L. Philip Caillouet PhD FHIMSS Louisiana Center for Health Informatics

1. Lafayette Parish Medical SocietyGeneral Membership MeetingHot Topics:Meaningful Use, EHRs, HIEsand More L. Philip Caillouet PhD FHIMSS Louisiana Center for Health Informatics The University of Louisiana at LafayetteSeptember 14, 2011

3. Objectives of This Presentation • To suggest a framework for discussion of the healthcare industry as “information intensive” • To consider a role for information technology as an “essential enabler” for improvements to effectiveness and efficiency • To recognize differing perspectives of the U. S. healthcare system – “top-down and bottom-up” • To discuss how the Louisiana Center for Health Informatics at UL Lafayette might best assist local physicians in these “interesting times”

4. “Information Intensive” Healthcare has two underlying processes: a. the provision of care b. gathering information to facilitate the provision of care in the future

5. Once Upon a Time ... … things were simple ...

6. Healthcare Information: Simple Beginnings The Doctor-Patient Relationship Physicians Patients

7. The Hypothetico-Deductive Approachfrom Biomedical Informatics, Shortliffe & Cimino editors, Springer, 2006.

8. Healthcare Information: Post-World War II Wage & Price Freezes; Government Subsidies Equip. Mfrs. Hospitals Suppliers Employers, Unions, & Assns. Physicians Workers Insurers

9. Healthcare Information: The Great Society Medicare & Medicaid Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians Citizens Insurers

10. Healthcare Information: Corporate Self-Insurance The Bottom Line Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians ASO TPAs Enrollees Insurers

11. Healthcare Information: Rise of the HMO, PPO, & IPA Wellness, Not Illness Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians ASO TPAs Network & Care Mgrs. Members Insurers

12. Healthcare Information: Direct Contracting & Data Services Who Has Data Wins Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians IPAs ASO TPAs Covered Lives Network & Care Mgrs. Insurers

13. Healthcare Information: Cost Sharing Sharing = “You Pay” Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians IPAs ASO TPAs Network & Care Mgrs. Consumers Credit Bureaus Claims Assistance Financial Services Insurers

14. Healthcare Information: Supply-Side Economics Technology & Cash Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. IPAs ASO TPAs Marginal Units Network & Care Mgrs. Credit Bureaus Claims Assistance Financial Services Insurers

15. Healthcare Information: Vertically Integrated Health Systems “Hospitals” to “Systems” Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. IPAs ASO TPAs Network & Care Mgrs. Populations Credit Bureaus Claims Assistance Financial Services Insurers

16. Healthcare Information: A State of Confusion!?! Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. IPAs Us! ASO TPAs Network & Care Mgrs. Credit Bureaus Claims Assistance Financial Services Insurers

17. Will We Live Happily Ever After? Enter Healthcare Reform andHealth Insurance Reform … one more time ...

19. So … Will We Live Happily Ever After? Accountable Care Organizations? Coordinated Care Networks? National Health Information Infrastructure? Meaningful Use? ???

20. “Essential Enabler”

21. Design Imperatives:Mirror Processes & Capture History • Applications for Healthcare Processes • Physician office processes • Visits, referrals, medical records, high volume • Hospital processes • Admissions, acute care, discharge, OP lab • Healthplan processes • Enrollment, service authorization, claims adjudication, fund management • Repositories for Healthcare History • Data and Exchange: recognizing shared responsibilities across the continuum of care and payers

22. Process and History:Operate and Compete Common User Interface Medical Databases & Literature Master Patient Index operate Clinical Decision Support General Acctg. Patient Sched. Reg./ A/D/T Patient Acctg. Computer-based Patient Record Lab IS Rad IS Data Repository compete Quality & Outcomes Analysis & Reporting Decision Support Exec.Info.Sys. administrative & financial clinical

23. Healthcare Information: Order from Chaos? Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. ASO TPAs Network & Care Mgrs. Credit Bureaus Claims Assistance Financial Services Color Key: Clinical (specific) Clinical (summary) Financial Administrative Patients Insurers

24. “Top-Down and Bottom-Up”

