march 16, 2004: i. sim crossing the chasm medical informatics crossing the quality chasm with emrs...

March 16, 2004: I. Sim Crossing the ChasmMedical Informatics

Crossing the Quality Chasm with EMRS

Ida Sim, MD, PhD

March 16, 2004

Division of General Internal Medicine, and Graduate Group in Biological and Medical Informatics

UCSF

Copyright Ida Sim, 2004. All federal and state rights reserved for all original material presented in this course through any medium, including lecture or print.


Outline

• Financial Costs and Benefits of EMRs

• Roadmap to Crossing the Chasm– why health IT fails

• E-Health: Reinventing Medical Care?

• Class Summary


Costs and Benefits of EMRs• “...Without a national pledge to create and fund [a

health informatics] framework, progress to enhance quality of care will be painfully slow.” (IOM Report, 3/01)

• Low penetration of EMRs – outpatient (MGMA, Oct. 2001)

• 1% (ACGroup) to 7% have one• 14% in implementation process• 68% have considered getting an EMR

– inpatient (HIMMS Leadership Survey, 2002)

• 13% fully operational• 32% in implementation process• 23% planning to implement


Costs• Initial costs $20-27,000 per MD for full-function

EMRs– can be as low as $99.95/month with Application

Service Provider (ASP) versions• subscribe to web service that stores your EMR (e.g., Logician

Internet)

– lower end EMRs with little functionality ~$300/MD

• Ongoing costs of $7-9,000 annually per MD• > 1/2 of costs are for hardware and software• Other half

– for “complementary innovations”(R Miller, I Sim, Health Aff 2004; 23(12):116-126)


Complementary Innovations• Everything you need to do to make the purchased “out

of the box” EMR work in your organization• Customization of

– installation: interfaces to exisiting (legacy) systems– user interfaces– user templates (e.g., for URI, DM)

• Workflow redesign• New quality improvement programs

– e.g., clinical pathways

• Organizational change– appoint, train, and pay physician EMR leaders/champions


Benefits

• Tangible (range $0 to $14,000 per MD)– reduction in dictation costs

– reduction in medical records staff (for chart pulls, etc)

– reduction in duplicate lab tests

• Intangible (in current reimbursement climate)– quality of care

– improvement in care coordination

– service improvement

– customer satisfaction


Cost/Benefit Equation• Costs are substantial, benefits vary widely• Extent of benefits dependent on many factors, but

especially on the nature and extent of complemen-tary innovations

• But complementary innovations – are costly

• often require new or extra staffing

– are difficult to implement• involve organizational change and changing physician behavior

– challenge the intellectual capital of the practice• managerial, financial, organizational change, quality

improvement


Buying an EMR

• You can “buy” an EMR in different ways

• Traditional– you buy hardware and software

• ASP (Application Service Provider)– you buy a monthly service

• Open Source– the software is free– you buy the hardware and support services


Traditional• Like buying shrink-wrapped software (e.g.,

Access, Quicken)• e.g., Epic

– you buy your own servers, clients

– you buy Epic software• you store your EMR data on your own computers

– you probably buy some consulting service (e.g., First Consulting) for help with complementary innovations

– if things break, Epic will help you


ASP• Like buying e-mail service from earthlink, an outsourcing

model• e.g., MedicaLogic ASP

– you use pre-existing client machine/browser– you may have to download a plug-in or small program– you have a login name to MedicaLogic website– your MedicaLogic website is your EMR– MedicaLogic stores and owns the data– you have little hardware investment, don’t need local technical

expertise, low start-up and ongoing ($99/month) costs

• Usually comes with some “complementary innovations” support


Open Source• Like Linux operating system• e.g., VistA (open source version of VA

system)– developed by VA, govt property, so is free to all– you buy your own hardware– implementation and support

• you hire someone to do this, and/or• you hire a support services firm to do this for you

