Blackford

Middleton, MD, MPH, MSc, FACP, FACMI, FHIMSS Director, Clinical Informatics Research & Development Partners Healthcare System Boston, MA

Meaningful Use of Health IT The Value of Healthcare Information Exchange and Clinical Decision Support SOA at Partners Healthcare Smart Forms in the Longitudinal Medical Record The Clinical Decision Support Consortium Issues and Limitations

Prone to error Lots of information but no data Limited decision support, or measurement Does not integrate with eHealthcare Will not transform healthcare

US Healthcare remains largely unwired, fragmented, variable in process and outcomes, with signiKicant disparities, and unabated growth in expense Despite increased efforts at improved quality, patient safety, cost containment, and HIT adoption HITECH Act (Health Information Technology for Economic and Clinical Health Act) $19.2B net ($36B overall) over 6 years for HIT Every American Citizen with EMR by 2014 HIT adoption as a prelude to healthcare reform Healthcare reform as component of economic recovery

President Obama signed into law the American Recovery and Reinvestment Act (ARRA) Feb 17, 2009
Title IV of Division B of ARRA amends the Social Security Act by establishing incentive payments to eligible professionals (EPs) and eligible hospitals to promote the adoption and meaningful use of interoperable health information technology and quali;ied EHRs. These provisions, together with Title XIII of Division A of ARRA, may be cited as the Health Information Technology for Economic and Clinical Health Act or the HITECH Act.

These goals can be achieved only through the effective use of information to support better decision- making and more effective care processes that improve health outcomes and reduce cost growth
Improved outcomes Advanced clinical processes Data capture and sharing

Phased-in series of improved clinical data capture supporting more rigorous and robust quality measurement and improvement.

Connecting for Health, Markle Foundation Achieving the Health IT Objectives of the American Recovery and Reinvestment Act April 2009

Entitlement Funds
Medicare Payments Medicaid Payments

Appropriated Funds
Healthcare Information Exchange

EHR Adoption Loans HIT Extension Programs Workforce Training New Technologies R&D Grants

 Goal 85% of patients with high blood pressure and cholesterol have it well controlled Advanced care processes Use of evidence-based order sets Monitoring and addressing medication adherence Clinical decision support at the point of care Patient outreach and reminders Quality benchmarking and reporting Clinical data capture (can be queried and trended) Systolic & diastolic blood pressure Medication and Problem list Laboratory tests and procedures Prescription Kill histories
ONC Health Policy Committee

 RAND: Systematic Review on health IT Increased adherence to guideline-based care: 5-66% (most clustering 12-20%) Improved medication safety:
Serious medication errors: 55-86% Improvements in dosing: 12-21%

Enhanced surveillance and monitoring Comparisons of VHA vs. national healthcare system performance measures. VHA was: 16% better on overall adjusted quality 13% better on chronic disease care 20% better on preventive care VHA factors: widespread EHR system adoption; PM program
Sources: Chaudhry, et al. Ann Intern Med, 2006. Asch S, et al. Ann Intern Med, 2004.

 EHR Effects Completeness, correctness, decision support, formulary, brand to generic, duplicate/redundant meds and tests, charge display WorkKlow support, messaging (pt/provider), referral, A/R, team CPOE Effects Reduction in hospitalization/LOS due to ADEs, clinical decision support HIEI Effects Reduction in unnecessary and redundant tests and procedures Labor cost savings Telehealth Effects Reduction in patient transport, utilization of hospitals, and physician ofKice visits PHR Effects Administrative time savings Reduction in hospitalizations and physician visit utilization www.citl.org Improved medication safety Reduction in redundant laboratory tests

 Net US could save $150B with HIT adoption, or approximately 7.5% of US Healthcare Expenditure The Value of Ambulatory Computerized Order Entry (ACPOE)
$44B US nationally; $29K per provider, per year

The Value of HealthCare Information Exchange and Interoperability (HIEI)

The Value of IT-enabled Chronic Diabetes Management (ITDM)

The Value of Physician-Physician Tele-healthcare

The Value of Personal Health Records

The Value of Health IT in the Veterans Health Administration

Class 1: Basic Rx- only 2: Basic Rx-Dx 3: Intermediate Rx-only 4: Intermediate Rx-Dx 5: Advanced RxDx

Medication (Rx) OE

Diagnostic (Dx) OE

Record and print prescriptions. Structuring data capture, passive references Record and print orders. Passive Passive medical references. medical references. Email or fax prescriptions. Rx & Order-specific decision support, Order-specific decision with some patientfax orders. Order-specific data Email or support. decision-support EDI with pharmacy. EDI with laboratory/radiology. Sophisticated Rx & Order-specific decision support, Patient-specific decision Patient-specific decision support. with most patient data, EDI support.

$28K $12.3K $16.6K

$2.2K

$2.5K

$44B $19.5B $26.3B

$3.5B

$4B

HIEI Healthcare Information Exchange and Interoperability US health care system is too complex to model. CITL focused on data from doctor-patient encounter:
Public Other Health Provide r Radiology

Provider
Pharmacy Payer Secondary

Providers (hospitals, outpatient ofKices) & common care partners Includes clinical & administrative data

Excluded:

Laboratory

Secondary transactions Transactions within organizations

Level

Description Non-electronic data Machine-transportable data Machine-organizable data Machine-interpretable data

Examples Mail, PC/information technology No phone PC-based and manual fax, secure e-mail of scanned Fax/Email documents Secure e-mail of free text or Structured messages, incompatible/proprietary file non-standard content/data formats, HL-7 message Automated entry of LOINC resultsStructured messages, into a from an external lab primary care providers electronic standardized content/data health record

1 2

Value during 10-year Implementation

Value per year after Implementation

Level 2 Level 3 Level 4

$141 B -$34 B $337 B

$22 B $24 B $78 B

Value of HIE standards is the difference between Level 3 & 4

A Roadmap for Na,onal Ac,on on Clinical Decision Support to ensure that op-mal, usable and eec-ve clinical decision support is widely available to providers, pa-ents, and individuals where and when they need it to make health care decisions.
Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. J. Am. Med. Inform. Assoc. 2007;14(2):141-145.

