Health IT

What went wrong, how do we avoid repeating mistakes ?

Jack Glode, MD, FACC

Major Barriers to Adoption

► Cost ► Lack of interoperability ► Privacy/Security concerns ► Product shortfalls ► Exaggerated benefits not realized ► Proprietary interests of vendors and the healthcare delivery system

Cost

► Frolich et al.,Retrospective: Lessons Learned from the Santa Barbara Project and Their Implications for Health Information Exchange, Health Affairs August 2007 ► The Santa Barbara County Care Data Exchange: What Happened, Miller, Health Affairs, August 2007. “Lack of a compelling value proposition” for potential investors was the main cause of the Santa Barbara Project’s demise.”

Cost

► Medical Groups’ Adoption Of Electronic Health Records And Information Systems, Gans, Health Affairs, 2005. “…..would translate into about a 10 % reduction in take-home pay each year for most primary care practices” ( assuming all IT costs paid by the practice)

Cost

► It Ain’t Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Heal Care Costs, Sidorov, Health Affairs,2006. “ A considerable body of evidence suggests that widespread adoption of EHR increases health care costs” “ the EHR has yet to be quantified or consistently used to reduce malpractice premiums or health care costs”

Cost

► QI gains may justify incurring the short term financial losses- and therefore justify a CHC’s investment in an EHR- but only if the CHC rapidly and extensively used the EHR for QI., Robert Miller, PhD,UCSF

Cost

► “Whether RHIOs represent small businesses that need viable business models, which requires the ability to generate profits as well as value for participants, or public goods that require public financing is an important unresolved issue”. The State of Regional Health Information Organizations: Current Activities and Financing, Milstein, Health Affairs, 2008

Interoperability

► “ ….opposition to portable health information is, by definition, support for proprietary health information. Think what it would be like to be in an emergency room where a doctor can’t make lifesaving decisions because your health information is at a competing hospital….we have one chance to get it right, and that means making portable health information our priority-David Brailer

Interoperability

► EHR’s and community-based health information networks have been slow to develop because of a lack of interoperability standards to support electronic data exchange. Steven Redhead, CRS Report for Congress 2005

Interoperability

► The hospitals and some offices are preparing to install potentially different EHR systems, and all want us to be expert users in their systems, Steven Benton, M.D., FACC, Cardiology, 2007 ► Wyoming has 160 vendors selling these products, with no intention/means of becoming interoperable with competitors

Interoperability

► A key problem today in the realization of EHRs for the patient’s continuity of care( RUPRI report), is the inability to share patient records across

disparate

enterprises., Dr. William Jeffrey, Committee on Science, U.S. House of Representatives, 2006

Interoperability

► ► ► ► ►

Health Information Exchange: Why Centralized

Data Banks Won’t Work, Rex Gantenbein, Ph.D.

Considerable resistance to centralized database in Wyoming, (John Snow, Final Report to the WHCC) Provides a target for hackers Physicians in England are rebelling against a national data warehouse, because of privacy and security concerns Federated model addresses these concerns (in depth discussion at Dec. 1 Whio meeting)

Interoperability

► UHIN has issued an RFP for an interoperability solution for Utah ► Community, patient centric, with emphasis on privacy/security and access to patient information at the point of care, ► Must be able to both push information to known entities and to query the system to collect information about a single patient from multiple data sources (with appropriate authorization)

Interoperability

► Competition among hospitals for physicians is a key factor driving adoption of proprietary systems. In contrast, provider and health plan competition and adversarial relationships between providers and plans are viewed as major barriers to communitywide clinical data sharing. Hospital-Physician Portals: the Role of Competition in Driving Clinical Data Exchange, Grossman, Health Affairs,2006

Perceived Benefits of Medical IT

► Eric Poon, MD MPH, Brigham and Women’s Hospital, Boston, MA, Lecture at Patient Safety Conference, WHCC, Cheyenne, Wy., April 2006 ► Myth #1-If providers could just find the capital to buy the hardware and software, we’d see clinical IT everywhere.

Benefits

► Debunking Myth #1 ► Most applications don’t work terribly well off-the-shelf (yet) ► Need to spend time to customize ► Training and leadership can shorten

recovery time

Benefits

► Poon Myth #2- Let’s install the application with the best features and everyone will just love the EMR ► build it and they will come ► The docs are smart. They’ll figure out how to use this new toy

Benefits

Debunking Myth #2 hard Changing people’s workflow is very Leadership, workflow redesign No-one can drink from a fire-hydrant Small can be beautiful

Benefits

► Myth # 3 - Information technology will largely solve the problem of medical errors ► ► ► ► ► Debunking #3 It’s all about better team work, communication and rational standardization IT can facilitate these processes Installing IT gives you an opportunity to address previous broken processes Every time you put a new process in place, you create opportunities for errors

Benefits

► Poon- Let the clinical process drive IT, not vice versa ► Never skimp on training and support ( role for Whio?) ► Leadership and vision ► Relentless focus on workflow, (what will work best at the point of care ? What will be counterproductive)

Benefits

► RUPRI WHCC Report- Abandon top down approach and do assessment at local level to determine IT needs, place in clinical context ► Docs need help with vendor

assessment( role for WHio)

Benefits

► ► ► Coupled with a nearly 50% failure rate for EHR’s, it is no wonder that many physician practices find the decision so daunting to move forward technologically, Evan Steel,CEO of SRS Software, Healthcare IT News. March 2006 Siderov- Not all reports on CPOE are positive. Its introduction in one pediatric ICU led to an increase in mortality rates that was blamed on delays and increased documentation time, compounded by policies that diminished access to life-saving therapies… AS implemented, EHR’s were not associated with better quality(17 quality indicators) ambulatory care, Linder, et al., Arch Intern Med, 2007 (Brigham and Women’s and Harvard School , Stanford University)

Privacy and Security

► Federal legislation for privacy and security, Bills in House and Senate were at odds, (see comments by Brailer), Dr Peel of Patient Privacy Rights Foundation says the bill doesn’t have much of a chance of passage due to heavy lobbying from companies interested in data mining ► GAO says HHS lacks strategy for ensuring HIT privacy 2006

Summary

► ► ► Wyoming needs a RHIO to address these issues, providing enlightened leadership, research, vendor evaluation, assisting in implementing measures to improve the healthcare delivery system as recommended in the RUPRI/WHCC report We cannot rely on grants to sustain these efforts, public-private partnerships must be developed and a solid business case must be established Interoperability with privacy/security assured must be a top priority

Summary

► ► ► ► ► Can we connect 160 different applications (vendor products)? System presented on Dec. 1, may be others?

IT must be placed in proper clinical context with careful design to avoid failures of the past—we should resist exaggerated claims for the benefit of IT in and of itself Use common sense– we need patient information from all sources at the point of care as our first priority, i.e. lab and radiology reports, reliable medication lists, history of illnesses Once interoperability is established, unlimited IT applications are possible: research, patient registries, disease management, programs to improve population health, improving the continuum of care, education Special need for Telemedicine to improve the delivery system in rural Wyoming? (RUPRI/WHCC)