Health Information Technology and Health Care: Challenges, Solutions,

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Health Information Technology and Health
CareChallenges, Solutions, Future
Opportunities

• Thomas Rundall, PhD
• John Hsu, MD, MBA, MSCE
• TEKES/Finnwell Conference
• CITRIS in Europe
• June 2006

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Introduction to Health IT

• Challenges
• What is wrong with health care today?
• Solutions What do we know about Health IT?
• Opportunities
• What are other opportunities for Health IT to
  improve health care?

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Health Care Challenges

• Healthcare delivery is highly fragmented in the
  US
• Multiple physicians/services multiple payers
• More than 360,000 care delivery sites in the US
• Increasing physician specialization - disease
  focus
• Inefficient or absent communication across
  physicians, delivery sites, and episodes of care
• --------------------------------------------------
  ----------------------------------------------
• Blumenthal, D, The Duration of Ambulatory Visits
  to Physicians, Journal of Family Practice, April
  1999
• Stafford, RS, Saglam, D et. Al., Trends in Adult
  Visits to Primary Care Physicians in the United
  States, Archives of Family Medicine, Vol. 8,
  Jan/Feb 1999

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Consequences - Poor Quality and Safety Problems

• Fragmentation leads to miscommunication and
  errors
• Examples
• Duplicate laboratory testing
• Drug safety problems - drug-drug interactions,
  polypharmacy, poor adherence
• Documentation problems - illegible handwriting
  and other mis-communication
• Effects
• Increased healthcare utilization and increased
  cost of care
• Reduced timeliness of care
• Inappropriate or unnecessary care
• Institute of Medicine, To Err is Human, 2000.

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Health Care Challenge Data Storage

• Problems with the data storage
• These communication problems arise partly because
  the data is stored in many ways and in many
  locations
• On Paper
• Within inaccessible silos behind the firewalls
  of institutions
• As tacit knowledge in someones mind
• What is communicated is often incomplete,
  inaccurate (wrong or out of date) or unclear
  (illegible, nonsensical)
• Clinical decisions based on invalid or
  out-of-date information can have disastrous
  consequences
• --------------------------------------------------
  ----------------------
• Cimino JJ, et. al, Theoretical, Empirical and
  Practical Approaches to Resolving the Unmet
  Information Needs of Clinical Information Systems
  Users, Proceedings of the Fall AMIA Annual
  Symposium, 2002170-74
• J. Walker et al., "The Value of Health Care
  Information Exchange and
• Interoperability,Health Affairs, 19 January
  2005
• http//content.healthaffairs.org/cgi/content/ab
  stract/hlthaff.w5.10

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Health Care Challenges Overuse Underuse

• Problems of Overuse and Underuse
• 30 of children receive excessive antibiotics for
  otitis
• 20-50 of surgical procedures are not necessary
• 50 of back pain x-rays not necessary
• 50 of elderly patients dont receive a pneumovax
• On average, patients only receive about 50 of
  recommended care
• Great disparities in access to healthcare
• --------------------------------------------------
  -----------------
• McGlynn, et al. NEJM, 2004
• The Dartmouth Atlas Project
• http//www.dartmouthatlas.org/
• The AHRQ National Healthcare Disparities Report
• http//www.qualitytools.ahrq.gov/disparitiesreport
  /browse/browse.aspx

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Health Care Challenges Adverse Drug Events

• Adverse Drug Events (ADEs) are a leading cause of
  morbidity (and mortality) in the US
• In a meta-analysis of ADEs, 84 were classified
  as preventable
• Many of the patients studied with permanent
  disabilities directly resulting from ADEs
  received higher than usual drug dosage
• The average settlement cost in the resulting
  litigations was 4.3 million!
• ----------------------------------------
  --------------------------------------------------
  -----
• Leap LL, Bates DW, et.al Systems analysis of
  adverse drug events, JAMA 1995 27435-43
• Kelly, WN. Potential Risks and
  Prevention, Part 2 Drug Induced Permanent
  Disabilities, American Journal of Health System
  Pharmacies, 2001 581325-1329

