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October 25, 2005

Realizing the Financial Benefits of Electronic Health Records: What do the Data Show? The VA Experience. October 25, 2005 Robert M. Kolodner, MD Chief Health Informatics Officer, VHA Department of Veterans Affairs. Cost Savings and EHRs in VA.

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October 25, 2005

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  1. Realizing the Financial Benefits of Electronic Health Records: What do the Data Show?The VA Experience October 25, 2005 Robert M. Kolodner, MDChief Health Informatics Officer, VHADepartment of Veterans Affairs

  2. Cost Savings and EHRs in VA • 20+ year history of computer use to support care in the Veterans Health Administration (VHA) • Sometimes challenging to tease out effects of the Electronic Health Record from other major changes in VHA, especially since 1995 • Shift from Inpatient to Outpatient care • Reorganization to 22 (now 21) regional networks • Implementation of performance measures • Shift from facility-centric to veteran-centric AMIA - S49 (Kolodner)

  3. Transformational Strategies for VA Health Care “In summary, electronic health records, performance management, and a patient-centric focus have been critical transformational strategies for the VA. They have been utilized to support achievement and are associated with measurable progress in each of the VA’s value domains.” The American Journal of Managed Care, November 2004 AMIA - S49 (Kolodner)

  4. 2005: Who is “VHA” . . . Veterans Health Administration • 5.2 million patients, ~ 7.6 million enrollees ~ $30 Billion budget ~ 1,300 Sites-of-Care • Including 171 medical centers or hospitals ~ 870 clinics • 207 counseling centers & • long-term care programs ~ 197,500 Employees (~14,000 MD , 56,000 Nurses, 33,000 AHP) ~ 150,000 volunteers • Affiliations with 107 Academic Health Systems • 1,500 Health Professions Training Affiliations • Additional 25,000 affiliated MD’s; +35,000 residents & fellows in 14,000 slots ~ 89,000 trainees in all disciplines • Nearly half US health professionals (>65% MDs) have some training in VA ~ $1.7B Research: Rehabilitation, Health Services, Clinical, Basic AMIA - S49 (Kolodner)

  5. VA’s Health Information System is VistA • “CPRS” is the integrated EHR application • VA runs 128 VistA systems these sites • Down from 172 VistA systems 10 years ago • ~180,000 PCs and thin clients • Delivers a complete hospital information system, electronic health record, imaging, Bar Code Medication Administration • Hardware, software, maintenance, upgrades, staffing • For FY2004: • Cost per enrollee • $78 / enrollee • Average cost per hospital (n=158) • $3.6 million AMIA - S49 (Kolodner)

  6. And VistA Is Actively Used... Some National VistA Statistics (Total…Daily) • Documents (Progress Notes, Discharge Summaries, Reports) • 742,000,000…….. +576,000 each workday • Orders • 1.48 Billion…….... +922,000 each workday • Images • 385,000,000……… +587,000 each workday • Vital Sign Measurements • 915,000,000……… +676,000 each workday • Medications Administeredwith the Bar Code Medication Administration (BCMA) system • 716,000,000……… +607,000 each workday Statistics as of September 2005 AMIA - S49 (Kolodner)

  7. VistA Data Trend – Rate of Increase AMIA - S49 (Kolodner)

  8. Financial Benefits of EHR in VA • Unable to provide overall benefits for the system since DHCP/VistA implemented and matured over 20 years and baselines were not taken HOWEVER • Many local examples with costs • Some local examples with implications without exact costs • Some speculations • …not counting savings by not repeating tests / or avoiding hospital admissions AMIA - S49 (Kolodner)

  9. Myths: VA’s Different . . . • “VA’s Command & Control” • Truth: Yes, 17,000 staff physicians, but 25,000 affiliated faculty & 35,000 housestaff through affiliations with 107 academic health systems • “VA has an appropriated budget” • True, but VA $1.5 of $25 B (FY03) was revenue from billing, increased from $300 M, 3 years prior • “VA’s patients are former military, thus overall healthier & follow instructions” • VA patients define adverse selection • Think of VA as “Living Laboratory” AMIA - S49 (Kolodner)

  10. Examples • Medications – Inpatient • Bar Code Medication Administration • Medications – Outpatient (local initiatives) • Drug Cost feedback • Disease Management - Diabetes • HgB A1c • Outcomes • Impact of Vaccinations • Pneumovax • Not having to pull charts or maintain a chart room AMIA - S49 (Kolodner)

