Health IT Success Stories

1. Health ITSuccess Stories AHRQ Conference September 29, 2010 Rebecca Roper

2. Success Stories • Easy-to-understand summaries of research project and its momentum to go forward • Enable Layman’s understanding of who and how health IT implementation was beneficial • Illustrations • Demonstrated, significant improvement in outcome(s) • Resiliency, Adaptability, Sustainability, Transferability of intervention, etc. • Quotes from different perspectives • Plus, succinct, substantive ~2-page detail discussion

3. Two Reports: • Using Health IT: Eight Quality Improvement Stories • Contract No. HHSA 290200900019I, T.O. 3 • Prepared by: Mathematica Policy Research • http://healthit.ahrq.gov/SuccessStoriesTHQIT (October 2010) • Success Stories from the AHRQ-Funded Health IT Portfolio (CY 2009) • Contract No. HHSA 290200900018I, T.O. 3 • Prepared by: John Snow, Inc (JSI) • http://healthit.ahrq.gov/SuccessStoriesCY2009 (November 2010)

4. 118 Individual Projects Transforming Healthcare Quality through Health IT (THQIT):

5. Transforming Healthcare Quality through Health IT (THQIT): September 2004 – January 2010 • 40 Cooperative Agreements, THQIT Implementation I (HS-04-011) • $ 53.6 Million from AHRQ, plus in-kind support • 24 No-cost extensions • 24 R-01 THQIT Value Grants (HS-04-012) • $ 33.0 Million from AHRQ • 22 No-cost extensions • 38 P-20 THQIT Planning Grants (HS-04-010) • $ 7.1 Million from AHRQ • 15 No-cost extensions • 16 Cooperative Agreements, THQIT Implementation II (HS-05-013) • $ 22.5 Million from AHRQ, plus in-kind support • 14 No-cost extensions

6. Quality Improvement

7. THQIT Implementation • EMS Responders Use Health IT to Improve Cardiac Care • Nursing home Health IT Reduces Pressure Ulcers and Increases Staff’s Job Satisfaction • Project Echo: Extension for community Healthcare Outcomes Through Telemedicine • Network of Rural Hospitals in Iowa Redesign Patient Care Workflow to Use EHR

8. EMS Responders Use Health IT to Improve Cardiac Care The Problem: • Many heart attack patients do not receive needed treatment in the recommended timeframe The Health IT Contribution: • Clinical Decision Support Software • Helped paramedics quickly determine proper treatment • Web-Based Quality Reporting System • Combined data from the prehospital and hospital experience • Data was used to tailor quality improvement programs Project Director: Dr. Harry Selker Project Location: Massachusetts AHRQ Grant: UC1 HS015124 http://healthit.ahrq.gov/FRPT_Selker_UC1HS015124

9. Results: 150% increase in the number of patients receiving treatment in less than 90 minutes Improved quality of care provided by paramedics Sustainability/Transferability: Technology was used in new communities and to address other conditions The system was integrated with other health IT EMS Responders Use Health IT to Improve Cardiac Care

10. Nursing Home Health IT The Problem: • Pressure ulcers are a prevalent and preventable condition for nursing home residents The Health IT Contribution: • Electronic documentation • Part of larger On-Time quality improvement program • Documented residents’ behavior, weight, and skin integrity • Produced reports to help identify residents at high-risk of pressure ulcer development Project Director: Dr. Susan Horn Project Location: Multi-state AHRQ Grant: UC1 HS 015350 http://healthit.ahrq.gov/FRPT_Horn_UC1HS015350

11. Nursing Home Health IT Results: • Decreased percent of residents with high-risk pressure ulcers • Improved job satisfaction Sustainability/Transferability: • 67 additional facilities have implemented or are starting to implement the technology • On-Time Manual being created On-Time emphasizes communication, you know the residents are better cared for; families are happy. ~ Quote from a staff member [At the beginning of the project] we had to practically beg [health IT] vendors to incorporate the set of On-Time reports into their system. Since then there has been a growing recognition that the value of health IT comes from impacting clinical decision making, not just automating the paper documentation process, and On-Time reports can add value to a vendor’s system. ~Quote from Principal Investigator