– you can change the program code if you want


Business Model ComparisonsTraditional ASP Open Source

Hardware to buy Servers, clients Clients only Servers, clients

Software Buy it from vendor

Monthly service fee

Free

Data Ownership You Usually them Depends

Support In-house, or buy from vendor

From ASP vendor

In-house, or buy from any vendor

Customizability Vendor controlled

ASP controlled A free-for-all


EMR Cost/Benefit Summary

• EMRs are not a “sure-fire” investment• EMR is an enabling technology

– enables more effective quality improvement programs

• To maximize quality benefits from an EMR, must invest in expensive and challenging complementary innovations

• New business models may change cost/benefit equation for smaller physician groups– hope that ASP and/or open source will increase EMR

adoption


Outline




• Class Summary


The Problem

• Pervasive gaps in quality• EMRs and CDSSs touted to help• Lots of talk, hand-wringing, $ spent• Low use of EMRs and CDSSs outside of

major centers, large physician groups• Pervasive gaps in quality• What needs to change? What’s the

roadmap?


The Barrier of Data Coding

• Better quality care <-- better decision support

• Better decision support <-- coded data

• Coded data <-- greater physician time

• Greater physician time --> no play --> no gain

• Any roadmap to crossing chasm must take physician time into account


Level I and II EMRs

• Level I: little physician coding– ICD-9 for billing, picking drugs from pick lists,

etc. – most everything is in (non-computable) text

• Level II: more physician coding– problem lists, diagnoses, SNOMED codes? – more structured notes, e.g., templates


Level I EMRs

• Little coding --> less decision support• Main benefits

– legibility– 24/7 anywhere accesibility, availability

• need data exchange across local community– pharmacies, community ERs, all clinics, hospitals, etc.

– care coordination• messaging, shared care plans with home nurse, etc.

• Quality and efficiency may improve


Level II EMRs• Identify “early adopter” physicians (who

type)• Decrease physician time required for coding

with more complementary support, e.g.,– more customized templates, dot-phrases– have nurses, patients enter data

• Potential benefits– improvements in more clinical outcomes– decision support for care coordination


Possible Approaches• Most groups procrastinate, some groups implement

Level I or II EMR/CDSSs– but most will miss out on Level I benefits– confusion about what to expect from implementations

• Everyone goes for Level II EMRs– most don’t have resources, failures are painful

• Most groups go for Level I, those who have requisite resources go for Level II– maximizes benefits for available “complementary

innovation” resources– should match expectations to level of EMR implemented


Outline




• Class Summary


Examples of Failures• Cedars-Sinai CPOE

– ~$30 million system abandoned after insurrection

• Hewlett-Packard EMR at Palo Alto VA– clinicians did not use the system

• display would log off after only a few minutes• huge monitors placed between doctor and patient

• MGH – results reporting system in 1970s led to resistance in

early 1990s to new systems


Classes of Failures• Total failure

– system never implemented or immediately abandoned

• Partial failure– major goals unattained, or significant undesirables

• Sustainability failure– lab ordering reduction systems

• Replication failure– “Bayesian” abdominal pain diagnosis system (DeDombal,

‘72)

• 8 study centers: diagnosis improved from 46% to 65% • laparotomy rate and appendiceal perforations fell 50%• not replicated elsewhere


Why Health IT (HIT) Fails• Is it a shortcoming of technology?

– didn’t capture the health problem correctly?

– didn’t have enough info or was too slow?

– used the wrong reasoning method?

– insufficient diagnostic/modeling/ etc. performance?

• Was it poor interface design?• Was it lack of user training?• If a system fails, what can be learned to prevent

another failure?


General IT Management Challenges

• HIT failures are instances of general IT failures– California DMV spent $45m from 87-93 on

aborted electronic license system– IRS, INS, FDA, …$165m on CONFIRM car

rental and hotel reservation system (AA, Marriott, Budget, Hilton) abandoned


Driving Perspectives• Technology driven

– a hammer looking for a problem• e.g. “Wow I have a Palm Pilot! What can I do with this?”