25. 1. History of the HIE Concept 1987-today- Health Level 7, ASTM E31, IEEE, ANSI X12N, NCPDP, WEDI, and other standards groups work to link computers in healthcare 1991- IOM’s “The Computer-based Patient Record (CPR): An Essential Technology for Health Care”- John A. Hartford Foundation ‘s “Community Health Management Information System, Functional Specifications” (by Benton International)- “Gore invents Internet” [“… I took the initiative in creating the Internet …”]High Performance Computing and Communication Act of 1991 (commonly referred to as "The Gore Bill”) i.e., Congress allows NSFNet to connect to commercial networks; George H. W. Bush signs legislation before leaving office 1992- WEDI’s “Report to the Secretary of U. S. Department of HHS” - World-Wide Web hypertext linkage capabilities deployed outside of research

26. 1. History of the HIE Concept(continued) 1993- Clinton Administration takes office and “Health Security Act” proposed, with many “Administrative Simplification” provisions to require EDI- Provider consolidation accelerates to grab market-share before reforms 1994- Singer’s “Community Health Information Networks: Hype or Reality?”- Wakerly’s “Community Health Information Networks: Creating the Health Care Data Highway”- Metropolitan Chicago CHIN and more successful efforts- Clinton’s “Health Security Act” defeated; Democrats lose Congress 1995- “dot-com” era begins- Even with federal health care reform unlikely, market consolidation continues - Emphasis on hospital-centric CHINs for “physician bonding” [“bondage”?]- Community Medical Network Society (ComNet Society)- 2nd Annual CHIN Summit (Chicago)- “Acadiana Hot Link” (Lafayette) launched as concept of GLCC;first industry focus to be healthcare; key players to be LGMC, USL, others

27. 1. History of the HIE Concept(continued) 1996- ComNet’s 1996 HIN Market Directory lists 522 “CHINs-In-Progress in 1995, including five in Louisiana- HIPAA passed & signed by Clinton; includes “Administration Simplification” provisions in “Health Security Act”- “Acadiana Hot Link” gets some buy-in, but never achieves critical mass by the time that GLCC leadership transition is made at the end of year 1996-2000- Internet commercialization and “dot-com” opportunities heavily hyped, including healthcare industry applications- “dot-com” bubble eventually bursts when venture capital sources dry up 2001-2003- Bush administration takes office, crossing Gore’s “bridge to new millennium”- Terrorist attacks force refocus on security and rooting out terror sources- Bush HHS Secretary Tommy Thompson makes slow but deliberate progress on HIPAA-mandated privacy and security rules, without which CHIN development cannot go forward

28. 1. History of the HIE Concept(continued) 2004- Office of the National Coordinator of Health Information Technology (“ONCHIT” or simply ONC”) created in 2004 within HHS, with David Brailer MD, appointed in 2004 as first ONC director - Brailer adopts the term “Regional Health Information Organization (RHIO)”; the term “CHIN” goes away virtually overnight- “Health Information Exchange (HIE)” used to describe the function of a RHIO- Eventually, HIE replaces RHIO as the generic name of any organization that performs the HIE function 2005-2009- Katrina and Rita devastate the Louisiana and Mississippi Gulf Coast, leading to the Markle Foundation’s “KatrinaHealth.org” project, “LaHIE-1”, the formation of the SGA Gulf Coast HIT Task Force, and ICE-Rx- Louisiana Recovery Authority (LRA) fails to recommend healthcare reforms- Louisiana Healthcare Redesign Collaborative (LHRC) proposes “Medical Home” concept heavily dependent on HIT (EHRs & HIE)- Louisiana Health Care Quality Forum (LHCQF) created to extend LHRC work- Robert Kolodner MD, replaces Brailer in 2006; serves until 2009

29. 1. History of the HIE Concept(continued) 2009- Obama Administration takes office; months pass before Sebelius joins HHS- “Stimulus Bill” (American Recovery and Reinvestment Acct or ARRA) is passed and signed into law in February 2009- ARRA contains “the HITECH ACT” which funds Cooperative Agreements with States to create HIEs within each jurisdiction- LHCQF is named “State-Designated Entity (SDE)” by Louisiana DHH for purposes of ARRA funding- David Blumenthal MD, replaces Kolodner in 2009; serves until 2011 2010- LHCQF awarded HIE Cooperative Agreement funding, as well as Regional Extension Center funding- “Healthcare Reform Bill” (Patient Protection and Accountable Care Act or PPACA) is passed and signed into law; Democrats lose House - LHQCF begins to establish relationships with Project Implementation Partners, IT Infrastructure partners, “preferred” EHR vendors, and with HIE developers and platform hosts- “Acadiana Hot Link” agenda back on the table?

