Models for Adoption: Options for ConsiderationAHRQs Experience

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Models for AdoptionOptions for
ConsiderationAHRQs Experience

• Lisa Dolan-Branton
• AHRQ Health IT Portfolio
• EHR Pathway to Healthier Communities
• May 4, 2005

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Overview of Session

• AHRQs Experience
• Current State of Quality and Safety
• National Strategy
• Health IT Portfolio Activities
• Array of Collaborative models funded
• Other Successful Models of Collaborative HIT
• Health Choice Network, Inc by Alex Romillo
• Council of Community Clinics by Vicky Penland

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AHRQ Mission Statement

• To improve the quality, safety, efficiency, and
  effectiveness of health care for ALL Americans
• Use of Computer-based health records in all
  settings
• Training of health care practitioners in the use
  of information systems
• Delivery and coordination of evidence-based
  health care services thru decision support
  systems
• Evaluations to advance the use of CIS for the
  study of health care quality and outcomes

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Shared HIT Initiative Drivers

• Increasing burden of chronic illness
• Challenges of Preventive Services Delivery
• Quality of Care and Patient Safety Gaps
• Overwhelming System Redesign Needs
• Complexity of implementation and Workflow
  integration
• High costs of care and IT systems

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Knowledge Gaps

• Research limited to a small number of sites
• Inpatient setting
• Limited data on important outcomes
• Adoption and implementation
• Incentives
• Barriers
• Workflow
• Efficiency and effectiveness
• Resources
• New technology and applications

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Percent of Americans Saying I Have A Chronic
Condition

Chronic Illness and Caregiving Survey, Harris
2000
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Diffusion of knowledge
Balas EA, Boren SA., Managing Clinical Knowledge
for Health Care Improvement. Yearbook of Medical
Informatics 2000.
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There must be a renewed national commitment to
building an information infrastructure to support
health care delivery, consumer health, quality
measurement and improvement, public
accountability, clinical and health services
research, and clinical education.2001 Quality
Chasm Report
Where We Are Where
We Want To Be

Implementation
Innovation
Education
Diffusion
Adoption
HIT
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How Hazardous Is Health Care?
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Patient Safety Achieving A New Standard For Care

• Americans should be able to count on receiving
  health care that is safe..This requires, first,
  a commitment by all stakeholders to a culture of
  safety, and, second, improved information
  systems.
• Institute of Medicine, 2003

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EHR Adoption GapThe United States Versus Others
Primary Care Physician Office 2002
Source "European Physicians Especially in
Sweden, Netherlands, and Denmark, Lead U.S. in
Use of Electronic Medical Records." Harris
Interactive Health Care News 2(16).
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Ambulatory CPOE

• The Center for Information Technology Leadership
  estimates that implementing advanced ambulatory
  CPOE systems would
• Eliminate over 2 million ADEs/year
• Avoid nearly 1.3 million physician visits,
  190,000 admissions, and over 130,000
  life-threatening adverse drug events/year.
• Nationwide adoption of advanced CPOE systems in
  the outpatient setting save 44 billion/year (60
  medications, 24 radiology, 11 labs, and 5
  ADEs)

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National Cost Saving projections from Ambulatory
CPOE 44 billion
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HIT Systems approach Can Make a Difference
Proportions of patients receiving the appropriate
discharge prescriptions

• Intermountain Health Care QI effort on CVD
• Results
• 90 prescription rates
• 27 decrease in unadjusted absolute death rates

Lappeacute, J. M. et. al. Ann Intern Med
2004141446-453
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Health IT Expert MeetingGeneral Themes

• Assess financial and non-financial incentives to
  adopt HIT
• Develop business case for HIT
• Educate public and policy makers
• Develop framework to assess value of specific
  features of HIT in diverse clinical settings
• including workflow considerations
• Evaluate HIT systems currently in use to
  understand successes and shortcomings

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Health IT Expert Meeting General Themes

• Develop clinical knowledge for the public domain
  (e.g., decision support rules, knowledge library)
  
• Regional and community collaboratives
• public/private partnerships
• Evaluate emerging technologies
• Role of clinical data standards and
  interoperability (public health included)

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Health IT Expert Meeting Specific Rural Themes

• Very similar themes and issues
• Need to study and promulgate best practices
• Need for technical assistance in communities --
  the rate-limiting step to HIT investment
• Build collaboration and sustainability into
  programs
• Develop HIT toolkit for rural providers

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AHRQ FY 04-07 HIT Portfolio

• 60M initiative
• 26M to implement proven technologies in small
  and rural communities where HIT penetration has
  been low
• 24M targeted for developing, implementing, and
  evaluating the use of new and innovative
  technologies to improve patient safety and
  quality of care in diverse health care settings
• 10M targeted for clinical data standards and
  interoperability

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Selected FY 04-07HIT Initiatives

• Transforming Healthcare Quality through
  Information Technology (THQIT)
• 3 Grant Solicitations
• Focus on community partnerships
• National Resource Center for Health IT
• State and Regional HIT Demonstrations
• CMS AHRQ collaboration
• Indian Health Service RPMS Project
• Privacy and Legal Framework

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HIT Community Partnerships

• Definition of partnerships Collaborative
  working relationship between three or more
  organizations through a written agreement.
  Agreements must include the following elements
• Substantial and meaningful contributions of
  personnel, expertise, money, equipment,
  facilities or other resources to and from each
  partner.
• Sharing of clinical and research data across
  sites.

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Health IT Grants

• Promoting access to Health IT
• Over 100 grants to communities, hospitals,
  providers, and health care systems to help in all
  phases of the development and use of health
  information technology.
• The grants are spread across 38 states
• Special focus on small and rural hospitals and
  communities.
• First year funding is 41 million and will total
  nearly 96 million over three years.