• Problem driven– a problem looking for a solution

• Latter perspective more likely to acknowledge important dimensions of organizational change – information– technology– processes– objectives and values– staffing and skills– management and structures– other resources: money and time


Example CDSS• Diabetic retinopathy leads to many cases of

preventable blindness• Referral and followup rates for diab. ret. low• Tele-opthalmology for routine opthal screening

– primary care doctors have tele-eye stations (EyePACS) in their offices

– take digital images of patient retina– transmit images to opthalmologist for decision

on need for referral


ITP...• Information

– is system satisfying a true need of intended users?• are retinal diseases not picked up? preventable blindness?

• Technology

– is technical infrastructure available and realistic?• broadband access to physician offices for teleopthalmology?

• Process

– is new workflow significantly different from old?• how to integrate into primary care visit workflow?


...OSMO• Objectives and values

– is it role/responsibility of internist to screen for eye diseases?

• Staffing and skills– internist office personnel will run the tele-eye station?

• Management and structure– who owns the tele-eye station? who owns the retinal

images?

• Other resources– opthalmologists lose the business of routine eye exams


Sources of Failures• IT projects often fail (spectacularly)• Important source of failure is “people and

organizational issues”• Technology is a just a tool for process change

– can be positive and/or negative

• Must consider people and organizational pitfalls during design and implementation– be careful if your research protocol involves new IT


Possible Approaches• Most groups procrastinate, some groups implement

Level I or II EMR/CDSSs– but most will miss out on Level I benefits– confusion about what to expect from implementations

• Everyone goes for Level II EMRs– most don’t have resources, failures are painful

• Most groups go for Level I, those who have requisite resources go for Level II– maximizes benefits for available “complementary

innovation” resources– should match expectations to level of EMR implemented


Getting to Level I • Complementary innovations support

– to help (smaller) practices handle the “people and organizational” issues

• 65% of US MDs work in practices of < 10 docs

• Community-wide data exchange– protocol standards (HL-7, etc)

– administrative and governance structures (e.g., Santa Barbara Care Data Exchange)

• Financial rewards for efficiency, care coordination, less-clinical quality of care measures


Getting to Level II

• All of getting to Level I

• Staff and organizations with resources– internal IT, re-engineering, financial, etc– physician champions, QI culture, etc– usually hospitals, large medical groups

• Financial rewards for more-clinical outcomes


Roadmap Summary• Health IT is fundamentally an organizational

intervention• Simple e-text (Level I) can provide lots of

important benefits– more easily implemented, can be done now by all

• Technical limitations (e.g., coding) will not be solved anytime soon– need to compensate with lots of complementary

innovations – restricts advanced decision support to hospitals/larger

practices


Outline




• Class Summary


Health on the Web• Estimated to be ~100,000 health websites1

• Used by 73 million adults2

– 62% of people who have web access– average of 3.3 times per month

• More than consult doctors each day2

– 6 million e-patients/day on the net– daily, 2-3 million patients see a doctor


Four E-Health Activities

• Content4

– predominant activity

• Community– 7% participate in health-related chat rooms

• Commerce– 21% buy medications and other health products

• Care– disease management, tele-consultations, etc.


Who are These Users?

User Type % ofUsers

Activities and Concerns

The Well 60 Looking for preventive care,general health news

The NewlyDiagnosed

5 Searching far and wide, mayencounter overload

The Chronically Ill& Their Caregivers

35 Actively managing disease,looking for assistance andcommunity


More on User Characteristics

• Women more likely to be e-health users than men– 73% of women vs. 65% of men


E-Health Users Worry About ...• … the quality of information on health websites4

– 5% not confident about the quality of physician or healthcare organization websites

– 27% not confident about … news media websites– 35% not confident about ... of patient-run websites– 51% not confident about … commercial websites

• … their privacy at health websites– 75% not confident that information will be kept

confidential5


Despite These Worries

• Half of all health website registrants provide personal health-related information

• Over 70% of e-health users say online information has influenced a treatment decision2


The Good and the Bad• Access to accurate information can lead to

– more knowledgable, more empowered, less anxious (?) patients

– more participatory health decisions– better care as patient and doctor become partners

• Mis-information can lead to – confused and angry patients– bad decisions, mis-placed hope, worse care, harm