30. 1. History of the HIE Concept(continued) 2011- Farzad Mostashari MD succeeds Blumenthal in 2011 (http://healthit.hhs.gov)- August 9, 2011 LHCQF selects Orion Health as LaHIE technology vendor (http://www.lhcqf.org/images/stories/LHCQF-LaHIE-080911.pdf)

31. 2. No Substitutefor Bottom-up Commitment • CHINs and RHIOs have failed in the past to be sustainable after seed money runs out because of flawed “value propositions” or “business cases”. • Organizers can fall prey to making good-faith assumptions (e.g., “if we build it, they will come”) when a top-down only approach is taken. • HIEs stand better chance of success with today’s technology compared to that of the 1990s, but only if the “business case” can deliver timely ROI to the participating users and to the community at large.

32. 2. No Substitutefor Bottom-up Commitment(continued) • It is not sufficient for an HIE to be an overall good idea, but rather a “value proposition” must be clear at the atomic level – i.e., for each and every “use-case” – or else participation will be rejected. • Benefits – both quantifiable and qualitative ROI • Beneficiaries – may not be the same as the investors

33. 3. Benefits fromUse-Case Scenarios • Use-Case Scenarios for ambulatory care • Pre-Arrival • Point of Arrival • Point of Care • Point of Departure • Post-Departure • Use-Case Scenarios for acute care • Use-Case Scenarios for disaster evacuations

34. 3. Benefits fromUse-Case Scenarios(continued)

35. 3. Benefits fromUse-Case Scenarios(continued)

36. “Interesting Times”

37. Interesting Times • Electronic Health Records: The Case for Quality and Changein part from Abdelhak et al, Health Information – Management of a Strategic Resource, Saunders, 2007 et seq. • Meaningful Use in part from Abdelhak et al, Health Information – Management of a Strategic Resource, Saunders, 2007 et seq. • ICD-10 Implementation [save this for another time] • Facing Decisions & Saving Face • Getting Continuing Medical Education? • The Focus (Basic “IT”? EHR Selection? Implementation?) • The Mode (In-person? On-line?)

38. “Top 5 Worst EMR Myths”(http://www.healthcareitnews.com/news/top-5-worst-emr-myths) • EMRs are bad for “bedside manner.“Does a computer ruin the interaction between patients and doctors? The opposite is true, according to a 2010 Government Accountability Office report. The study found that EMRs help doctors have more information about the patient and contribute to better communication. A good EMR allows a doctor to spend more time with a patient and less with paperwork. Plus, patients can get real-time access to their own health records online through the doctor's EMR system. • You can't teach old doctors new tricks.Although there is an initial learning curve during the EMR adoption process, an easy-to-use EMR can significantly improve workflows once an EMR is fully implemented. Older physicians often lead the charge for an EMR transition in order to prepare their practice for sale when they retire. Tools such as dictation software and customizable templates can help win over even the most technology-adverse docs. • Only hospitals use EMRs.While EMRs are more common in large medical facilities such as hospitals, health technology is starting to sweep into smaller private practices. Private practice physicians deliver more than 80 percent of all care provided for uninsured patients and serve as the front-lines for primary care in the U.S. – so getting them to use technology that improves the quality of care is especially important. • Having my data stored in an EMR is a security risk.Federal HIPAA regulations are very strict about who can see inside your chart and give your EMR records protection beyond what's possible with paper charts. In order to open an electronic chart, a medical professional needs strict login permissions. The EMR system tracks each time your records are accessed and backs up data in a safe and secure way so that records are always available to you and your doctors when needed. Plus, Web-based EMR systems protect from disasters, floods, building fires, and tornadoes that could easily destroy paper records. • EMRs are expensive.The final myth is actually true a lot of the time. Legacy EMR vendors still charge small medical practices $100,000 or more for software, with additional money spent on hardware and IT maintenance. However, new affordable EMR technology is emerging that is making it easier for small practices to join the technology transformation.