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Crossing the Quality Chasm in Eastern Rural Kern
County

• Participants
• Project Director Kiki Nocella
• Tehachapi Valley Healthcare District
• Eastern Kern Healthcare District
• Mohave Community Medical Center
• Lancaster Community Hospital
• USC Keck School of Medicine
• Project Aims
• Develop Regional collaborative for HIT planning
  and implementation
• (EMR, Chronic Disease registry, PHR)
• Focus on improving care in CAD, DM, CA and
  Obesity
• Develop HIT Business plan for the county health
  care partners
• Development of a rural family medicine residency
  program
• Telemedicine demonstration
• Evaluation Plan
• TM Demo eval to build the larger implementation
• Provider collaboration, referral patterns,
  patient expectations/concerns

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Taconic Health Information Network and Community

• Participants
• Project Director John Blair, MD
• 9 County area
• Taconic IPA, Several Hospitals, Labs
• Project Aims
• Health care portal through ASP with clinical
  messaging, EMR, Clinical decision support,
  registries, Clinical data repository
• Community wide data exchange
• Evaluation plan
• Physician office efficiency improvement and cost
  reduction
• Payer ROI
• Patient Safety Improvement
• Quality Improvement

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Enhancing Quality in Patient Care Project

• Participants
• Project Director Fred Rachman, MD
• Alliance of Chicago Community Health Services
• 4 Federally funded health centers and Network in
  Chicago
• Project Aims
• Implement EHR with decision support
• Initial focus on DM, Asthma and HIV
• Interfaces with PMS, Labs
• Building data warehouse for clinical care, QI and
  research
• (data-sharing collaboration with other CHCs
  using GE product)
• Utilize AMA set of consensus-developed,
  evidence-based practice measures
• Evaluation Plan
• Improve outcomes thru guideline driven care
• Process evaluation

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Value of Health Information Exchange in
Ambulatory Care

• Participants
• Principal Investigator J. Marc Overhage, MD, PhD
• Regenstrief Institute, IN
• Indiana Network for Patient Care (transitioning
  to IHIE)
• 11 Hospitals, 5 health systems, 1.5 M population
  in Indianapolis Metropolitan Statistical Area
• Three research aims
• Re-analyze model developed by C!TL to verify cost
  savings from HIE in IN MSA
• Create laboratory for measuring the value of HIE
• Connect primary care and specialty practices
• Randomize by patient
• Conduct a randomized controlled trial
• Use claims data
• Measure reductions in laboratory and radiology
  utilization

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Impact of Health Information Technology on
Clinical Care

• Participants
• Principal investigator John Hsu, MD, MBA, MSCE
• Kaiser Permanente Northern California
• 110 primary care teams with 3M patients
• Focus 780,000 patients with chronic diseases
• Asthma, CHF, CAD, diabetes, hypertension
• Quasi-experimental natural experiment (2004-2007)
• Staggered introduction of EpicCare, an ambulatory
  HIT system with
• electronic medical record (EMR)
• computer-based provider order entry (CPOE)
• computer-based decision support systems (CDSS)
• Two research aims
• HIT quality and safety
• Use of guideline-consistent drugs, laboratory
  monitoring, and physiologic disease control
• Resource use
• Visits to hospitals, EDs, and offices

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AHRQ National Resource Center for Health
Information Technology

• Scope of Work
• Provide technical/expert support and rapid
  learning environment
• Convene Health care community
• Rapid Dissemination vehicle of HIT Lessons
  learned
• Five year Contract with U of Chicago / NORC
• In partnership with
• Vanderbilt University
• Center for IT Leadership (Partners Healthcare)
• Indiana University
• Foundation for the eHealth Initiative
• Computer Sciences Corporation
• Burness Communications

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State Regional HIT Demonstrations Prototype
RHIOs

• Five-year state-based contracts
• Help states develop secure statewide networks
• Ensure privacy of health information
• Make an individuals health information more
  available to health care providers
• FY04 Five states awarded 1M/year
• Colorado
• Indiana
• Rhode Island
• Tennessee
• Utah

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Goal of RI HIT Demo Project

• Create, implement and evaluate a Master Patient
  Index as the backbone of an interconnected
  information system putting the right information
  into the hands of clinicians and their patients
  when and where it is needed.

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Initial MPI Data Sharing Partners

• HEALTHs KIDSNET
• HEALTHs Millenium- clinical laboratory system
• Lifespans Lifelinks- EMR plus Lifespan,
• SureScripts - electronic information exchange
  between physicians and pharmacies
• Rhode Island Health Center Associations patient
  registry and data warehouse
• East Side Clinical Laboratorys web-based
  reporting system
• Medicaids paid claims database (evaluation
  only) 

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IT Principals

• Data is shared but stored where it resides
• Access to data is controlled by the patient
• Patients will consent to participate
• Data will be stored and presented in a patient
  centric manner
• Data will be accessed and transmitted in a secure
  manner
• Patient identified data will only be used for
  clinical care
• Data used for quality measurement will be
  aggregated and de- identified  

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Indian Health Service EHR Project

• RPMS GUI development
• OB module
• CVD registry module
• Integrated Case Management system
• Evaluation of EHR Implementation/Outcomes

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Future Program Emphasis

• Regional collaborations
• Regional Health Information Organizations
• Linkage with existing and future initiatives
  (e.g. payment or quality)
• Delineate Privacy and Legal Framework
• Federal
• State
• Synergize ongoing and future medication
  therapeutic initiatives
• ePrescribing (grants to physicians, MMA eRx
  programs)
• Chronic Disease Programs
• Integrate decision support with eRx
• Create avenues enhancing technical and resource
  support for stakeholders

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• For additional questions, please contact
• Lisa Dolan-Branton ldolan_at_ahrq.gov