TRI-STATE HIT CONFERENCE

1. TRI-STATE HIT CONFERENCE November 2009

2. AGENDA • Obligatory joke or light-hearted reflection on the topic that mildly surprises the audience and gets their attention (at least for the moment) • (Extra bonus points if it has an underlying deep concept that connects with the audience and with the rest of the presentation) • (Extra Extra bonus points if it’s a joke AND a deep concept) • (Extra Extra Extra bonus points if the audience agrees) • Federal Health Information Technology Landscape • MA eHealth Collaborative experience with health IT • The role of hospitals in health IT

3. HEALTH CARE ISN’T THE FIRST..........IT’S THE LAST • In 1901, there were 2,000,000 phone users in the US • Cumulative public and private investment was $500M, or $13B in 2009 dollars (about $6500 per user) • Networks were operated by: • AT&T: ~1.3m • Independent networks: ~700k • Number of independent networks: 2,811

4. MUCH OF THE ACTIVITY IN A CLINICAL SETTING IS ABOUT INFORMATION MANAGEMENT Integrate information Take action Gather information Medical history Document in record Physician’s own knowledge Recommend diagnostic test Medical record Recommend therapy Physical exam Medical references Recommend consult Laboratory & other tests Consultation with colleagues Communicate with colleague Consultants & colleagues Communicate with patients Billing Source: Adapted from Ebell MH, Frame P, “What can technology do to, and for, family medicine?” Family Medicine.

5. THE CHALLENGE IS THAT THIS INFORMATION COMES FROM MANY DIFFERENT PLACES AND IN MANY DIFFERENT FORMS Hand-written notes, transcribed notes Hard copy reports (fax, mail) Images Letters Copies of copies, faxes Faxes of copies, faxes Medical record Existing chart Medical history Hand-written notes Transcribed notes Physical exam Patient visit Laboratory & other tests Consultants & colleagues Hand-written notes Hard copy reports (fax, mail) Electronic reports Hard copy images Electronic images Phone Fax Mail Computer

6. Prescription refill request on fax machine (Right behind the joke of the day) “Hey Sally! Where is Mrs. Jones x-ray?” THE REALITY Printer with results from one lab Unopened mail Courier just dropped off more envelopes Unsorted results Web portal (from one hospital) About to ring with stat results

7. OUR HEALTH CARE “SYSTEM” ISN’T REALLY A SYSTEM AT ALL 7,500 hospitals 670K practicing physicians in US 67% are community hospitals 150K hospital-based 520K ambulatory 170K practices 80% are solo or 2-physician practices 96% don’t have a fully functional EHR

8. EHR IMPLEMENTATION PROCESS Illustrative EHR Implementation Value Chain Overall project management Vendor contracting and management Readiness assessment & planning Practice transformation & workflow planning System deployment & Implementation Reporting, decision support, and performance measurement Inter-operating with internal and external systems Post- implementation support • Gaps at any point along the way will kill adoption

9. 50+ physicians 1-9 physicians % % 50+ physicians 1-9 physicians Growing at about 1.5 percentage points per year CAGR = 8.6% CAGR = 8.2% 110 million 801 million 911 million visits in 2004 THE EHR MARKET IS MOVING, SLOWLY, BUT ALSO CREATING A DIGITAL DIVIDE IN THE PROCESS • Source: CDC; Center for Health Systems Change; National Ambulatory Care Survey

10. American Recovery and Reinvestment Act (ARRA) (aka “the Economic Stimulus”)

11. RECOVERY ACT FUNDING FLOWS Funding Source Distribution Agency Program Funding Use Fund Recipients / Beneficiaries Medicare Payment Incentives ~$20B CMS Medicare Carriers& Contractors • Acute care hospital • Children’s hospitals Entitlement Funds Requires ‘Meaningful’ use of EHR Physicians Medicaid Payment Incentives ~$14B CMS • Nurse Practitioner • Midwife State Medicaid Agencies Requires 30% share of Medicaid (except Children’s Hospitals) Federally Qualified Health Centers Designated State Entity HIE Planning & Development (at least $300M) ONC Planning Grants Implementation Grants • Non-profit • Consulting • Vendors EHR Adoption Loan Program ONC Loan Funds for States State Gov’t Loan Funds for Indian Tribes Loans Health IT Extension Program HHS Agency TBD Provider Organizations Health IT Research Center Indian Tribes Appropriated Funds Services Regional Extension Centers • Non-profit • Consulting • Vendors Least Advantaged Providers Workforce Training Grants HHS, NSF Medical Health Informatics EHR in Med School Curricula • Higher Education • Medical School • Graduate schools NST, NSF New Technology R&D Grants Health Care Information Enterprise IntegrationResearch Centers • Federal Gov’t Labs 10

