ARRA Health Informatics Initiative and Health Reform How will we know when we get there?

1. ARRA Health Informatics Initiative and Health ReformHow will we know when we get there? Tim Carey MD MPH Jan 2010

2. Clinical Informatics under ARRAMany programs coordinated at state level • $17B to providers and hospitals to compensate them for EMR installation • Program starts in 2010 through 2013; federal coordination • $2B for ‘planning and implementation grants’ to states- to be awarded in Jan 2010 • 70 Extension Centers ($~4-12M) • 50 Health Information Exchange (NC share ~$13M) • State loan programs • Although not explicitly tied to health reform bill, many linkages and similar time-line

3. HIT Policy Committee’s “Ultimate Goal” • “The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities.” • -HIT Policy Committee, “Meaningful Use: A Definition,” Recommendations from the Meaningful Use Workgroup to the Health IT Policy Committee, June 16, 2009

4. Goals of health reformToo soon to tell whether we will have health vs health insurance reform • Enhanced access to care and insurance • Improved equity in insurance products • Improved quality of care • Improved efficiency of care (bending the cost curve)

5. From David Blumenthal • The incentives are not just about the placement of machines, they are “a down payment on health system improvement” • EHRs are part of a larger health care reform agenda that has as its goals outcome and performance improvement • Between the enactment of the legislation and the publication of final rules there will be a “period of uncertainty” • July 9, 2009; discussion with the AAMC’s Advisory Panel on Health Care

6. The Problem • EMR has been technically available for decades • Uptake has been modest: ~20% of providers • Rising health care costs, components include: • test duplication, • use of expensive options when less expensive may work just as well • Limited incorporation of evidence-based practices into clinical work flow • Patient safety • Chronic disease management

7. EMR as (part of) the solution • Reliable, legible record storage • E-prescribing (most helpful if record shared) • Disease management (most helpful if conducted at population level) • Prompts and reminders (most helpful if evidence-based, targeted, up-to-date and consistent) • Interoperability (currently difficult due to vendor issues, standards only now being developed for sharing some elements of clinical care) • Implementation has significant productivity costs, changes both hospital and office functioning.

8. EMR technologyStandards hopefully final 4/2010 • Patient demographics • Medical history • Clinical notes • Problem list • Medication list • Lab • Clinical decision support/CPOE • Ability to query for quality assessment and improvement • Registries, reminders, prompts (pop-up alerts?) • Exchange with other EMR systems • Printout AND electronic format of notes and tests for patients • ‘Results’ for radiology studies- text reports or images? AAMC 2009

9. Quality of care improvement • Low hanging fruit • No lost charts • No illegible prescriptions • Data can be accessed by all providers in a hospital/practice • More complicated but we have the technology • Moving data among providers • Chronic disease registries • Prompts and reminders (beware prompt fatigue) • More complicated and may be political • Pay for performance • Multiple quality measures

10. Improved efficiency of care • Efficiency declines with EMR installation • Improves with time ~6 month learning curve • Some savings through avoidance of duplicate lab testing (savings to whom?) • Most expensive duplicate testing is advanced imaging (savings to whom?) • Major savings in reduced hospitalizations • EHR will have little role by itself • Payment reform, QI implementation, disease management

11. Hospital Incentive Payment and Penalty Timeline Payment Year

12. Will providers be able to rise to the challenge? • Leaders and early adopters already using EHR • May have to pay to upgrade • Late adopters qualitatively different • Implementation rules from the ONC are complex • Critical role for ‘Extension Centers’ • Rural providers and small practices will present special challenges • Financially stressed, will need on-site assistance, may utilize limited EMR, ASP technology • Implementation may work best if tied to payment reform and ‘medical home’ implementation