Relationship Between: Clinical IT Adoption, Pay for Performance, and Care Improvement

1. Relationship Between: Clinical IT Adoption, Pay for Performance, and Care Improvement IHA P4P Conference A presentation by; Jeremy Nobel, MD, MPH February 15, 2007

2. A Humbling Way to Begin… “We don’t know one tenth of one percent about anything.” - Albert Einstein

3. And a Note of Urgency… “History is a race between education and catastrophe.” - H.G. Wells

4. Today’s Educational Agenda • Quick review of the health care environment and emerging and converging forces driving IT adoption • Should we care about improved clinical information management anyway? • Do economic incentives change receptivity to IT adoption and effective use? • So what? What next? • Your turn

5. Evaluating the HC Landscape Still a bigpain point Increases in premiums and workers’ earnings

6. Where is all the cost coming from? Data from: Harvard Public School of Health's project on the global burden of disease Growth in chronic diseases will continue to put increased pressure on ALL healthcare systems, worldwide. Source: WSJ WALDHOLZ ON HEALTH By MICHAEL WALDHOLZ: November 20, 2002

7. Despite Enormous Expenditures, We’re Simply Not Getting the Job Done Catherine Cowie, Researcher at the National Institute of Diabetes and Digestive and Kidney Diseases

8. 45% 55% Patients do not receive care in accordance with best practices Patients receive care in accordance with best practices And Are We Even Getting Value for What We’re Paying? % of Recommended Care Received 64.7% Hypertension 63.9% Congestive Heart Failure 53.9% Colorectal cancer 53.5% Asthma 45.4% Diabetes 39.0% Pneumonia 22.8% Hip Fracture Source: Elizabeth McGlynn et al, RAND, 2003

9. What Else is Going On…? Consumerism is re-defining the healthcare landscape Increasing consumer expectations Transformation of doctor-patient relationship Demands for a greater quantity of in-depth information Members seeking out health and wellness information Willingness to manage/control greater portion of activities Increased interest in understanding and monitoring health conditions

10. And Let Not Forget: The HHS Policy Mandates • Transparency • Emphasis on Performance • Reimbursement Reform • Information Technology

11. Is Information Technology an “Ends” or a “Means” • Necessary vs. sufficient • Current “provider-side” clinical IT options: • EHRs • CDMS • E-Rx • Telehealth • On line consultations ( E-visits) • Unintended consequences

12. Skills Awareness Tools Motivation Its not a secret: Keys to Sustained Behavior Change How can we achieve this with providers, and drive engagement with improved care delivery processes?

13. Evolution of Technology Evolution of P4P Evolution of Benefit Designs What is the Opportunity Right Now? Cheaper Faster Better Smaller Ubiquitous Connected Moving from Pay for “Improved Process” to Pay for “Improved Outcomes” Personal Health Record Consumer-directed movement HSA/HDHPs Employer-sponsored lifestyle reward programs Incentives for lower-cost alternatives

14. 1,000 Patients 750 “Health Events 250 Saw Physician 4Hospitalized So What’s the Opportunity? Distribution of Health Events in a Typical Population Preventive Care Self-Care Coordinated Care

15. Can P4P Get Us There? • IT Depends… • Here is some of what we have observed

16. IT Measure 2:Point-of-Care Technology Percentage of Groups

17. Correlation Between IT and Other P4P Domains

18. Condition Mgt. General Health Communications But are we anywhere close to having the information management we need? Personal Health Record

19. Real-time info and decision support for: providers, payors, patients, others? Efficiency Engine PHR-enables mid-level provider for higher-touch, lower- cost care delivery PHRenables self-care, avoids duplicate tests, eliminates medication conflicts Consumer-ControlledPermissions Care TeamCoordinatedCommunications The PHR: More Than Just a Documentation System! Personal Health Record

20. Advantages: • Seamless Information Exchange • Build & Maintains Relationships • Coordinate Effective Action • Emergence of: • Adv. Telephony • Linked Networks • “Smart” Devices • Internet & Web Converging Communication Channels “High Tech - High Touch” I Admire Technology, But…Just a Reminder,Its Still All About People

