Electronic Health Record (EHR) Adoption in Arizona: A View from the Frontlines

1. http://www.ahcccs.state.az.us/eHealth/Presentations/Endsley.ppthttp://www.ahcccs.state.az.us/eHealth/Presentations/Endsley.ppt Electronic Health Record (EHR) Adoption in Arizona:A View from the Frontlines Scott Endsley MD MSc Medical Director, System Design Health Services Advisory Group

2. Health Services Advisory Group • Medicare Quality Improvement Organization (QIO) for Arizona • Founded in 1979 by Arizona doctors and nurses, HSAG is one of the most experienced QIO’s in the nation. • Dedicated to improving quality of care delivery and health outcomes through information, education, and assistance • Partner with physicians, health plans, nursing homes, hospitals

3. Most Healthcare Comes from Small Practices • 1460 primary care practices • 92% 1-3 physicians • 98% less than 8 physicians

4. Health Information Technology Use in Arizona • AzAFP/ACP/AOMA Survey (Jan-March 2005) • Harris Survey (Maricopa County Medical Society) Summer 2004

5. Key Findings • 87% have high-speed Internet access • 13.5% currently using electronic health records • 25% ready to purchase in next 2 years • 29+ electronic health record vendors active in Arizona market

6. Office Practices are Saying…. • Drug checking, reminders sound great, but can I afford this as a solo practitioner? • Will I be able to connect with my hospital? • Will the vendor be able to support my needs? • Will my patient’s information stay private? • Most of my colleagues still use paper, shouldn’t I wait till electronic medical records are the standard of care? • I have been using paper for 20 years, how will I ever get them all into my electronic medical record?

7. The IT Adoption ‘Gap’ How do we get here We are here

8. PREDICTING THE FUTURE • Tipping point in next 3 years • Interpersonal effect 20x more potent than mass marketing effect Source: Ford et al. “Predicting the Adoption of Electronic Health Records” JAMIA, 2006, 13: 106

9. IT Market Failure: A Prisoner’s Dilemma • $1.6 billion in health care • Highly fragmented delivery and financing models • Asymmetric risk assumption and benefit sharing • 12% DECLINE in proportion of pay for performance programs with IT incentives • IT incentives small = 4% of total incentive. Are you locked behind your medical loss ratio?

10. If HIT were a Gallon of Gas…. We spend 400X LESS than Great Britain

11. $28K $12.3K $16.6K $2.2K $2.5K Per “Average” Provider Annual Cost Saving Projections Only 11% ($3080) accrues to physician

12. The Market Opportunity $200 Billion Market

13. Costs • Highly variable (e.g. $3,000- $134,000) • Components: • Hardware • Application (both primary and 3rd party) • Training • Support • Maintenance • Interfaces

14. Bridging the GAP Ten Key Strategies • Demonstrate relative advantage • Triability • Observability • Use multiple channels of communication • Work with homophilous groups • Stay tuned to changes • Social networks • Opinion leaders • Compatibility • Infrastructure Source: Cain and Mittman, Diffusion of Innovation in Health Care, Institute for the Future, May 2002

15. Barriers to Electronic Transformation • Financial • High up-front cost • Underdeveloped business case • High initial physician time costs • Technical • Inadequate technical support • Lack of standards • Security and privacy Behavioral • Concerns about IT effect on office culture Organizational Change • Patient-physician communication • Workflow changes • Technical competence • Staff Training

16. Hard Dollar Benefits Example Conditions Amount Hard DollarBenefits ROI ~$33,000/provider starting at 2.5 years after investment, most of which accrues from better coding and charge capture

17. Doctors Office Quality Information Technology (DOQ-IT) Initiative • 3-year initiative of Centers for Medicare & Medicaid Services (CMS) focused on small to medium sized primary care practices • Aim: transformation of care through widespread adoption of electronic technologies in office practice • State Quality Improvement Organizations have developed technical assistance services Expand the Adoption Rate by 5-6%