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Health Care Challenges Knowledge Management

• Challenge to continually keep up to date
• Physicians must keep track of 10000 different
  diseases and syndromes, 3000 medications, 1100
  lab tests and 40000 articles in the biomedical
  literature
• -- Harvard Business Review (July 2002)
• It takes 17 years for known best-practices to be
  actually applied in clinical care
• Systems often have limited information on its own
  organization, available supplies, and existing
  knowledge
• --------------------------------------------------
  -----------------
• Lenfant, C, Clinical Research to Clinical
  Practice Lost in Translation, N Engl J Med,
  2003 349 868-74
• Berwick, DM, Disseminating Innovations in
  Healthcare, JAMA 2003 2891969-75

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Solutions Health Information Technology

• Health IT is very complex with many cultural,
  technical, financial and logistical components
• This complexity can be simplified using the
  following framework
• Application Level
• CPOE, CDS, ePrescribing, eMAR, Results Reporting,
  Electronic Documentation, Interface Engines
• Communication Level
• Messaging Standards
• HL7, ADT, NCPDP, X12, DICOM, UB92, HCFA, ASTM,
  EDIFACT, etc.
• Coding Standards
• LOINC, ICD-9, CPT, NDC, RxNorm, Snomed CT, etc.
• Process Level
• HIE, MPI, HIPAA Security/Privacy
• Device Level
• Tablet PCs, ASP models, PDAs, Bar Coding,

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Six Aims for Health Care Improvement

• Safe avoiding injuries to patients from the
  care that is intended to help them.
• Effective providing services based on
  scientific knowledge to all who could benefit,
  and refraining from providing services to those
  not likely to benefit.
• Patient-centered providing care that is
  respectful of and responsive to individual
  patient preferences, needs, and values, and
  ensuring that patient values guide all clinical
  decisions.
• Timely reducing waits and sometimes harmful
  delays for both those who receive and those who
  give care.
• Efficient avoiding waste, including waste of
  equipment, supplies, ideas, and energy.
• Equitable providing care that does not vary in
  quality because of personal characteristics such
  as gender, ethnicity, geographic location, and
  socioeconomic status.
• Institute of Medicine Report, Crossing the
  Quality Chasm A New Health System for the 21st
  Century. National Academy of Sciences, 2001

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Changes to Achieve Quality Health Care

• Necessary health care changes
• Reengineered care processes
• Knowledge and skills management
• Development of effective teams
• Coordination of care across conditions, services,
  sites over time
• Transparency
• Effective use of information technology
• Institute of Medicine Report, Crossing the
  Quality Chasm A New Health System for the 21st
  Century. National Academy of Sciences, 2001

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Health Information Technology(HIT) as a Solution

• HIT is an integral part of all other changes
• Redesign of the health care delivery system
• Better access to patient information and decision
  support at the point of care
• Better information exchange among multiple health
  care providers
• Better information collection and management for
  patients and for systems
• More comprehensive and coordinated approach to
  care
• Better communication with patients

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US and Finland

• Lessons from the US
• Lessons from Finland
• Goals
• Sharing knowledge about Health Information
  Technology
• Finding opportunities to improve health care
  through better technology and use of technology

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Finnish and US Health Systems
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Health Care Complexity

• Mean Number of Outpatient Visits in 2004
• Patients in KPNC with Diabetes

N167,761 diabetes patients in 2004. Mean of 27
of visits with the primary care physician.
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Health Care Complexity in KP

• Mean Number of Clinicians Writing Drug
  Prescriptions in 2004
• Patients in KPNC with Diabetes

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Examples of Previous HIT Studies in KP

• Physicians and patients
• Resource use
• Organization and systems
• Example of Ongoing HIT Studies in KP
• Quality, safety, resource use, and the delivery
  structure

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Study of HIT and Physician-Patient Interactions