21. Greatly enhances the quality of data populating personal health records Easy-to-use, Web-enabled facilitates utilization Daily use introduces new health behaviors Dramatic price drops enable cost-effective deployment of devices Continua Alliance recently formed; goal is to reduce barriers to deployment and use Leveraging the PHR: Biometric Tools For Patients and Providers

22. Good News!Much of this is Ready to Go Right Now!

23. Logical Ties Among Various Data Sources

24. Interruption @ Work High-Cost Care Office Follow-up Asthmatic High-Risk Asthma Event Without IT Enabled Personal Disease Management System... Adds to Escalating Care/Coverage Costs along with Possible Productivity Impact = 1.5 days

25. Biometric Web Portal Health Coach/MD Remind or Adjust Follow-up Emergent Patient/Employee Database Early-warning prevention Asthmatic ComplianceOn-track At-a-boy With IT Leveraged Personal Disease Management System...

27. How Can We Best Include Providers? Simple: Give them convenient and secure access to the information and tools in the PHR, in advance of full EHR deployment • Online patient registries • Evidence based guidelines • Automated regulatory and quality reports: HEDIS, DQIP, DPRP; payments tied to outcome achievement • Trend identification at the population and patient levels • Automated uploads from personal monitoring and POC devices

28. EHR “Lite” For Providers-Patient Registry, Alerts and Reminders

29. 1,000 Patients 750 “Health Events 250 Saw Physician 4Hospitalized What would “winning” look like? Distribution of Health Events in a Typical Population Preventive Care Self-Care Coordinated Care

30. Reducing…resources required to achieve same or better outcome Elimination of duplicate diagnostic tests Streamlining of work-ups to exclude low-yield dx tests Avoiding provider visits simply to “check in” and collect data Substituting…lower resource-intensive option in either prevention, diagnosis or treatment People (e.g. mid-level providers, pharmacists, health coaches, “efficient” provider networks) Place (e.g. shift to home or lower cost ambulatory setting) Product (e.g. shift to generic Rx) Potential Gains in Efficiency and Quality are Clear Avoiding… complications, adverse reactions, or sub-therapeutic treatment improves both quality and efficiency • Medical regimen adherence • Early detection or avoidance of ADE’s or side-effects • Reduction of ED and Hospital use

31. Summary: What are the KEY IT “Wins” that P4P should address? • The ability to share critical administrative and clinical information among different stakeholders, accompanied by guidance for improved clinical decision making and behaviors • A way to link explicit rewards and incentives to encourage specific “actions” on the part of both patients and providers • Automatic accumulation of outcome related data on cost and quality that will allow continuous system improvement • AND most importantly, a way to enhance efficiency and make health care more affordable

32. Potential Barriers and Obstacles • Linking various data sources • How do we build and manage cooperation among payer systems, provider systems, and various 3rd -party vendors? • Participation among providers • How do we gain adoption and utilization and make this part of health care? • Return on investment • How do we measure and demonstrate success?

33. How can we get started? • Building on good work already done • Creating alignment among stakeholders • Developing an IT approach that is configurable, flexible and low cost • Using IT to create “connectivity” between patients and providers • Design “Wide”, Implement “Skinny”

34. We Have Met the Enemy and They Are Us! “The intricate machinery of our health care system can no longer grasp the threads of experience…. Too often, payers, physicians, and health care executives do not share common insights into the life of the patient… The health care system has become an organism guided by misguided choices; it is unstable, confused, and desperately in need of a central nervous system that can help it cope with the complexities of modern medicine.” Paul Ellwood, M.D.

35. Real-time info and decision support for: providers, payors, patients, others? Efficiency Engine PHR-enables mid-level provider for higher-touch, lower- cost care delivery PHRenables self-care, avoids duplicate tests, eliminates medication conflicts Consumer-ControlledPermissions Care TeamCoordinatedCommunications A New “High Performance” Central Nervous System for Health Care! Personal Health Record