12. Nursing Home Health IT More information: http://ahrq.gov/research/ontime.htm http://innovations.ahrq.gov/content.aspx?id=2153

13. Telemedicine Connects Rural Residents to Specialty Care The Problem: • Rural residents often have problems accessing specialty care for complex conditions The Health IT Contribution: • Project ECHO: Extension for Community Healthcare Outcomes through Telemedicine • Enabled patients to be treated long-distance • Provided a platform for rural providers to hone their clinical skills Project Director: Dr. AroraSanjeev Project Location: New Mexico AHRQ Grant: UC1 HS 015135 http://healthit.ahrq.gov/FRPT_Arora_UC1HS015135

14. Telemedicine Connects Rural Residents to Specialty Care Results: • Improved access to care for 4,000 patients with hepatitis C Sustainability/Transferability: • Expanded program to other conditions • Project selected as winner in search for Disruptive Innovations in Healthcare-New Models We’re developing our knowledge networks so that every doctor can provide best practice care without being an expert in all chronic diseases. ~Quote from Principal Investigator.

15. Telemedicine Connects Rural Residents to Specialty Care

16. Telemedicine Connects Rural Residents to Specialty Care Facility Count=233

17. Enhancing Use of EHR Functions to Improve Quality of Care The Problem: • If EHR functions are not used effectively, preventable quality and safety issues may persist The Health IT Contribution: • Enhance use of EHR functions, examples: • 54 clinical decision support rules were added to the system • Pharmacists from the rural referral center use the EHR to remotely check medication dosing and drug alerts at critical access hospitals • Nursing documentation functionality added • Electronic ordering of tests and medications added Project Director: Dr. Donald Crandall Project Location: Iowa AHRQ Grant: UC1 HS 015196 http://healthit.ahrq.gov/FRPT_Crandall_UC1HS015196

18. Enhancing Use of EHR Functions to Improve Quality of Care Results: • Improved the timeliness of indwelling catheter removal Sustainability/Transferability: • Implemented additional clinical decision support rules • Enhanced EHR function use in other system hospitals

19. Planning and Implementation THQIT Grants • Public-Private Partnership Creates Web-Based System to Improve Rural Children’s Access to Health Care Through a Medical Home • Replication of Health Information Exchange Framework Across Oklahoma

20. The Problem: Rural, lower income children lack access to appropriate healthcare The Health IT Contribution: iReach web-based system Tracks patients enrolled in a program that helps children obtain insurance and links children to providers (Access El Dorado) Public-Private Partnership: Web-based System Improves Childrens’ Access Project Director: Dr. Gregory Bergner Project Location: California AHRQ Grants: P20 HS 014908 (planning) UC1 HS 016129 (implementation) http://healthit.ahrq.gov/FRPT_Bergner_P20HS014908 http://healthit.ahrq.gov/FRPT_Bergner_UC1HS016129

21. Results: iReach reduced errors by Access El Dorado staff 23% reduction in time to manage a single case Sustainability/Transferability: Health care providers are funding ongoing operating costs for program Public-Private Partnership: Web-based System Improves Childrens’ Access I feel that iREACH has been extremely efficient. I just know from before, it’s a much less tedious process, more streamlined….The paper process was bogging us down. ~ Quote from a user A great success [of the AHRQ-funded planning process] was creating a community of trust and commitment among the partners, so that they perceived those being served as “our” patients rather than “yours” or “mine.” ~ Quote from ACCEL program director

22. HIE Spreads Across Oklahoma The Problem: • Patients often see multiple providers and their care becomes fragmented The Health IT Contribution: • Health Information Exchange (HIE) • Local groups of providers use an established framework to develop an HIE • Local HIEs are connected to create a “network of networks” Project Director: Mark Jones Project Location: Oklahoma AHRQ Grant: P20 HS 015365 (planning) UC1 HS 016131 (implementation) http://healthit.ahrq.gov/FRPT_Jones_P20HS015364 http://healthit.ahrq.gov/FRPT_Jones_UC1HS016131