39. Electronic Health Records:The Case for Quality and Change

40. Principal repository for information concerning a patient’s health care Rapidly changing to a hybrid paper-electronic format or a fully electronic format Patient record systems may: Store data electronically through online systems Maintain clinical data repositories Combine elements with scanned copies of paper images Electronic Health Records: The Case for Quality and Change The Patient Record

41. Two-fold challenge for the industry: Information in the records is continually expanding in context and form. Technology to make the content available for health care team members across multiple settings is more available and a more realistic option. Electronic Health Records: The Case for Quality and Change The Patient Record

42. There is a prediction that “a 50% growth in health care software investment could enable clinicians to cut the level of preventable deaths by half in 2013” (Gartner Research Group on Information Technology). New England Journal of Medicine (2008) reports that physicians identify positive effects of EHR in several dimensions of quality of care and high levels of satisfaction. Electronic Health Records: The Case for Quality and Change Industry Forces that Advance Electronic Health Record Adoption

43. Drive to adoption of EHR is strengthened by: Patient safety concerns National focus on health information technology Health services quality Paper record shortcomings Cost-containment demands Electronic Health Records: The Case for Quality and Change Industry Forces that Advance Electronic Health Record Adoption

44. Institute of Medicine (IOM) issued series of reports on the nation’s health care on the basis of a concerted, continuing effort to assess and improve the quality of care. Following reports that call for better systems and data, push for EHR increased. The Veteran’s administration (VA) has made substantial progress in use of hospital EHR systems and has shown that care can be improved and made more efficient through their use. Kaiser system demonstrated patient safety improvements through use of EHR and new care team measures – reduced cardiac death by 73%. Electronic Health Records: The Case for Quality and Change Patient Safety Concerns

45. April 2004 – President Bush called for “the majority of Americans to have interoperable electronic health records within 10 years” named a national coordinator for health information technology established the Office of the National Coordinator for Health Information Technology (ONC) Current Coordinator is Dr. Farzad Mostashari Electronic Health Records: The Case for Quality and Change National Focus on Improving Health Information and Technology

46. Electronic Health Records: The Case for Quality and Change National Focus on Improving Health Information and Technology • The ONC supports the efforts of several related initiatives to facilitate nationwide adoption of health IT • Nationwide health information network • State-level health initiatives • Federal health architecture • Adoption • Clinical decision support and the CDS Collaboratory

47. In February 2009 – President Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act which is part of the American Recovery and Reinvestment Act of 2009 (ARRA). It provided 17.2 billion dollars to providers to facilitate EHR adoption. It uses incentives through the Medicare and Medicaid programs. It gives support for providers to acquire technology. Established technology centers. There is workforce retraining to improve the technological skill set in the industry. Electronic Health Records: The Case for Quality and Change National Focus on Improving Health Information and Technology

48. Health care organizations must use their information systems to: Deliver data for more efficient operation of daily business activities Demonstrate cost effectiveness through work and data flow improvements Standardize communications Define and deliver data as an organizational resource through clinical data repositories Provide patient data as an organizational resource through clinical data repositories Provide patient data to a growing number of authorized users within and beyond the organizations Offer streamlined data capture Electronic Health Records: The Case for Quality and Change Health Services Quality

49. They are found in a single location for a single use. Are restricted to one user at a time. Information collected by diagnostic tests and bedside monitoring devices has become more sophisticated and is not supported by paper records. Clinicians want access to test results in order to act quickly to meet patient needs. Style and completeness of documentation in patient records varies from one setting to another. It is difficult to identify which facts are missing. Electronic Health Records: The Case for Quality and Change Paper Record Drawbacks

50. There is no easy way to check for data and information inconsistencies. Data cannot be rearranged for display in alternative formats. Limited to the fundamental chronological flow of information. Caregivers or researchers must review thick documents to connect related information from many diverse locations. Patients and providers want the patient record to function beyond a basic data repository. Health care needs data in aggregate form: To understand the effectiveness of care For evaluation of cost and quality Electronic Health Records: The Case for Quality and Change Paper Record Drawbacks