients
65 years or older
6. Labs
Provide structured electronic lab results to EPs for more
than 20%
24
HITPC Stage 3 MU Timeline
•
•
•
•
•
•
•
•
•
Aug, 2012 – present draft preliminary stage 3 recs
Oct, 2012 – present pre-RFC preliminary stage 3 recs
Nov, 2012 – RFC distributed
Dec 21, 2012 – RFC deadline
Jan, 2013 – ONC synthesizes RFC comments for WGs review
Feb, 2013 – WGs reconcile RFC comments
Mar, 2013 – present revised draft stage 3 recs
Apr, 2013 – approve final stage 3 recs
May, 2013 – transmit final stage 3 recommendations to HHS
HITPC: MU Workgroup Stage 3
Recommendations
25
Guiding Principles
MU Objectives
• Supports new model of care (e.g., team-based, outcomesoriented, population management)
• Addresses national health priorities (e.g., Million Hearts)
• Broad applicability (since MU is a floor)
−Provider specialties (e.g., primary care, specialty care)
−Patient health needs
−Areas of the country
• Promotes advancement -- Not "topped out" or not already
driven by market forces
• Achievable -- mature standards widely adopted or could be
widely adopted by 2016
HITPC: MU Workgroup Stage 3
Recommendations
26
April 2013
April – By the Numbers
Registered Eligible Hospitals
12.77%
5,011 Total Hospitals
87.23%
Registered Hospitals
27
April-2013
April – By the Numbers
Paid Eligible Hospitals
22.57%
77.43%
5,011 Total Hospitals
Hospitals Paid
28
Hospital 1st vs. 2nd year
Core Objective Performance
2011
2012
833
746
CPOE for Medication Orders
86.9%
85.2%
Maintain Problem List
95.7%
95.2%
Active Medication List
97.6%
97.7%
Medication Allergy List
97.9%
97.8%
Record Demographics
97.0%
96.9%
Record Vital Signs
94.0%
92.5%
Record Smoking Status
94.9%
93.6%
Electronic Copy of Health Information
95.0%
96.9%
Electronic Copy of Discharge Instructions
95.0%
94.9%
Number of Attestations
29
Hospital 1st vs. 2nd year
Menu Objective Performance
2011
2012
Advance Directives
96.1%
95.8%
Clinical Lab Test Results
96.1%
95.6%
Patient-Specific Education Resources
74.1%
72.3%
Medication Reconciliation
87.5%
84.7%
Transition of Care Summary
80.2%
81.8%
Immunization Registries Data Submission
51.9%
58.2%
Reportable Lab Results to Public Health Agencies
17.6%
13.8%
Syndromic Surveillance Data Submission
18.7%
16.8%
30
• Much
of innovation has come from a few sites
• Vendor systems now being implemented
• Need support for innovation in future
• Essential to look at what is implemented, not just potential
• Links with external incentives will be pivotal
Looking Forward
• How fast to go?
• What are most effective things to ask for?
– What should be included in terms of clinical
decision support?
•
•
•
•
How should people qualify?
What about core vs. menu?
How do you prevent gaming?
How do you know if the criteria are actually
improving care?
Predictions
It’s tough to make predictions, especially when
they are about the future
Yogi Berra
We always overestimate the change that will
occur in the next two years, and
underestimate what will occur in the next 10
Bill Gates
Where Will the U.S. Be in 2016?
• National adoption rate will be over 90% in
hospitals
– Essentially universal in big hospitals
• National adoption rate will be over 90% in
practices
– Universal in large practices
– Most of holdouts will be small practices
– There will have been a lot of consolidation
• Certain areas like nursing homes will still be
behind
• Data exchange will still be a major challenge
Who Will Be Struggling?
• Small hospitals, and disproportionate share
hospitals
– Especially if they don’t have relationships with larger
entities
• Small practices
– Evidence shows that many practices actually become
less efficient after conversion, especially if they don’t
adapt their workflow
• Regional health information organizations
– Think they need public support and right now no plan
to give it to them
Remaining Gaps:
EHRs and Care Coordination
• Continuity within team
• Documentation of information
• Referrals issues
• Sharing care plans with other providers
• Assisting with transitions
Today’s EHRs do most of these things poorly
Safety Results of CPOE Decision Support
Among Hospitals
• 62 hospitals voluntarily participated
• Simulation detection only 53% of orders which
would have been fatal
• Detected only 10-82% of orders which would
have caused serious ADEs
• Almost no relationship with vendor
Metzger et al, Health Affairs 2010
Jane Metzger, Emily Welebob, David W. Bates, Stuart Lipsitz, and David C. Classen,
Mixed Results In The Safety Performance Of Computerized Physician Order Entry,
Health Affairs, Vol 29, Issue 4, 655-663
Copyright ©2010 by Project HOPE, all rights reserved.
Conclusions (I)
• US healthcare has huge room for improvement in
efficiency, safety, quality
• Overall HIT policy direction taken so far has been
terrific
– Early returns very positive
• Information technology will become ubiquitous in
healthcare—near a tipping point
– Electronic prescribing is a big early win
– Yet adoption is just the beginning
• EHRs and HIT more broadly can provide major
benefits with respect to safety, quality, efficiency
• Safety is perhaps most straightforward
– Checklists, reliable processes
Conclusions (II)
• Quality improvement is achievable with HIT in many
domains
• Efficiency benefits least well-demonstrated and
linkages with incentive key
• Lots to be learned about how to get benefits
– HIT is simply a tool—part of a program
– But nearly every other effort to improve
safety/quality/efficiency will rely on HIT
• Getting right decision support in place is central
Implications for UK
• Incentive approach has worked well
• Adoption rate has climbed very rapidly
– Still uncertain though about to what extent will
improve quality, safety
– Need some post-implementation checking
• Secondary care applications are ready now for
implementation
– Electronic prescribing, medication administration
records ready in particular
– Integrated ePrescribing applications are universal
“Insanity is doing the same
things the same way and
expecting different results”
Albert Einstein