• Privacy violations can cause emotional and economic damage


State of Consumer Informatics

• Trustworthiness and privacy protection– Health on the Net (HON) code of conduct– HIPAA and e-health sites

• Information accuracy and completeness


HON Code Certification• Dominant “seal of approval” for health websites

– websites passing a formal review get a special link to www.hon.ch

– click on HON seal or link to check legitimacy

• But all HON means is – privacy policy, any financial interests, date and source of all material

must be disclosed

– website design separate ads from content, and allows users to provide feedback to the webmaster

– users have a choice on collection and sharing of personal information

– site “acknowledges” professional practices and legal obligations

• Rather toothless, and no guarantee of clinical content quality or privacy


HIPAA to the Rescue?

• Covered entities– health providers– health plan or managed care organization– health “clearinghouses”

• Protects individually identifiable personal health information

• Does HIPAA cover health websites?6


Is Website a “Health Provider”?• Must provide “health care treatment,” or therapies

by prescription– doesn’t cover sites that sell books, tapes

• eDiet.com

– doesn’t cover non-prescription meds• herbs, condoms, etc from cvs.com

– doesn’t cover pharmaceutical company sites• Prozac.com e-mail reminders to take Prozac

– doesn’t cover clinical trial enrollment sites• clinicaltrials.com


Does Website Accept Insurance?

• HIPAA covers only providers who submit health insurance claims in “standard format”

• Not covered if website takes cash/credit only– “rogue” sites for Viagra, Cipro– HealthStatus.com for disease-specific risk assessments– MDExpert.com for second opinions– cyberanalysis.com for online counselling

• Not covered if claims not in “standard format”– huh??


Who Else Isn’t Covered?

• webmd.com– not a health plan, doesn’t take insurance

• PersonalMD.com, store your own e-chart online– does not provide health care

• Cleveland Clinic e-Newsletter– not health care? other website services may be covered

under HIPAA

• MedicaLogic, maker of electronic medical records– business associate of covered entity– HIPAA does NOT cover their EMR databases


Trustworthiness Summary

• Trustworthiness is a big consumer concern

• Many health websites are not covered by federal medical privacy rules (HIPAA)

• In meantime– preferentially use websites that subscribe to

ethical codes, e.g., the HON code– look for and read privacy policies


State of Consumer Informatics

• Trustworthiness and privacy protection– Health on the Net (HON) code of conduct– HIPAA and e-health sites

• Information accuracy and completeness


% WithAt LeastMinimal

Coverage

% WithCompletelyAccurate

Information

% With Min.Coverage &CompleteAccuracy

% WithConflictingInformationWithin Site

Breast CA 67 91 63 43

ChildhoodAsthma

43 84 36 52

Depression 53 75 44 73

Obesity 40 86 37 43

OVERALL 51 84 45 53

JAMA 2001; 285:2612-2621

Review of 10 Health Websites

• 1/3 of material dated within last year


Summary of Information Quality

• No independent health information quality rating service exists

• Overall accuracy is generally good• Quality is very variable• Very few sites are comprehensive• Conflicting information is common• Consumer behavior variable

– generally visit 2-5 sites, spend 30 mins.

– 1/3 bring info they find to their doctor


Whither E-Health?

• What are some possible futures of e-health?

• How will e-health change the patient-doctor relationship?


Consumer Health is Driver• New driving force for health care change is

consumer-centric health care– “Tomorrow, employers will look to consumers to be

the drivers of the health-care system by giving them the quality information and the financial incentives they need to make better choices.” (P. Lee, PBGH)

• Plan member becomes the primary customer– if they are more satisfied, they will be willing to pay

more in premiums...

