Transcript ARRA Health Informatics Initiative

ARRA Health Informatics Initiative
and Health Reform
How will we know when we get there?
Tim Carey MD MPH
Jan 2010
Clinical Informatics under ARRA
Many programs coordinated at state level
• $17B to providers and hospitals to compensate them for EMR
installation
– Program starts in 2010 through 2013; federal coordination
• $2B for ‘planning and implementation grants’ to states- to be
awarded in Jan 2010
– 70 Extension Centers ($~4-12M)
– 50 Health Information Exchange (NC share ~$13M)
• State loan programs
• Although not explicitly tied to health reform bill, many
linkages and similar time-line
HIT Policy Committee’s
“Ultimate Goal”
• “The ultimate vision is one in which all patients
are fully engaged in their healthcare, providers
have real-time access to all medical information
and tools to help ensure the quality and safety of
the care provided while also affording improved
access and elimination of health care disparities.”
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-HIT Policy Committee, “Meaningful Use: A Definition,”
Recommendations from the Meaningful Use Workgroup to the Health IT
Policy Committee, June 16, 2009
Goals of health reform
Too soon to tell whether we will have health vs health insurance
reform
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Enhanced access to care and insurance
Improved equity in insurance products
Improved quality of care
Improved efficiency of care (bending the cost
curve)
From David Blumenthal
• The incentives are not just about the
placement of machines, they are “a down
payment on health system improvement”
• EHRs are part of a larger health care reform
agenda that has as its goals outcome and
performance improvement
• Between the enactment of the legislation
and the publication of final rules there will
be a “period of uncertainty”
• July 9, 2009; discussion with the AAMC’s Advisory Panel on Health Care
The Problem
• EMR has been technically available for decades
• Uptake has been modest: ~20% of providers
• Rising health care costs, components include:
– test duplication,
– use of expensive options when less expensive may
work just as well
– Limited incorporation of evidence-based practices
into clinical work flow
• Patient safety
• Chronic disease management
EMR as (part of) the solution
• Reliable, legible record storage
• E-prescribing (most helpful if record shared)
• Disease management (most helpful if conducted
at population level)
• Prompts and reminders (most helpful if evidencebased, targeted, up-to-date and consistent)
• Interoperability (currently difficult due to vendor
issues, standards only now being developed for
sharing some elements of clinical care)
• Implementation has significant productivity costs,
changes both hospital and office functioning.
EMR technology
Standards hopefully final 4/2010
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Patient demographics
Medical history
Clinical notes
Problem list
Medication list
Lab
Clinical decision support/CPOE
Ability to query for quality assessment and improvement
• Registries, reminders, prompts (pop-up alerts?)
• Exchange with other EMR systems
• Printout AND electronic format of notes and tests for
patients
• ‘Results’ for radiology studies- text reports or images?
AAMC 2009
Quality of care improvement
• Low hanging fruit
– No lost charts
– No illegible prescriptions
– Data can be accessed by all providers in a hospital/practice
• More complicated but we have the technology
– Moving data among providers
– Chronic disease registries
– Prompts and reminders (beware prompt fatigue)
• More complicated and may be political
– Pay for performance
– Multiple quality measures
Improved efficiency of care
• Efficiency declines with EMR installation
– Improves with time ~6 month learning curve
• Some savings through avoidance of duplicate lab
testing (savings to whom?)
• Most expensive duplicate testing is advanced
imaging (savings to whom?)
• Major savings in reduced hospitalizations
– EHR will have little role by itself
– Payment reform, QI implementation, disease
management
Hospital Incentive Payment and
Penalty Timeline
Payment Year
Year of
Adoption
2011
2012
2013
2014
2015
No
adoption by
2015
FY2011
FY2012
FY2013
FY2014
FY2015
FY2016
100%
75%
50%
25%
100%
75%
50%
25%
100%
75%
50%
25%
75%
50%
25%
50%
25%
FY2017
¾* of
¾* of
¾* of
percentage
percentage
percentage
increase in
increase in
increase in
market-basket market-basket market-basket
reduced by 33 reduced by 66
reduced by
1/3%
2/3%
100%
Will providers be able to rise to the challenge?
• Leaders and early adopters already using EHR
– May have to pay to upgrade
– Late adopters qualitatively different
• Implementation rules from the ONC are complex
– Critical role for ‘Extension Centers’
• Rural providers and small practices will present
special challenges
– Financially stressed, will need on-site assistance, may
utilize limited EMR, ASP technology
• Implementation may work best if tied to payment
reform and ‘medical home’ implementation