18. Roadmap • ASSESSMENT – practice readiness, workflow analysis • PLANNING – make business case, prioritize needs, set goals • SELECTION – identify options, evaluate, decide, contract • IMPLEMENTATION – prepare, build interfaces, go-live, problem solve • CARE MANAGEMENT- chronic care redesign, report data, improve Vendor Selection Care Management Assessment Planning Implementation

19. DOQ-IT Services • EHR University • Onsite consultations • Web resources – www.azdoqit.org • Physician Champions Network • IT Events/ Vendor Fairs

20. DOQ-IT Support

21. Our Website – www.azdoqit.org • Tools & Resources • Consulting Services • Arizona IT news & events • Register for EHR University • Complete Practice Readiness Assessment

22. Early Lessons from Frontlines • Cost and loss of productivity concerns • Huge disinterest on part of payers • Second wave of adoption • Free isn’t free enough • Waiting for the government solution

23. University of Arizona implementing Allscripts systems across 22 site network • Arizona Community Physicians implementing Allscripts across 89 providers • Arizona State Physicians Association promoting Synamed to 900 practice network • Arizona Medical Clinic implemented GE Centricity, uses as basis for pay for performance • Canyonlands Community Health Centers rolling out NextGen across 5 clinics • …..and many more clinics and organizations engaging in electronic transformation

24. Yuma Regional Center for Border Health • Administer a discount care program – Community Access Program of Arizona (CAPAZ) • 52 providers, 500 patients • Exploring use of CCR-based technology to track patients (especially medications across Arizona/Sonora border)

25. Our Challenge • Define electronic health care as the standard • Close the technology gap-help small offices find ways to finance technology • Assist practices accomplish the practice redesign to effectively use new technologies, including use of data for improvement • Connect all parts of the healthcare system including consumers

26. THANK YOU! Scott Endsley 602.745.6342 sendsley@hsag.com Email: azdoqit@hsag.com Website: www.azdoqit.org

27. Maximizing Personal Health!

28. http://www.informatics-review.com/talks/TEPR-2003/max.ppt “Electrifying” 1/7th of US Economy May 13, 2003 Presentation to TEPR Gary A. Christopherson, Senior Advisor to Under Secretary Veterans Health Administration, Department of Veterans Affairs

29. Population, Person/Enrollee, Episode BP/ Ideal BP/ Ideal H&IT H&IT Status - Well, Acute Illness, Chronic Illness, Custodial Maximize Health/Ability & Satisfaction US Health System National Health Policy Care Episode / Chronic Care Clinical Care Death Health Surveillance Preventive Measures Education Evaluation/Diagnosis In-/Outpatient Treatment Community Treatment Rehabilitation Information “Community” Environment “Occupational” Environment Quality Assurance Community Care (Home / Workplace) Research & Development Health Surveillance Preventive Measures Education Evaluation/Treatment Rehabilitation Information Health Risks Birth Direct Care / Info/Prevention US Health – Goals, Strategic Principles, Outcomes, Leadership/Management, Benefits, Culture/Environment, Resources, Information, History

30. Drivers for health • Maximize health/abilities • Maximize satisfaction • Maximize quality • Maximize accessibility/portability • Maximize affordability • Maximize patient safety (defects/errors to zero) • Minimize time between disability/illness & maximized function/health (time to zero) • Minimize inconvenience (inconvenience to zero) • Maximize security & privacy

31. Potential timetable to “paperless” • Standards • Data • Communications • --------------------- • Health Info Systems • Electronic Health Records Systems (EHRs) • Personal Health Record Systems (PHRs) • Info Exchange Paperless (IOM) Affordable, high quality, standards-based EHRs, PHRs & Info Exchange Adoption by health organizations Adoption by persons 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

