Quantifying the value of RHIOs for Nursing

1. School of Nursing University ofWisconsin-Madison Quantifying the value of RHIOs for Nursing Patricia Flatley Brennan With collaboration from Stephen Robinson, Michael Ferris, Stephen Wright, & Jenna Marquard LM 8949 University of Wisconsin-Madison

2. By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”--President George W. Bush, State of the Union Address, January 20, 2004 President Bush has outlined a plan to ensure that most Americans have electronic health records within thenext 10 years. …

3. 10 years - it’s not so much time…and what once was new is now familiar • Jan Zeller contributed new insights about psychoneuroimmuniology • Cheryl Beck brought together the research on post-partum depression • Susan Bennett, Sandy Dunbar and Jerilyn Allen gave us ways to measure significant cardiac experiences • Barbara Daly, Sara Douglas and Ellen Rudy introduced the concept of chronically critically ill

4. Or look at health care… HPV vaccine P4P NHII, NHIN, RHIO, SNO CMS Vioxx, then no Vioxx Stem cells Just ask a kid… Wireless everywhere Harry Potter iPods & Palm Pilots Purple M&Ms Spinning No air travel without shoe removal MMORPG Faceplace, myspace & iTunes Just how much can happen in a decade?

5. Progress towards the 10 year vision? • July 2004 • NIHN • August 2005 • CMS/OIG announce relaxation of the Stark • 2006 • Federal Employees Electronic Personal Health Records Act • Creating a sustainable, credible financial model remains a significant barrier

6. Health Information Exchange relationships(formerly known as RHIOs )form the core building blocks of the information flows necessary to support high-quality, safe, evidence-based care

7. RHIO, SNO, what-evah! Alliances of hospitals, clinics, nursing homes, public health authorities (and suppliers and payers and schools and ..) (and maybe patients)

8. Many Configurations

9. The evolution of RHIOs Behavior of groups Norming, storming, forming Governance/Policy * Rates * Incentives * Penalties Joining Patterns

10. Should more players join a RHIO? It depends on * present and future state of RHIO * policy considerations * regulatory requirements * business case

11. First, let’s look at some general economic considerations of RHIOs

12. Financial considerations • Provider-level costs and benefits • Information management at the point of care • The cost of information • The expected value of perfect information • Institution-level • Preparing and sustaining information exchange • Alliance perspective • Establishment & maintenance costs • Generating revenue: fees, subscriptions & services

13. Participation in a RHIO depends in part on a positive financial appraisalbut…this requires anticipating the behavior of RHIO & its participants over time -- which most cost models can’t handle

14. What can be learned from current approaches to financing HIT? • Net Present Value models • Focus on single institution • Presume perfect knowledge • Risk is known, fixed, and unaffected by the behavior of other institutions • Network models • Experts’ estimates of societal benefits & institutional investment (Warner, 2005; Kaushal et al 2005) • Static, unchanging participation (Chismar & Thomas, 2004) • Optimization of network performance in a stable HIE environment (Berman & colleagues, 2001)

15. To make the RHIO participation decision, the institution must… • Value participation using key parameters: • Startup costs, including institutional readiness • Network maintenance • Incentives or penalties for delay • Value participation at many points in time • Sensitive to network configuration, behavior of other participants, and benefit to institution • Therefore, • business planning models for RHIO participation must incorporate network performance, risk, and change over time

16. What does a hospital need to know ? • The present & future state of the RHIO • Entry cost • Maintenance costs • Number & size of participants • Policies: • Incentives, penalties & caps • Institution: • Cost-to-participate (Institutional IS, cost to convert) • Anticipated benefit • Base benefit • Incremental benefit

17. Using Operations Research models to make the business case • On the value of models • Make explicit representations of complex situations • Capitalize on computational strength • Explore consequences • Model approach: • mixed-integer linear programs within the GAMS modeling system, CPLEX solver

18. Model parameters • Model Inputs: • Hospital size • Tiny, small, medium, large • Entry Costs • Maintenance costs • Base and Incremental benefits • Exploration: Capacity limits and Penalties • Results: • RHIO size and composition

19. Findings: Institutions join RHIO when net benefit over time is positive both for the RHIO and the institution

20. Benefits over time: four hospitals • Basic assumption: perfect knowledge of deterministic benefit over time • Sample joining pattern • Three hospitals join; one never does

21. Capacity limits effect RHIO size and composition

22. Penalties influence growth and participation

23. Major discussion points • Conversion costs do not exert a strong effect on participation • Participation is highly sensitive to incremental benefit caps • Changing the price-to-enter has a slight effect on participation • Participation is highly sensitive to benefit reduction and penalties due to RHIO size

24. Modeling Strategies and Directions • Models provide a way to examine structure and policies of innovation • Realistic application to healthcare and to RHIOs in particular requires • Careful work with industry partners • Data collection, adaptation to the business • Close interaction to ensure models’ output is relevant and useful for healthcare decisions • Application of more sophisticated and robust models awaits exploration and validation of preliminary work and the input of care providers, including most essentially, nurses!

25. So what does all this matter to Nursing?

26. Why should nurses be concerned about the economic value of RHIOs? • Assuring the information needed for patient care • Insuring a positive information benefit/burdens balance • Envisioning both data coordination and clinical practice benefits

27. imagine...

28. … the dinner plate that knows what is on it

29. Imagine that the dinner plate that knows what is on it can… … weigh the food … do a chemical analysis … use an embedded chip to … obtain nutritional information from an USDA database … query your health goals & recent intake … flash green if you’re OK or red if you must skip dessert!

30. What if there was a information pathway from the point of care, anywhere! • What if -- • All hospitals had such a plate and a patient’s nutritional status could be tracked exactly? • A kid with peanut allergy had a lunch box with a sensor to alert her whenever a peanut-containing substance was entered? • A band aid could alert you if an infection was starting?

31. Technology-enhanced Practice Nurses Activated, engaged patients & their care teams Technology in the service of nursing

32. What makes up the economic value of RHIOs to nursing? Value of information Expected value of perfect information Cost of acquiring information

33. How do RHIOs benefit Nursing? • Access to pertinent (!) health information • Clinical care providers’ records • Personal health histories • Family health history • Resources • Information • Authentication and authorization • Public health monitoring • Evidence in the context of care • Extends nursing’s patient care opportunities • Promoting self-monitoring • Creating the personal health record

34. Nursing’s role in insuring Health Information Exchange: Framework for action Point-of-Care Process of Care Delivery

35. Point of Care Issues • Safeguarding the clinical care process • Insuring knowledge for action • Creating tools for effective information integration • Assessing the economics of data collection & management

36. Process of Care Delivery • Articulate the many points of care • Expand the vision from cost/charge/drug to information for action • Advocate for fair sharing of benefits & burden

37. Capitalizing on RHIOs: Informing the Debates • Creating a full-view of the patient • When does information matter? • When does evidence matter?

38. Quantifying the costs and benefits to nursing • Practice benefits • Practice costs • Workload benefits • Workload costs • Advancing the care of vulnerable populations • Creating the nursing response set

39. Will automation change nurses, nursing orboth? H. Peplau, 1962

40. Quo Vadis, Nursing, and how will you pay for it?

41. Thanks for your interest!pbrennan@engr.wisc.eduhealthsystems.engr.wisc.edu

42. healthsystems.engr.wisc.edu