• Findings
• Greater patient satisfaction with and
  understanding of medical activities
• ? Overall patient satisfaction with visits
  (OR1.50, 95 CI 1.012.22)
• ? Satisfaction with physicians familiarity with
  patients (OR1.60, 95 CI 1.012.52),
• ? Satisfaction with communication about medical
  issues (OR1.61, 95 CI 1.052.47)
• ? Comprehension of decisions made during the
  visit (OR1.63, 95 CI 1.062.50).
• No evidence of crowding out of non-medical
  discussions, e.g. patient psychosocial concerns
• Conclusion
• The exam room computers appeared to have
  positive effects on physician-patient
  interactions related to medical communication
  without significant negative effects on other
  areas such as time available for patient
  concerns.
• Hsu J, Huang J, Fung V, Robertson NR, Jimison H,
  Frankel R. Health Information Technology (HIT)
  and Physician-Patient Interactions Impact of
  Computers on Communication During Outpatient
  Primary Care Visits, JAMIA 2005 12 474-80.

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Study of HIT and Physician-Patient Interactions

• Findings
• Exam-room computing affected the visual, verbal,
  and postural connection between clinicians and
  patients. We observed variations across the
  visits in the magnitude and direction of the
  computers effect.
• We identified four domains in which exam room
  computing affected clinician patient
  communication visit organization, verbal and
  non-verbal behavior, computer navigation and
  mastery, and spatial organization of the
  exam-room.
• We observed a range of facilitating and
  inhibiting effects on clinician patient
  communication in all four domains.
• In all four domains, there was little change
  observed in exam room computing behaviors from
  the point of introduction to seven-month follow
  up.
• Conclusions
• Effective use of computers in the outpatient
  exam room may be dependent upon clinicians
  baseline skills that are carried forward and are
  amplified, positively or negatively, in their
  effects on clinician-patient communication. More
  study of the effects of new technologies on the
  clinical relationship is also needed.
• Frankel R, Altschuler A, George S, Kinsman J,
  Jimison H, Robertson NR, Hsu J. The Effects of
  Exam-Room Computing On Clinician-Patient
  Communication A Longitudinal Qualitative Study,
  JGIM 2005 20 677-82.

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Study of HIT and Resource Use

• Findings
• Office visit rates decreased 9
• Primary care visits decreased 11, as did
  specialty care visits
• Scheduled telephone visits increased in one
  region
• No measurable differences in laboratory or
  radiology services use
• Advice on smoking cessation, cervical cancer
  screening, and retinal examination in diabetics
  remained unchanged
• Conclusions
• Health information technology that provides
  integrated clinical information appeared to
  decrease use of ambulatory care, without
  adversely affecting select measures of quality.
• Garrido T, Jameison L, Zhou Y, Wiesenthal A,
  Liang L. Effect of Electronic Health Records in
  Ambulatory Care, BMJ 2005 330 581.

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Study of HIT Implementation Challenges

• Findings
• Users perceived the decision to adopt HIT as
  flawed
• Software design problems increased HIT resistance
• The HIT system reduced doctors productivity,
  which fueled resistance
• The HIT system required clarification of clinical
  roles and responsibilities
• A cooperative culture created trade-offs
  throughout the implementation
• No single leadership style was optimal
• The implementation process fostered a counter
  climate of conflict
• Conclusions
• Throughout the implementation process,
  organizational factors such as leadership,
  culture, and professional ideals played complex
  roles, each facilitating and hindering
  implementation at various points. A transient
  climate of conflict was associated with adoption
  of the system.
• Scott JT, Rundall TG, Vogt TM, Hsu J. Kaiser
  Permanentes experience of implementing an
  electronic medical record a qualitative study,
  BMJ 2005 331 1313-1316.