32. Toward standards & high performance info systems

33. S S S S S S S S S S HealthePeople - High Performance Information Systems Components/Links/Standards My HealthePeople [web site, virtual health Outside health record, trusted information, self - reported information, organizations “e” communications/ link to other health transactions providers] Registration, Enrollment Management & & Eligibility System Financial System Health Provider (including clinical Interface, e.g. CPRS, CHCSII, & RPMS) & Data System Database/ Standards Database/ Standards Database/ Standards Blood System Laboratory System Scheduling System System Pharmacy System Billing System Enrollment System Provider Payment Radiology System

34. Personal Health Record S S S S S S S S S S HealthePeople - High Performance Information Systems Components/Links/Standards My HealthePeople [web site, virtual health Outside health record, trusted information, self - reported information, organizations “e” communications/ link to other health transactions providers] Registration, Enrollment Management & & Eligibility System Financial System Health Provider (including clinical Interface, e.g. CPRS, CHCSII, & RPMS) & Data System Database/ Standards Database/ Standards Database/ Standards Blood System Laboratory System Scheduling System System Pharmacy System Billing System Enrollment System Provider Payment Radiology System

35. S S S S S S My HealtheVet / My HealthePeople Other health organi-zations Electronic Health Record System My HealtheVet / HealthePeople [Personal Health Record System] “health in a box” on PC & web site via community, health, non-health, government Software & Hardware Database/ Standards • Health Record • Access to health records • Sharing health records • Self-entered health record • Services • Checking/filling prescriptions • Checking/confirming/making appointments • Checking/paying co-payments • Participating in support groups • Health decision support • Health self-assessment • Messaging with health provider • Diagnostic/therapeutic tools • Reminders • “Checking in” • Safety services/tools • Links to other health sites • Information • Trusted information Person Primary health provider Electronic Health Record System (e.g. VistA) Software & Hardware Database/ Standards

36. My HealtheVet Phasing • Phase 1 • Presentation framework • Health education content • VA developed content (e.g., seasonal health bulletins, health tip of the day, Veterans Health Initiatives, interactive chat) • Portal personalization features • Phase 2 • Rx Re-fill • Self Entered Data (excluding self entered metrics) • Phase 3 • View Co-pay balance • View Appointments • Self Entered Metrics • Phase 4 (Electronic Health Record) • eVAult • VistA extracts • Delegate function • User and system administration functions

37. My HealtheVet Timeline • Summer 2003 • Foundational online environment with VA-developed content, health education information, and self-assessment tools • Fall 2003 • Prescription refill and self-entered data* • Winter 2004 • View total co-payment balance, view next scheduled appointment** • Spring 2004 • Electronic patient record data and migration from pilot to national system*** * Requires proofing solution in place ** Requires Secure Web Transaction Architecture; otherwise, reduced-capability service still possible. *** Requires Secure Web Transaction Architecture implementation

38. Potential of “Best Practices” / Ideal Systems

39. Potential of “Best Practices” / Ideal Systems

40. National standards & high performance systems National Health Information Standards Exchange/ Sharing High Performance Health Info Systems Personal Health Record Systems VA, DoD, IHS individual/joint adoption Convergence Consolidated Health Informatics (CHI) HealthePeople(Fed) • Public/Private • Individual (e.g. Kaiser Permanente) • Joint (Connect. Health, eHealth, NCVHS, SDOs, … HealthePeople Health Information Systems Standards DoD CHCS II VA HealtheVet-VistA IHS (upgraded RPMS) HealthePeople(Fed) Public/Private (CMS, VA, health providers/ payers/regulators, private sector vendors) Convergence HealthePeople 2001 2010 Standards – Jointly develop/set/use. Systems – Develop/enhance/use high performance, interoperable. Exchange – Develop two way with computable data. Standards – Nationally accepted. Systems – High performance, interoperable. Exchange – Two way with computable data.