12. Office of the National Coordinator HIT Policy Committee Private HIEs Office of Civil Rights Military Health System EHR Product Vendors HIT Standards Committee EHR Product Certifiers Private Providers NIST SSA Veterans Health (largest provider) CMS (largest payer) HHS TAKE 2: RECOVERY ACT FUNDING FLOWS • Payoff: • Safer, higher quality care • Cost savings • Privacy protection • Healthier people Nationwide Health Information Exchange (NHIN) Privacy & Security Regulations & enforcement Premiums / Eligibility VA-DOD Health Info Exchange (largest HIE) “Meaningful Use” Measures HIT policy & stds EHR Standards Reimbursement EHR Standards Claims/MU Policy “Meaningful Use” Measures EHR/MU Standards EHR Products EHR Products EHR Products Policy Certifier Accreditation Product Certification 2

13. TAKE 3: RECOVER ACT FUNDING FLOWS Various studies and reports Health information exchanges Regional health IT resource center Regional health IT extension centers State implementation and planning grants EHR loan funds NIST certication infrastructure $47B $2B $45B Direct payments to individual providers

14. US GOV’T EXPECTING TO GET 50% PAYBACK ON ARRA HEALTH IT INVESTMENTS -$13B +$35B +$1B Financial benefit: $16B $2B -$3B $2B $33B Net cost: $20B $18B Increased tax revenues Incentives & ONC funding Savings to government Cost of administration

15. MEANINGFUL USE

16. MEANINGFUL USE FLOW CHART 2015 2013 2011 Outpatient Objectives & Measures 2015 Vision Health Outcomes Policy Priorities Care Goals 2015 2013 2011 Inpatient Objectives & Measures

17. MEANINGFUL USE VISION FOR 2015 • Prevention, and management, of chronic diseases • A million heart attacks and strokes prevented • Heart disease no longer the leading cause of death in the US • Medical errors • 50% fewer preventable medication errors • Health disparities • The racial/ ethnic gap in diabetes control halved • Care Coordination • Preventable hospitalizations and re-admissions cut by 50% • Patients and families • All patients have access to their own health information • Patient preferences for end of life care are followed more often • Public health • All health departments have real-time situational awareness of outbreaks

18. Vision gets boiled down to Policy Priorities and Care Goals…. • Provide access to comprehensive care data • Use evidence-based order sets and CPOE • Apply clinical decision support at the point of care • Generate lists of patients who need care and use them to reach out to patients (e.g., reminders, care instructions, etc) • Report to patient registries for quality improvement, public reporting, etc Improve quality, safety, efficiency & reduce health disparities Engage patients & families • Provide patients and families with access to data, knowledge, and tools to make informed decisions and to manage their health 2015 Vision Improve care coordination • Exchange meaningful clinical information among professional health care team Improve population and public health • Communicate with public health agencies Ensure adequate privacy & security protections for PHI • Ensure privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law • Provide transparency of data sharing to patient

19. 94 MEANINGFUL USE REQUIREMENTS IN CURRENT RECOMMENDATION TO CMS • Involve health information exchange

20. ALIGNMENT OF INPATIENT AND OUTPATIENT REQUIREMENTS • Inpatient • Outpatient • Involve health information exchange

21. FROM HERE ON IN, IT GETS PRETTY UGLY..... Detailed Meaningful Use Requirements (as recommended by HIT Policy Committee)

22. MEANINGFUL USE REQUIREMENTS AND HIE • Lab results delivery • Prescribing • Claims and eligibility checking • Quality & immunization reporting, if available 2011 • Substantially steps up exchange • Provider to lab • Pharmacy to provider • Office to hospital & vice versa • Office to office • Hospital/office to public health & vice versa • Hospital to patient • Office to patient & vice versa • Hospital/office to reporting entities • Registry reporting and reporting to public health • Electronic ordering • Health summaries for continuity of care • Receive public health alerts • Home monitoring • Populate PHRs 2013 • Access comprehensive data from all available sources • Experience of care reporting • Medical device interoperability • Starts to envision routine availability of relatively rich exchange transactions • “Anyone to anyone” • Patient to reporting entities 2015 Meaningful Use objectives requiring health exchange • Increases volume of transactions that are most commonly happening today • Lab to provider • Provider to pharmacy