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IMPACT STUDYImpact of Information Technology on
Clinical Care An Evaluation of the Technology on
Quality, Safety and Efficiency of Chronic Disease
Care
Funding United States Agency for Health Care
Research and Quality R01HS015280
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IMPACT Research Team

• John Hsu, MD, MBA, MSCE (KP DOR)
• Tom Rundall, PhD (UCB)
• Richard Brand, PhD (UCSF)
• Robert Miller, PhD (UCSF)
• Jim Bellows, PhD (KP CMI)
• Yvonne Zhou, PhD (KP)
• Bruce Fireman, MA (KP DOR)
• Jie Huang, PhD (KP DOR)
• Mary Reed, DrPh (KP DOR)
• Hui Hui Huang (KP DOR)
• Julian Wimbush (UCB)
• Joe Kim, MD, MPH (UCLA, KPSC)
• Joseph Selby, MD, MPH (KP DOR)
• Steve Shortell, PhD (UCB, Scientific Advisor)
• Joseph Newhouse, PhD (Harvard, Scientific
  Advisor)
• Emmett Keeler, PhD (RAND, Scientific Advisor)
• David Bates, MD (Harvard, Scientific Advisor)

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Basic Conceptual Framework
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Integrated Delivery System

• Health System (Region)
• Medical Centers
• Outpatient Care Inpatient Care
• Primary Care Teams
• Primary Clinicians
• Disease Subspecialists
• Pharmacists
• Disease Managers
• Other providers - Educators, Behavioralists
• Patient Self-care

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Health Information System

• Electronic medical record
• Computer order entry system decision support
• Messaging system
• Patient portal
• IT and Organizational Transformation

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HIT ? Quality, Safety, Resource Use
Resource Use
Direct Effects
Care Practices Structure
Intermediate Outcomes
ED Visits
Drug Use
Drug Adherence
Point-of-Care Impact
Hospitalizations
Lab Results/ Levels
Lab Monitoring
HIT Use Office Visit
HIT Implementation
System Integration Impact
Repeat Office Visits
Office Monitoring BP
Blood Pressure Control
Patient Self-Care (unmeasured)
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HIT Mechanisms of Action
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Aim 1. HIT USE ? QUALITY AND SAFETY
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Aim 2. HIT USE ? RESOURCE USE
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Aim 3. BASELINE VARIATION IN STRUCTURE AND
ORGANIZATION (pre-HealthConnect)
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Aim 4. HIT USE ? STRUCTURE OF CHRONIC CARE
MANAGEMENT
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Aim 5. STRUCTURE OF CHRONIC CARE MANAGEMENT ?
QUALITY AND SAFETY
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Methods

• Design Longitudinal study with
  quasi-experimental changes in exposure to HIT,
  and using a pre-post analytic design with
  concurrent controls
• Three years 2004-2007
• Population IDS Members with any of the five
  chronic diseases in January 2004
• Data
• Administrative databases
• Surveys

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Key Informant Survey Topics/Domains

• Organizational Support
• Decision Support
• Self-Management Support
• HIT Support
• Delivery System Design / Care Management
  Practices

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Team Member Survey Topics/Domains

• Description of chronic care delivery
• Feedback reports
• Use of guidelines/protocols
• Self-management support
• HIT tools use/integration
• HIT training
• Coordination of Care
• Team climate

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Future Opportunities

• Redesign of the health care delivery system
• Better access to patient information and decision
  support at the point of care
• Better information exchange among multiple health
  care providers
• Better information collection and management for
  patients and for systems
• More comprehensive and coordinated approach to
  care
• Better communication with patients

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Future Opportunities

• HIT use
• Interfaces
• Data sources
• Connectivity
• Workflow and information flow
• Individual clinicians
• Teams (horizontal)
• Health systems (vertical)
• Patients
• Clinical coordination
• Clinical efficiency
• Clinical and self-care management
• Organization and system management
• Knowledge generation and management

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HIT Transformation

• New technologies require new ways of providing
  care
• Questions Which of the new ways work?
• Delivering care
• Using technology
• Capturing information
• Sharing information
• Managing knowledge

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Perspectives

• Clinicians
• Managers
• Researchers
• Policy-makers
• Entrepreneurs
• Patients

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Goals

• Health care that is
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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Health Information Technology

• Challenges
• Many problems with health care in 2006
• Solutions Health IT can be an integral part of
  the solution for health care problems
• Opportunities
• New ways of delivering care,
• New ways of using technology,
• New ways of capturing information
• New ways of using information gained,
• New ways of managing knowledge gained