Welcome Great to be back in Grand Junction Thanks to my good friends at QHN and CBC for the invitation! I bring greetings from CU dept of family medicine and our practice based research consortium, SNOCAP.
No more conflicts!
Here's what we're going to cover...
So, lets start with the connection between Health Information Technology and transformation...
Read the slide... Just a short time ago, this is what I heard when I was recruiting practices for a study of the software that became Cielo Clinic...
With the exception of colorectal cancer screening, We have hit a ceiling
So this might be the answer...not exactly We have entered the era of "measured" care
The big question is, who is doing the measuring and how good are the tools? Ideally...
We know that measurement done well, changes practice... (Discuss slide)
In reality, practices need more than just measurement, they need targets.
Without measurement and meaningful targets... Essentially we are talking about a working speedometer and a reasonable speed limit.
How can measurement transform our work?
So, if we accept that measurement makes a difference... Now we have to examine our yardsticks... What are we using to do the measuring?
So lets talk about those yardsticks... Mostly we are talking about EMRs, but also the other kinds of tools you've been using here on the western slope like CCR.
But first, EMRs... Oh boy...here we go.
Is Newt Gingrich to blame for this too???
Nah, President Bush gets some too.
And President Obama! But where are we in terms of adoption?
One measure is meaningful use attestations. Could be characterized as high end users. This graph was published earlier this year...
It shows progress as of May 2012
More recent data from CMS shows that as of January of this year we've added some more, but still not where we'd like to be. As many of you know this is not easy... It's hard work... And we are seeing some concern growing...
Read the bullets
One more piece of concerning news...
And yet, folks are still buying EHRs This curve is steadily marching up.
Read the slide.
Well, here's mine. Epic! Can I tell easily in this mess what this patient might be due for? Reminds me out of something from the X-files...
The truth is in there...somewhere...if you can find it...let me know if you can!
So what about our colleagues on the edge...those real early adopters... Where are they now and what are they using...
So, it remains an open question whether our EMR vendors will really step up to the plate. They are still selling software. Is there a business case for them? Rumor has it they are lobbying to take decision support out of MU. We won't speculate about population health. Yikes!
Read the slide Beyond decision support, what about population health tools... Here we are beginning to see talk about "big data"
These guys are going to be under the gun... Big money is flowing into big data.
Here's an industry analysis from Silicon Valley.
Lots of factors driving this...
Lots of challenges too...but it is going to be disruptive when players like IBM really weigh in.
These are the questions I'm asking as I look at this space... Read the bullets. What if changing population health tools was as easy as redirecting a URL?
So now, lets look a little farther out...
Patient engagement is a big deal. How can we get more active participation by patients in maintaining health?
So, lets examine this from a few angles...
EMRs have been featuring portals for a while. I just got a notice from my doctor about a bill. Now that's engagement! But this big question looms...if we build it... Patients in my practice in Denver are not signing up in droves.
The ONC has big plans... We partnered with QHN and Rocky on a grant proposal to come ask you what you think and what patients think. Stay tuned!
Patient generated data through things like step counters represents another kind of engagement This is my Fitbit screen. What if I could share this with my care team? What if they could give me feedback and encouragement?
Some of this is possible now... My Fitbit data flows into HealthVault. Why not an EMR?
Here's another tool we are researching at CU. This is designed for a patient to use to give information about their health status and self management priorities...
The information flows into a patient focused form and a provider focused form.
Discuss the slide.
BlueButton is a federal initiative. Somewhat limited now, but could grow substantially. They have published specs that could allow vendors to participate. Some already are...
Here's an example... Big question here is where is the EMR? This data appears to live outside the EMR. Watch this space!
So, with new kinds of data and applications, we may have new measures, new yardsticks, and new aspects of transformation. No, we are not done... But, you have done much of the hard work. You have learned to use yardsticks. So, while there may be some new ones, the principles are not likely to change a lot.
These principles are still very important and valid!
While we may have made some missteps, we have started down the road. I'm optimistic. The tools will improve. Driving with a speedometer and speed limits is much better than the alternative!
Thank you again for the opportunity to be with you all this morning. Now it's your turn. What's this look like to you?
What's on the Horizon, How HIT Supports Practice Transformation and Chronic Disease Management
Whats on the Horizon,How HIT Supports PracticeTransformation and ChronicDisease ManagementDon Nease, MDVice Chair for Research - Dept of Family MedicineDirector of Practice Based Research - Colorado Health OutcomesUniversity of Colorado - Anschutz Medical CampusMeaningful Use & HIT Innovation ConferenceQuality Health Network - Grand Junction, CO - April 26, 2013
conflicts• Senior Medical Director - Crimson CareRegistry,The Advisory Board Company, Inc.
overview• why are HIT and transformation linked?• yardsticks• the far horizon• what’s it going to take to get there?
ideally...in the era of"measured" care...• HIT provides the speed gun both...• at the point of care• and for your population as a whole• and gives you tools to address the gaps
lessons from EPIC• Colorado based RCT on qualityimprovement• Tested 2 styles of practice improvement• Facilitated RAP model - 15 practices• Facilitated IPIP model - 10 practices• with registry based targets• Guess who did better...