• Web is enabler for consumer-centric healthcare


More E-Care• Health plan and physician sites will allow

– checking own lab results online– e-mail doctor or advice nurse

• 8% patients e-mail now, many more would like to

– refill medications, make appointments

• 30% of practices and hospitals have websites now• Hospital and MD quality websites

– IBM, Xerox, Verizon, and PepsiCo in NY have website on 150 hospitals’ surgical outcomes


Disease Management• Chronic-disease management

– chronic diseases account for large proportion of healthcare costs

• asthma, congestive heart failure, AIDS

• Websites for self-care, symptom management– e.g., www.myasthma.com, www.lifemasters.com

– cared for by teams of (e-)providers

• Patient is full partner, physicians are one of a multi-disciplinary team


Electronic Medical Records• HIPAA gives pt. legal right to own record• Personal health record

– patients maintain their own health record on a website

• e.g., www.personalmd.com

– patients have access to a patient version of their own electronic medical record

• e.g., www.aboutmyhealth.com

• Patients will “own” their medical information as never before


Consumer-Centric E-Care• Care and information from multiple sources,

anytime, anyplace

• Knowledge and information “equalized” between doctors and patients– health information– patient medical record

• Risk of fragmentation, discontinuity


Patient Empowerment and Responsibility

• Patients will have to take greater charge– coordinating and managing (self-)care– finding information and making decisions

• Web tools will support this

• More choice, control, and customization– generally good for The Well– likely to be good for some Newly Diagnosed,

and Chronically Ill


What Will Healthcare be Like...

• ... for those who can’t handle or don’t want choice and control?– for cognitive, cultural, illness reasons– the average consumer will have trouble reading

most health websites7 • 2/3 of written at college level

• standard for lay medical writing is 8th grade

– for digital divide reasons


Digital Divide• Fewer low income families have Internet access

– 36% of households earning under $25,000, vs– 77% of households earning over $75,000

• Fewer African-Americans have Internet access, but almost all attributable to income differences– 25-35% of African-American households, vs.– almost 60% of Caucasian households


Digital Health Divide• Spanish-language sites have lower quality

– 45% of English-language sites vs. 22% with minimal coverage & complete accuracy

• Broadband access required for some e-care services (e.g., tele-consultation)– about 10% of Internet users have broadband

access at home– 30% of broadband users are in NY, LA, SF,

Boston, Seattle


• Whither the Doctor-Patient Relationship?


Conclusions

• Health information on the web is– somewhat difficult to find– is often incomplete, conflicting, difficult to read

• Privacy protection is spotty

• Consumers want a lot more e-connectivity from their providers

• E-health is pathway towards consumer-centric healthcare


Class Teaching Points• The more “computable” the information, the

more the computer can do for us• Standardization of terms absolutely critical but

not a solved problem– SNOMED most comprehensive but use is unproven

• For clinical research– coding and standardized research variables critical– EMR and data warehouses can help research but not

necessarily– much can be done today but overall infrastructure is

at “critical crossroads”


Class Teaching Points (cont.)

• For clinical care– Level I (free text) EMRs offers many immediate

benefits– Level II (more coded) EMRs and decision support

systems still not widely practicable• equivocal evidence for improving care quality

– privacy and organizational issues often trump the technological ones

– e-health is huge and transformative


Take-Home Message• Need a shared infrastructure for information

systems that support both clinical research and care

• “Smarter” computers for improving quality of care, etc. bumps up against the vocabulary and coding problem– fundmental informatics problems won’t be solved in the

near term

• Be excited but tempered about what computers can do for medical care and research


References• 1 Gomez.com, October, 2000.• 2 Vital Decision, Pew Charitable Trust, May, 2002.• 3 Pew Charitable Trust. In preparation, Nov. 2001.• 4 Ethics and the Internet: Consumers vs. Webmasters. Harris Interactive and

Internet Healthcare Coalition, October 2000.• 5 Ethics Survey of Consumer Attitudes about Health Web Sites. California

HealthCare Foundation and Internet Healthcare Coalition, Sept. 2000.• 6 Exposed Online: Why the new federal health privacy legislation doesn’t offer

much protection to Internet users. Health Privacy Project, Nov. 2001• 7 Prescription Drugs and Mass Media Advertising, Research Brief, Sept. 2000.

National Institute for Health Care Management• Proceed with Caution: A Report on the Quality of Health Information on the

Internet. RAND Health and California HealthCare Foundation, 2001.

march 16, 2004: i. sim crossing the chasm medical informatics crossing the quality chasm with emrs...

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