Clinical decision support has been applied to increase quality and patient safety improve adherence to guidelines for prevention and treatment avoid medication errors Systematic reviews have shown that CDS can be useful across a variety of clinical purposes and topics, but dissemination is limited EHRs have been limited in their ability to provide physician performance feedback on quality

Current adoption of advanced clinical decision support is limited due to a variety of reasons, including: Limited implementation of EMR, CPOE, PHR, etc. DifKiculty developing clinical practice guidelines. A lack of standards Absence of a central knowledge resource. Functional limitations of CDS in commercial EHRs. Challenges in integrating CDS into the clinical workKlow. A limited understanding of organizational, and cultural issues relating to clinical decision support.

Chaudry B., et al. Ann Intern Med. 2006;144:742-752.

Regenstrief Institute

Brigham & Womens Hospital / Partners HealthCare

VA Healthcare System

Intermountain Healthcare

a recent systematic review in Annals of Internal Medicine found that 25% of all studies took place at the above institutions.

Example: CPOE Application 1

Example: CPOE Application 2

Example: CPOE Application 3

Applications Have:
Different Presentation Different Logic Different Rules Different Dictionaries Different Databases

GUI and Work;low

GUI and Work;low

GUI and Work;low

LOGIC

LOGIC

LOGIC

Dictionaries And Rules

Dictionaries And Rules

Dictionaries And Rules

Patient Data

Patient Data

Patient Data

PORTAL Application 1 GUI and Work;low Application 2 GUI and Work;low Application 3 GUI and Work;low

Shared Knowledge-bases, Dictionaries, Rules Engine, and Data

Logic Dictionaries and Knowledge- bases Patient Data

Maintaining duplicative knowledge, rules, and patient data is expensive People must manually keep knowledge-base and rules in sync Maintaining duplicative logic, rules, and patient data is dangerous Clinical logic and rules can become outdated if poorly or inconsistently maintained Users have fragmented, incomplete access to patient data Sharing logic, rules, and patient data Does not mean that all applications must look the same or share the same workKlow Makes future portals (mash-ups) easier to create

Increasing the level of enterprise integration is supported by core IT services that can be integrated with and/or accessed by site-based applications. These IT services integrate and communicate with the site-based and enterprise applications via a service-oriented architecture made up of layered components.

This approach leverages: A common technology infrastructure; Common data, terminology and rules (especially those associated with allergies, problems and medications); Shared clinical services and applications; and Customized views and capabilities for speciKic user types.

ID Number: G00130115

Secure Messaging

Patient Lists Schedule

Clinical Alerts

Knowledge Links Population Management Task Management

11/12/09

32

Clinical documentation-based Actively engage user during workKlow Organize relevant data Request new data Integrate decision support, ordering, patient education, and documentation

ClinicalTrials.gov Identifier: NCT00235040

Now GE Office Centricity

Smart View: Data Display

Smart Documentation

Smart Assessment, Orders, and Plan

Assessment and recommendations generated from rules engine Lipids Anti-platelet therapy Blood pressure Glucose control Microalbuminuria Immunizations Smoking Weight Eye and foot examinations

Medication Orders

Lab Orders

Referrals

Handouts/Education

Rules If patient has DM then goal BP < 130/80 If the average of the blood pressure at the last 2 visits (in the last year) is above goal then return..

To assess, de;ine, demonstrate, and evaluate best practices for knowledge management and clinical decision support in healthcare information technology at scale across multiple ambulatory care settings and EHR technology platforms. www.partners.org/cird/cdsc
AHRQ Contract #: 290-08-10010

 Goal: To assess, deKine, demonstrate, and evaluate best practices for knowledge management
and clinical decision support in healthcare information technology at scale across multiple ambulatory care settings and EHR technology platforms.

Signi;icance: The CDS Consortium will carry out a variety of activities to improve knowledge
about decision support, with the ultimate goal of supporting and enabling widespread sharing and adoption of clinical decision support.

1. Knowledge Management Life Cycle 2. Knowledge Specification 3. Knowledge Portal and Repository 4. CDS Public Services and Content

5. Evaluation Process for each CDS Assessment and Research Area 6. Dissemination Process for each Assessment and Research Area

40

41

120000

100000

80000 Total calls: Total success calls: Total failure calls: 40000

60000

20000

49

28

2807

February

March

May

500 450 400 350 300 250 200 150 100 50 0 February March May

Perceived Bene;its
Simpler software design and implementation, by decomposing complex problems into smaller, more manageable ones. Improved software reusability through enhanced reuse of existing IT resources. Improved adaptability to changing business requirements. (knowledge management) Cost savings consequent to the above beneKits.

Limitations
Designed for independent re- usability from outset? Localization to context of consuming application Framework building and reference architecture Service orchestration and discovery Business case (traditional, as well as IT) Service-level agreements (and trust) Fair market economy

Nadkarni PM, Miller RA J Am Med Inform Assoc. 2007;14:244 246.

Where are we?

Blackford Middleton, MD [email protected]