41. Back-up Slide

42. This & Next Generation Strategy HealtheVet-VistA • Operate current generation VistA • Develop, implement & operate HealtheVet-VistA, incl. My HealtheVet • Develop, implement & operate Next Generation HealtheVet-VistA as open source, componentized high performance system with partners HealthePeople, including HealthePeople-VistA • Push development & adoption of health information standards • Push availability & use of public/private sector high performance health information systems, including NextGen HealtheVet-VistA used externally as HealthePeople-VistA, and personal health records

43. http://www.ieeeusa.org/volunteers/committees/mtpc/documents/EMBC06-NYC-Panel.ppthttp://www.ieeeusa.org/volunteers/committees/mtpc/documents/EMBC06-NYC-Panel.ppt MAINTAINING SECURITY AND PRIVACY OF PATIENT INFORMATION September 2, 2006 Frank E. Ferrante, MSEE, MSEPP President FEFGroup, LLC Past Chair, Medical Technology Policy Committee IEEE-USA, Washington, DC Presented at 28th IEEE EMBS Annual International Conference Aug 30-Sept. 3, 2006, New York City, New York, USA

44. Outline • Why Electronic Medical Records? • Software Sample/hardware samples • Barriers/Standards for EHR • HIPAA Security and Privacy Regulations • Medical data transmission requirements • Wireline and Wireless Telecommunications Services Security • Security of Patient Medical Records • References

45. Why Electronic Medical Records (EMRs) • Time spent filing and pulling patient charts, searching for charts • Time re-creating records if destroyed by natural disaster or accident • Cost of supplies to maintain charts • Cost of facility space for records (can better use of space be made?) • Storage and Backup Cost • Transcription services cost • Cost of doing nothing today • Better Security/Privacy Maintainable

46. Software/Hardware Supporting Digital Medical Records • Electronic Medical Record (EMR)Software • Soapware - check it out $300 Starting Price see: http://soapware.com/ • e-MDs Electronic Medical Record Support Software http://www.e-mds.com • a4Healthsystems EMR and Access systems http://www.a4healthsystems.com • Companion Technologies http://www.companiontechnologies.com • Security and Privacy - all EMRs must be protected • Sample approach: indigenous authentication of digital information (US Patent 6,757,828 B1 of June 29, 2004) by Signa2 http://www.gjtdc.com • Backup routinely onto remote servers or storage offerings

47. What are the Barriers to EHR and e-Health Implementation?* • Lack of a Unique Personal Identifier • Lack of HIPAA Compliant Middleware • Lack of Incentives • No Paradigm or “First Mover” for Some System Components • Evolving Standards • Disincentives • Lack of an NHIN Architecture • [Fear of Cost/Benefit] * [Corr 06]

48. Barriers and SolutionsIdentifiers and Middleware • Lack of a Unique Personal Identifier: • Solutions: • Voluntary Personal Healthcare Identifier (IEEE-USA Voluntary Healthcare Identifier Position Statement, 17 June 2004) • Center for Certification of Health Information Technology Multiple ID Approach (Provider ID + Provider Unique Personal ID) • DOD Common Access Card Model • Lack of HIPAA Compliant Middleware: • Solutions: • RHIO Contracts • Marketplace Solutions • Shortcomings: • Public Health and Research Interfaces may not be included HIPAA compliant Identification, Authentication, and Access * [Corr 2006]

49. EHR Standards Evolution* • International Statistical Classification of Diseases and Related Health Problems (ICD) from ICD-9 to ICD-10 • ASCI X12 Version 4010 to ASCI X12 Version 5010 (HIPAA Business Transactions) • National Council for Prescription Drug Programs Telecommunication Standards from version 5.1 to version D.0 • Conversion of all standards to XML * [Corr 06]

50. HIPAA Security and Privacy Regulations • Health Insurance Portability Assurance Act (HIPAA) • Security - Required stronger and more focused provision of security around medical information (supports maintaining of information privacy) • Privacy - Enforces increase in privacy protections for medical information (Not just speaking privacy- required under penalty if failure occurs)