23. THE INCENTIVES ARE SPREAD OUT OVER A NUMBER OF YEARS • Represents maximum allowable payments • Actual incentive equals LOWER of 75% of annual Medicare Part B professional services charges or $44K

24. PAYMENTS MAY NOT COVER THE OUTLAYS AT AN INDIVIDUAL PHYSICIAN-LEVEL $K Physician cost Medicare incentive Net gap: -$21K -5 +8 -10 +4 -5 +2 -5 +12 -30 -5 +18 -5 2009 2010 2011 2012 2013 2014 2015

25. NATIONAL REGIONAL HIT EXTENSION CENTER PROGRAM HIT Research Center (HITRC) REC REC REC REC REC REC REC REC REC REC REC REC REC REC REC REC REC REC REC REC REC REC

26. ESTIMATED STATE-LEVEL HIE FUNDING ALLOCATIONS $ millions IL OH IN

27. State Medicaid Orgs HIT Policy Committee HIT Standards Committee National Coordinator CMS FEDERAL REQUIREMENTS PROCESS OVERVIEW New technology certification regime Meaningful Use Certification Requirements Meaningful Use Incentive Rules New technology certification regime State Medicaid Meaningful Use • Meaningful use • EHR certification • Health exchange • Clinical quality • Clinical operations • Privacy & Security HITSP – enabling healthcare interoperability Slide

28. Company launched September 2004 • Non-profit registered in the State of Massachusetts • CEO on board January 2005 • Backed by broad array of 34 MA health care stakeholders MAEHC MISSION: FACILITATE UNIVERSAL EHR ADOPTION

29. Outcomes analysis MAeHC-level: Analysis • Benchmarking • Negotiated reporting to plans • P4P • Chart review MAeHC-level: QDC Community-level: HIE • Brockton • Newburyport • North Adams Provider-level: EHR MAeHC ARCHITECTURE AND DATA FLOWS

30. CLINICAL USE OF DEPLOYED EHRs% of Encounters Documented Clinically in EHRs (Q2 2006 – Q2 2008) % Community 1 Community 2 Community 3

31. ACTIVE USAGE MEASURMENT Note: These measures are valid as relative scores, not absolute measures, because not all visits require documentation in each of these categories

32. CLINICIAN ATTITUDE TOWARD EHRs (I) Worse At least as good as before Effect of EHRs on: Controlling costs Quality of care Interactions within healthcare team Workflow Patient-physician communications Efficiency of providing care Medication errors n = 319, 2009

33. CLINICIAN ATTITUDE TOWARD EHRs (II) Worse At least as good as before How much do you agree: EHR has hurt my earning potential from clinical activities EHR has been more costly than expected EHR has created more opportunities for errors EHR has prevented more errors than it as created EHR has given me more control over my practice than I had before EHR has helped to streamline processes and improve office productivity n = 319, 2009

34. Records Received By MAeHC QDCThrough May 2009 000 • 437,000 total records since Jul 2008 • 57,000 records received in May 2009 Brockton Newburyport North Adams

35. MAEHC QDC DATA COUNTS (I) Patients Patient visits Brockton Newburyport North Adams Diagnoses Procedures

36. MAEHC QDC DATA COUNTS (II) Problems Lab results Brockton Newburyport North Adams Medications Vaccinations

37. MAEHC QDC REPORT SCREENSHOTS Peer comparison report (2) Peer comparison report (1) Benchmark summary report Drill-down report

38. QDC BUFFER PROMOTES EFFICIENCY AT BOTH ENDS eMeasures Quality Data Center QRDA Level 1 CMS “meaningful use”

39. LESSONS LEARNED FROM 600+ EHR IMPLEMENTATIONSKey Failure Factors Lack of leadership Lack of preparation Lack of office commitment Lack of project management Over-confidence in vendors Disruption in revenue cycle IT failures

40. WORKFLOW? WHO CARES? Common physician perception MAeHC experience “I’m not going to worry too much about this – that’s what I’m paying my vendor for” • EHR and IT vendors can’t do this – they’re technology experts, NOT business experts • Vendors aren’t responsible for the entire picture anyway – only you are • Your current processes are optimized for a paper world, not an electronic one • “Paving over the cowpaths” will make things worse – the EHR will magnify existing problems “My workflow is basically fine – I just need to make it electronic” • You can’t afford to wait until later • Workflow redesign concepts apply to all EHRs • You’ll refine more once you’ve gotten to know the system……and yourself “I can’t afford to think about workflow change until I know the software better” Poor workflow planning is thought to be the leading cause of EHR failure