23. HIE Spreads Across Oklahoma Results: • HIE has 49 member organizations and data on 3 million patients Sustainability/Transferability: • In 2011, HIE is expected to cover 70% of Oklahoma • Central Florida providers use “network of networks” model This started as 1 network with 4 health facilities and 400,000 records, and it grew to 5 networks across Oklahoma with 49 health facilities and 37 million records in 2.5 years. ~ Quote from Principal Investigator

24. HIE Spreads Across Oklahoma

25. Value Grants • Electronic Prescribing: Lowering Patients’ Prescription Drug Costs • Integrated Telemedicine System Demonstrates Reduction in Children’s Emergency Department Visits

26. Electronic-Prescribing Lowers Drug Costs The Problem: • Prescription drug costs can put much-needed medication beyond the reach of low-income patients and those with chronic conditions The Health IT Contribution: • Electronic-Prescribing • Color-coded drug list indicating the relative cost of drugs Project Director: Dr. Joel Weissman Project Location: Massachusetts AHRQ contract: R01 S015175 http://healthit.ahrq.gov/FRPT_Weissman_R01HS015175

27. Electronic-Prescribing Lowers Drug Costs Results: • $3.26 saved per electronic prescription Sustainability/Transferability: • Health plans offered the system free of charge to more providers [The study findings indicate that] doctors want to do the right thing, but they don’t always have the right information available. ~ Quote from Principal Investigator

28. Telemedicine Reduces Children’s ED Visits The Problem: • Children often exhibit symptoms of illness and school staff are unable to decide which students need to be sent home • Wages lost when parents care for children who could be at school can be detrimental for low income families • Low income parents, needing to quickly return to work, often seek attention from costly EDs The Health IT Contribution: • Telemedicine • Schools and child care centers have access to telemedicine equipment • PCPs provide remote consultations Project Director: Dr. Kenneth McConnochie Project Location: New York AHRQ Contract: R01 HS 015165 http://healthit.ahrq.gov/FRPT_McConnochie_R01HS015165

29. Results: 83% of providers were equally confident in their telemedicine diagnoses and in-office diagnoses Children with access to telemedicine sites had 24% fewer ED visits Sustainability/Transferability: Payers started reimbursing telemedicine visits Telemedicine program is expanding to other settings Telemedicine Reduces Children’s ED Visits It’s both convenience—health care when and where you need it—and continuity—by people you trust. Who couldn’t use more of that from health care? ~ Quote from Principal Investigator

30. Results: 83% of providers were equally confident in their telemedicine diagnoses and in-office diagnoses Children with access to telemedicine sites had 24% fewer ED visits Sustainability/Transferability: Payers started reimbursing telemedicine visits Telemedicine program is expanding to other settings Telemedicine Reduces Children’s ED Visits It’s both convenience—health care when and where you need it—and continuity—by people you trust. Who couldn’t use more of that from health care? ~ Quote from Principal Investigator

31. Visits for Illness: Total: 22.9 % increase Emergency Department: 23.6 % decrease Costs of illness visits: 3.0 % decrease Telemedicine Reduces Children’s ED Visits

32. Telemedicine Reduces Children’s ED Visits Number and Cost of Medical Care Visits, by Type of visit, For Children Enrolled in Health-E-Access vs. Comparison Children

33. THQIT Synthesis • Grantee Surveys (early 2011) • Group of Follow-up Grantee interviews • Depth, Clarification • Tool/Guideline: • Use of EHR and HIE in rural hospitals

34. AHRQ’s Interest No expiration date Send articles to AHRQ JournalPublishing@ahrq.hhs.gov Include grant citation in your presentations and publications

35. Questions?

36. Success Stories from the AHRQ-Funded Health IT Portfolio (CY 2009) • Contract No. HHSA 290200900018I, T.O. 3 • Prepared by: John Snow, Inc (JSI) • http://healthit.ahrq.gov/SuccessStoriesCY2009 (November 2010)

37. Research Grants • Larry Garber: SAFEHEalth, A Health Information Exchange Improving Health Care Delivery in Central Massachusetts • PascaleCarayon: Using Human Factor Research to Increase the Success of a Health Information Technology Implementation • DenniMcColm: Measuring Quality in Physicians’ Practices in Southwestern Missouri Using and Electronic Health Record