"Within ten years, we want mostAmericans to have electronic health carerecords—that means your records,"President Bush - 27 May 2004
“As President, I will invest $10 billion peryear for five years to move the U.S. healthcare system to broad adoption of standards‐based electronic health informationsystems...Candidate Barack Obama - 2008"Within ten years, we want mostAmericans to have electronic health carerecords—that means your records,"President Bush - 27 May 2004
as of May 2012...• 62,226 totaleligible providersattested• 12.2 percent• calculated basedon estimated509,328 potentialWright A, Henkin S, Feblowitz J, McCoy AB, Bates DW, Sittig DF. Early results of the meaningful useprogram for electronic health records. N Engl J Med. 2013 Feb 21;368(8):779–80.
as of Jan 2013• 115,918 attestations - CMS data• 23% of a potential 509,328• a one and three quarter times increaseover 7-8 months
“User satisfaction with electronic health recordshas decreased since 2010”
AmericanEHR survey• Overall, user satisfaction fell12 percent from 2010 to2012.• The percentage of clinicianswho would not recommendtheir EHR to a colleagueincreased from 24 percentin 2010 to 39 percent in2012.• 32 percent of theresponders had notreturned to normalproductivity compared to 20percent in 2010.http://www.americanehr.com/about/News/13-03-05/
Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests thatelectronic health records will yield revenue gains for some practices and lossesfor many. Health Affairs. 2013 Mar;32(3):562–70.
and yet...Xierali IM, Hsiao C-J, Puffer JC, Green LA, Rinaldo JCB, Bazemore AW, et al.The rise of electronic health record adoption among family physicians. TheAnnals of Family Medicine. 2013 Jan;11(1):14–9.
• trend suggests 80% adoption by end of2013 among FM• adoption vs. attestation• could signal a large bolus of attestersyet to come - last year to enter is 2014• but will EMR’s provide our yardsticks?
• ER docs were early adopters• Now moving into “niche solutions”• Niche solutions have higherphysician direct documentationand reported accuracy.• Niche solutions alsooutperform enterpriseEMRs in improving patient care.• This via better layouts, lessentry errors, more prompts andalerts.• A top concern and request forimprovement is clinical decisionsupport.on the edge...http://www.klasresearch.com/news/pressroom
Once providers try a thirdparty solution to help withclinical decision making few goback to building it themselveshttp://www.klasresearch.com/news/pressroom/2013/cds
• EMRs challenged to providedecision support (patient yardstick)• Will this improve???• Billing trumps for now
• EMR vendors may be close to cedingthis ground• Payers are investing huge amounts inbuying analytics vendors• Big data is become a big deal
• Trends and drivers• Affordable Care Act and accountable careorganizations• The experience in non-healthcare sectorswith big data• Dramatic growth in health data with theneed to manage and use it• Fraud and inefficiencies• End of the blockbuster-drug erahttp://www.slideshare.net/gigaom/gigaom-research-sector-roadmap-healthcare-
• Challenges• Unstructured data• Enterprise-wide data managementpolicies• Shortage of health informatics and datasciences specialists• Ownership, stewardship and governanceof data• Interoperability and legacy systemshttp://www.slideshare.net/gigaom/gigaom-research-sector-roadmap-healthcare-and-big-data-in-2012
• Big questions looming...• will existing leaders adapt?• EMR/CDS/pop. health• is there a role for non-profit/public utility models?• especially for data acquisition
“Patient engagement is theblockbuster drug of the century.”National Coordinator for Health ITDr. Farzad MostashariDr. Farzad MostashariDr. Farzad MostashariDr. Farzad Mostashari
patient engagement• In the EMR• Via companion tools• Apps, etc.
EMR engagement• A major piece of Stage 3 Meaningful use• Most vendors already have some capacity• If we build it will they come???
Stage 3 engagement• submit patient-generated healthinformation to improve performance onhigh priority health conditions, and/or toimprove patient engagement in care• provide patients with the ability to requestan amendment to their record online
Connection to Health• CU based, NIH funded RCT of a web-basedtool to assist with self-managementsupport• Also testing how much facilitation helpswith integrating CTH into practice• Looking for practices now!
• Provides a download ofyour (patient) electronicdata• Currently somewhatlimited -VA/Medicare• Vendors getting veryinterested