  11. INFORMATION TECHNOLOGY – SAFETY Bar Code Med Administration (BCMA)

  12. What is the AssociatedCost Avoidance or Cost Savings? AMIA - S49 (Kolodner)

  13. INFORMATION TECHNOLOGY – EFFICIENCY Using Technology to Manage Drug Costs Drug Costs are listed in the order menu

  14. INFORMATION TECHNOLOGY – EFFICIENCY Using Technology to Manage Drug Costs Here Fluoxetine is listed as the preferred drug, costs are also listed

  15. INFORMATION TECHNOLOGY – EFFICIENCY Using Technology to Manage Drug Costs Conversion from Citalopram to Fluoxetine

  16. Diabetes Mellitus (DM) • Prevalence of DM among VA patients is 20% • Substantially higher than in the general population • More than 1 million patients per year • Nearly all are male (2.4% women) • Largest group is >65 years old AMIA - S49 (Kolodner)

  17. Performance MeasurementSetting the U.S. Benchmark for 18 Comparable Indicators AMIA - S49 (Kolodner)

  18. INFORMATION TECHNOLOGY – QUALITY CLINICAL REMINDERS

  19. INFORMATION TECHNOLOGY – QUALITY Effect of Clinical Reminders at 1 VAMC

  20. INFORMATION TECHNOLOGY – QUALITY Effect of Clinical Reminders at 1 VAMC

  21. Highest Quality of Care For Patients with Diabetes in VA “Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care.” Annals of Internal Medicine, August 17, 2004 AMIA - S49 (Kolodner)

  22. VA-TRIAD Adjusted Intermediate Outcomes AMIA - S49 (Kolodner)

  23. Amputations per 1000 patients FY99-04 Changes in Total, Major and Minor Age-Adjusted Amputation Rates Among Patients With Diabetes AMIA - S49 (Kolodner)

  24. What is the AssociatedCost Avoidance or Cost Savings? AMIA - S49 (Kolodner)

  25. Pneumococcal Vaccination Rates in VHA --BRFSS 90th-- --BRFSS-- • Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz • HHS: National Health Interview Survey, >64 AMIA - S49 (Kolodner)

  26. Pneumonia: Acute InpatientImproving Efficiency by Reducing Excess Health Care Utilization • DRG89-90; Unadjusted for Pt. Population (up 20%, FY99-01) 9,500 fewer bed days 8,000 fewer discharges AMIA - S49 (Kolodner)

  27. Vaccine Cuts Pneumonia Risk in High-Risk Patients* • 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine. • VA Medical Center study of 1,900 elderly patients with chronic lung disease; 2/3 vaccinated against pneumonia. • Pneumococcal vaccination: • 43% reduction in hospitalizations for pneumonia and influenza, and a 29% reduction in the risk of death. • Pneumonia and Influenza vaccination: • 72% reduction in hospitalizations for these two diseases and an 82% reduction in deaths from all causes. • Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period. *Archives of Internal Medicine 1999;159:2437-2442Dr. Kristin Nichol, VAMC / Minneapolis AMIA - S49 (Kolodner)

  28. Extrapolating from Dr. Nichol’s Study: Between 1996 and 1998, Increased Rates of Pneumococcal Vaccination Averted 3914 Excess Deaths Nationally in VHA Patients with Chronic Lung Disease… Today, over 6,000 lives have been saved. AMIA - S49 (Kolodner)

  29. What is the AssociatedCost Avoidance or Cost Savings? AMIA - S49 (Kolodner)

  30. Priceless AMIA - S49 (Kolodner)

  31. AMIA - S49 (Kolodner)

  32. AMIA - S49 (Kolodner)

  33. Paper versus Electronic – Elimination of Processes • Without an EHR • Paper charts were pulled & delivered to clinic locations for scheduled appointments • Also involved re-filing • Resulted in a 60% average chart availability rate • One VA Medical Center • Budget of 1% of the entire VHA • Closed file room - cost avoidance estimated at $600,000 • VERY Conservative estimate • $1 per pull, delivery and re-file • Some estimates in private sector as high as $10/pull • Eliminating this for VA’s 50 million outpatient encounters estimated $50 million cost avoidancein staff resources AMIA - S49 (Kolodner)

  34. Home Telehealth And what savings might we see from Home Telehealth? AMIA - S49 (Kolodner)

  35. Home-Telehealth Technologies AMIA - S49 (Kolodner)

  36. AMIA - S49 (Kolodner)

  37. What is the AssociatedCost Avoidance or Cost Savings? AMIA - S49 (Kolodner)

  38. This presentation is available on the VHA internet at: www.va.gov/vha_oi Select “Office of Information Document Library” on the left hand bar Presentation is Titled “AMIA 2005 - Presentation by Robert M. Kolodner M.D.” http://www1.va.gov/vha_oi/docs/AMIA_2005_Panel.pps AMIA - S49 (Kolodner)

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