38. SAFEHealth: A Health Information Exchange Improving Health Care Delivery in Central Massachusetts • Regional HIE that securely transfers patient health information in “real time” between providers • Dr. Lawrence Garber, AHRQ grant (UC1 HS015220)

39. SAFEHealth: A Health Information Exchange Improving Health Care Delivery in Central Massachusetts • Goal: Improve patient safety, quality of care, and health care efficiency, while protecting patient privacy • Data exchange includes medication lists, allergies, vital signs, lab results

40. SAFEHealth: Steady Increase in Number of Documents Exchanged No more huge piles of paper. I can set up a follow-up with a Fallon Clinic specialist based on the ER note…. Essentially, we have cut out the middle man – talk about GREEN and LEAN! ~ Quote from primary care physician at Fallon Clinic

41. SAFEHealth Key Decisions/Success Factors • Available through different EHRs • Single Opt in, automated at patient registration, revoke at any time/any or all organizations • Developed internally, costs shared by partners

42. SAFEHealth: Continuing as a Successful HIE • Still continues as an active HIE • Key is to instill trust and value to stakeholders • Must integrate into workflows of patients, registration staff and providers • Patients will see greater value as more organizations participate • Providers are most satisfied when data is easy to find, so data should be sorted by sections into EHR

43. Using Human Factor Research to Increase the Success of a Health IT Implementation CPOE • CPOE can reduce medication errors • Success is tied to how well CPOE is designed and integrated into workflow • Examined impact of implementation in ICUs on quality of care and safety, staff tasks and perceptions, and financial value • Conducted human factors research to evaluate and identify issues with interface and workflow • Dr. PascaleCarayon, AHRQ grant R01 HS 015274

44. Impact CPOE • Decrease in some errors while increase in others • Increase timeliness of antibiotic medication administration • Short term negative staff perception, disappeared after 12 months. • Staff tasks changed • No impact on financial value, no difference in ICU costs or physician productivity

45. Human Factors Research: Leading to More Effective Technology CPOE • Identified potential problems with the system • Addressed issues by changes in workflow or design interface • Identified potential negative impact on patients & providers before the system went live in the ICUs. ‘I thought this was a very useful process with different perspectives generating good discussion of potential issues” ~ Geisinger Employee

46. Measuring Quality in Physicians’ Practices in Southwestern Missouri Using an EHR • EHRs have potential to provide reliable, valued clinical data for quality measurement • Challenge lies in having unstructured documentation, often in many places within EHR • complicates search algorithms & makes for confusing results • Aim: To use pre-existing EHR technology to facilitate quality measurement Denni McColm, AHRQ grant (HS017094)

47. Ambulatory EHR System Used in Quality Measurement for PQRI Reporting • Participants included 15 practices within Citizens Memorial Healthcare (CMH) • Toolkit was developed to help w/ implementing quality measures into CMH’s EHR • EHR data elements were standardized • Automated data extraction was developed • Efficiency/accuracy of automated vs. manual data extraction was evaluated

48. Accurate quality measurement for PQRI reporting through an ambulatory EHR system • Compared manual to automatic for 3 diabetes measures • Coding completeness 20% for manual coding compared to 100% for automated data extraction • Automated data extraction also more accurate in reporting results

49. Outcomes and Lessons • Without accurate documentation; quality of care may not be accurately reflected • 62 quality measures built into documentation and workflow • Automated data extraction relied heavily on the use of custom documentation queries • Toolkit was expanded and refined to include custom queries • Various strategies can improve physicians’ documentation within the EHR system. • Web-based report on aggregate organizational performance (developed through this project) • Additional training on quality measures and effective use of the EHR (as was done in this project)

50. Research Contracts • Dr. Lynne Nemeth: Electronic Standing Order in Primary Care Physician Offices Boosts the Delivery of Adult Vaccinations and Other Health Maintenance Services • Dr. Doug Bell: Electronic Referrals Show Promise for Improving Quality Care in Outpatient Settings