Effects of Health Information Technology on Ambulatory Care: Results from New York State

1. HITEC Effects of Health Information Technology on Ambulatory Care: Results from New York State Lisa M. Kern, MD, MPH Associate Professor of Public Health and Medicine, Weill Cornell Medical College Deputy Director, Health Information Technology Evaluation Collaborative

2. What is Unique about Health IT in New York State? • The Healthcare Efficiency and Affordability Law for New Yorkers (HEAL NY) • $250 million investment in interoperable EHRs began in 2005 • With additional matching funds • Focused around communities • 8 times larger than the next largest state based investment

3. Why Evaluate? • HIT is not just one intervention. • Software, hardware, configuration, training, users and compliance can all vary across implementation efforts. • Understanding what works, what does not and why is critical for shaping future implementation efforts. • Standardizing evaluations maximizes the lessons learned.

4. Health Information Technology Evaluation Collaborative (HITEC) • Academic collaborative across 4 universities in New York State • Established to conduct rigorous, independent evaluations of New York’s health IT initiatives • Directed by Drs. Rainu Kaushal, Lisa Kern and Jessica Ancker

5. Overview of 4 Early Studies • An organizational survey of HEAL 1 grantees • Funded by the Commonwealth Fund • Electronic prescribing and medication safety • Funded by the Agency for Healthcare Research and Quality (AHRQ) • Electronic laboratory result viewing and quality • Funded by AHRQ • Development of quality metrics for interoperable EHRs • Funded by AHRQ

6. 1. HITEC Survey of HEAL 1 Grantees • Organizational assessment of HEAL 1 grantees • At baseline and follow-up (2 years after award announcement) • 100% response rate • 100% of grantees still existed • 100% implementing or attempting to implement interoperable health IT Kern, Barrón, Abramson, Patel, Kaushal. Health Affairs. 2009

7. HEAL 1 Grantees with Various Project Goals and the Presence of Users at Follow-up (N = 26) 26 22 17 17 13 12 9 9 8 Kern, Barrón, Abramson, Patel, Kaushal. Health Affairs. 2009

8. Policy Implications • Financial sustainability is a major concern, despite HEAL NY funding. • Concerns about technical issues and workflow integration are high. • Communities require long periods of time to adopt health IT and HIE. • New York State considered organization and governance to be extremely important.

9. 2. Electronic Prescribing: Overview Aim: To compare the effects of 2 e-prescribing applications (stand-alone and integrated into an EHR) on medication errors Versus paper-based prescribing Design: Prospective cohort study (pre-post) with concurrent controls Sample sizes: 78 primary care physicians 13,596 patients 9,452 prescriptions 5,968 medication errors Kaushal, Kern, Barrón, Abramson. J Gen Intern Med 2010 March.

10. Electronic Prescribing: Results * 42.5 38.4 37.3 Errors per 100 prescriptions 26.0 16.0 6.6 * P < 0.001

11. Policy Implications Prescribing errors are very common Stand alone e-prescribing versus integrated into an EHR

12. 3. Electronic Laboratory Result Viewing Aim: To determine any associations between use of an electronic portal for result viewing and quality of care Design: Prospective cohort study of 168 primary care physicians Kern, Barrón, Blair, Salkowe, Chambers, Callahan, Kaushal. J Gen Intern Med. 2008.

13. 3. Electronic Laboratory Result Viewing: Results Electronic laboratory result viewing was associated with higher quality of care Adjusted OR in baseline, cross-sectional study: 1.25 (95% CI 1.003 – 1.57) Adjusted OR in longitudinal study: 1.42 (95% CI 1.04 – 1.95) Longitudinal study adjusted for the physicians’ baseline quality of care Kern, Barrón, Blair, Salkowe, Chambers, Callahan, Kaushal. JGIM. 2008.

14. Policy Implications Push versus pull provision of clinical information Push

15. Policy Implications Push versus pull provision of clinical information Pull

16. 4. Quality Metrics for Capturing the Effects of Interoperability • Aim: To develop a set of electronically reportable quality metrics that capture the expected quality effects of interoperable EHRs • Methods: • Literature search • Two rounds of quantitative rating of metrics • 36-member national expert panel Kern, Dhopeshwarkar, Barrón, Wilcox, Pincus, Kaushal. Jt Comm J Qual Patient Saf, 2009.

17. 4. Quality Metrics for Capturing the Effects of Interoperability • Results: • Of 1,064 existing metrics, we selected 18 top-scoring metrics • We developed 14 novel metrics • Focusing on the portion of quality that overlaps with utilization • Lessons learned have implications for the current national discussion. Kern, Dhopeshwarkar, Barrón, Wilcox, Pincus, Kaushal. Jt Comm J Qual Patient Saf, 2009.

18. Conclusion • Health IT has never been more important • Very large national investment in interoperable EHRs • Value hasn’t been clearly demonstrated • Best policies for implementation and support have not been determined. • New York State’s experiences will be extremely useful in informing national directions.