41. MANY PLAYERS MUST MESH FOR SMOOTH IMPLEMENTATION Your Project Manager You Your EHR Vendor Your IT Vendor

42. MAEHC IMPLEMENTATION TAKES ABOUT 16 WEEKS I Design Workflow optimization System design II Site prep System install and check EHR customization III Pre-training preparation Go-Live Plan On-site training IV Support kickoff Evaluate Improve Project Kickoff EHR vendor Kickoff Clearing-house setup Hardware install Trainer on-site Go live • Week • 16 • Week • 12 • Week • 8 • Week • 4 • Week • 0 • Project phases Deploy Activities performed by MAeHC staff Train Master • Key dates

43. COORDINATION REQUIRED AT THE TASK-LEVELMAeHC Small Practice Example HW integrator EHR vendor Practice Implementation Phase Milestone Step • Workflow Design Meeting • Initial Design • EHR Implementation Kick-Off Call • Set baseline schedule • Clearinghouse enrollment filed • Final design • Site remediation complete • Hardware delivered • Hardware deployed • EHR vendor network check • EHR application installed • Lab interface acceptance • Existing data migration acceptance • Total System Check • Trainer on-site • PMS go-live • Full-system go-live • EHR Support Kick-Off Call • Post-Implementation Check-In Design I Deploy II Train III Master IV

44. WHAT TO DO NOW? • If you don’t have an EHR: • Get yourself emotionally and financially prepared to get one • Seek out implementation assistance – DON’T DO THIS ON YOUR OWN • Seek out financial assistance – IPA incentives, existing Medicare incentives (PQRI, eRX), etc • If you do have an EHR: • Are you on a CCHIT-certified EHR? • Assess what you’re going to need to do to get to “meaningful use” • Interoperability • Are you really doing eprescribing? • Are you receiving lab results electronically? • Are you ordering labs electronically? • Quality reporting • Are you documenting to enable electronic reporting of quality data? • Is your system capable of electronic reporting of quality data?

45. NO MATTER HOW MUCH YOU PREPARE, YOU’LL BE IN FOR A RIDE …but if you plan, prepare, and commit yourself and your staff, you should be able to achieve something like this…. Your Hopes You may not be able to avoid this… Time Go-live day

46. HOSPITALS WILL BE A KEY ORGANIZING FORCE IN THE TRANSITION TO A ‘WIRED’ SYSTEM • Along with IPAs and PHOs, hospitals are the only real connection points in the health care delivery system • As IT plays an increasingly important role, physicians will lean even more heavily on hospital expertise in information technology, project management, and vendor management • Hospitals’ large role in laboratory and imaging markets requires engagement in this IT transition, whether they want to or not

47. IF INFORMATION TECHNOLOGY IS THE ANSWER,WHAT’S THE QUESTION? CPOE Lab/rad Other HIS • How important is it to your hospital strategy to align these entities? • What levers do you already have? • What levers do you need to get?

48. OVERALL STRATEGIC VIEW OF HOSPITALSYour Mileage May Vary Strengths Weaknesses • Established organization • IT organization • Project management experience • Vendor management experience • Trust in community • Lack of understanding of ambulatory IT • Resource constrained • Lack of trust in community Opportunities Threats • Use IT as way to align physicians and hospital for mutual gains • Mutual reinforcement of CPOE and ambulatory outreach strategy • Inability to align individual physician IT strategies • Physician expectations exceeding hospital capabilities • Lose business • Future funding liability

49. WHERE ARE YOU NOW? WHERE DO YOU WANT TO BE? Arms length “Authority” Respected partner Community leader Selective In-kind Would love to, but…. Resources Dedicated Highly penetrated with disparate systems IT landscape Few large systems Greenfield No formal physician organiztion No employed docs Single physician organization Lots of employed docs Multiple physician organizations Organizational landscape Self-contained market Little lab/rad competition Competing large system nearby Lab/rad competition Competing community hospital Competition

50. WHAT “ROLE” WILL SUPPORT YOUR STRATEGY? Sugar daddy Governance & leadership IT organization Infrastructure steward Data provider