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Lessons from Meaningful Use: Implications for the UK
David W. Bates, MD, MScCQO, and Chief, General Internal Medicine, Brigham and Women’s
HospitalMedical Director of Clinical and Quality Analysis, Partners
Healthcare
London, 2013
Overview• Where U.S. is starting– Quality/Safety/Efficiency– Health care reform
• HIT policy in the U.S.– How important is this to organizations
• Evidence about HIT in the U.S. and electronic prescribing
• Conclusions
Question
• What are the chances of getting injured by the care you receive during hospitalization?– 1 in 100– 5 in 100– 10 in 100– 25 in 100
Harm is Ubiquitous: Rates of Adverse Events Around the World
• 3.7% of hospitalizations in New York– 58% preventable
• 2.8% Colorado-Utah• 16.6% in Quality in Australian Health Care study• Near 10% in Canada, New Zealand, Denmark
among others– Approximately 10% in UK
• Rate in most developed countries appears to be at least 10%– Recent study by Classen found adverse events in a
third of admissions in U.S. using trigger tool
Adverse Events are Expensive:Costs of Safety Issues in the U.S.
• JJJEvent Type Annual Costs (Billions)
Preventable ADEs $3.8
All hospital-acquired infections $5.8
Thromboembolic disease $3.1
Other adverse events $3.3
Total Preventable Adverse Events $16
Jha et al, Health Affairs 2009
Health Care Reform• Affordable Care Act– Provides access to all patients– Incentives to improve costs, quality, efficiency• “Accountable care organizations”• Bundling
• Many have questioned whether pressure on costs will be sufficient
• Still politically contentious• No strong movement to single payer
Electronic Medical Record Adoption by Country
Zimlichman, CMAJ 2011
Adoption in Hospitals: Jha et al. NEJM 2009
• By panel definition:– 1.5% have
comprehensive system
– 10.9% have basic system
– Installed across major clinical units
Another View of the Hospital Data
Percent of hospitals fully implementing:• Laboratory and radiology reports: 77%-78%• Drug allergy/interaction alerts: 45%-46%• Medication lists: 45%
President Obama’s First Weekly AddressSaturday, January 24th, 2009
“To lower health care costs, cut medical errors, and improve care, we’ll computerize the nation’s health records in five years, saving billions of dollars in health care costs and countless lives.”
HITECH will Advance the “Tipping Point”
TIME
Technology Adoption
2004 2012
National Coordination
EnhancedTrust
GrantPrograms
PaymentIncentives
2009 2011 2013 2015HIT-Enabled Health Reform
HITECH Policies
2011 Meaningful Use Criteria
(Capture/share data)
2013 Meaningful Use Criteria
(Advanced care processes with
decision support)
2015 Meaningful Use Criteria (Improved Outcomes)
Meaningful Use is Being Defined and Will Follow an “Ascension Path”
14
*Report of sub-committee of Health IT Policy Committee
Three Key Components for Higher-Performing Healthcare System
• Better information on what works and what doesn’t
• Ability to rapidly apply knowledge to practice• Changes in the financing and organization of
care that reward physicians for considering cost and quality in decision-making
Blumenthal, ONCHIT coordinator
Health IT Policy Committee• Required to make recommendations to the National
Coordinator on:• A policy framework for the development and adoption
of a nationwide health IT infrastructure• The areas in which standards, implementation
specifications, and certification criteria are needed• Working groups– Meaningful Use– Certification/Adoption– Interoperability and information exchange
Everything has been conducted in openStakeholders on group from many perspectivesRegulations have gotten much better after public
commentary, responseSometimes has been significant time pressureCan’t keep everyone happy, but highly successful
overall◦ Lately vendors and providers are asking to slow down,
consumer groups and insurers to keep going/move faster◦ Has been consensus about direction
Observations from HIT Policy
Health System IT Priorities
Integration of IT Medical Devices
Interoperability
Focus on Ambulatory Systems
Leveraging Information
Optimizing Current Systems
Focus on Clinical Systems
Meaningful Use
0 10 20 30 40 50 60
Percent
0%
2011 HIMMS Leadership Survey
2%
Health IT Standards Committee• Required to make recommendations to the National
Coordinator on standards, implementation specifications, and certification criteria for adoption by the Secretary.
• Three workgroups: – Clinical quality– Clinical operations– Privacy and security
Payment Incentives and Meaningful Use
• A hospital or eligible provider must be a meaningful user to receive payment incentives
• Changes the focus from technology potential to clinician behavior
• By law, a “meaningful user” must:1. Use a certified EHR2. Exchange health information3. Report quality measures
• Primary care vs. specialty– Superspecialty
• Big practices vs. small• Big hospitals vs. small• What do you include/exclude?– Emergency departments– Psychiatric hospital
Issues in Setting Up Criteria
22
Eligible hospitals must meet all 16 core objectives:Core Objective Measure
1. CPOEUse CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology
2. Demographics Record demographics for more than 80%
3. Vital Signs Record vital signs for more than 80%
4. Smoking Status Record smoking status for more than 80%
5. InterventionsImplement 5 clinical decision support interventions + drug/drug and drug/allergy
6. Labs Incorporate lab results for more than 55%
7. Patient List Generate patient list by specific condition
8. eMAReMAR is implemented and used for more than 10% of medication orders
Stage 2 Hospital Core Objectives
23
Eligible hospitals must meet all 16 core objectives:Core Objective Measure
9. Patient AccessProvide online access to health information for more than 50% with more than 5% actually accessing
10. Education ResourcesUse EHR to identify and provide education resources more than 10%
11. Rx ReconciliationMedication reconciliation at more than 50% of transitions of care
12. Summary of Care
Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR
13. Immunizations Successful ongoing transmission of immunization data
14. LabsSuccessful ongoing submission of reportable laboratory results
15. Syndromic Surveillance
Successful ongoing submission of electronic syndromic surveillance data
16. Security AnalysisConduct or review security analysis and incorporate in risk management process
Stage 2 Hospital Core Objectives
24
Eligible Hospitals must select 3 out of the 6:
Menu Objective Measure
1. Progress NotesEnter an electronic progress note for more than 30% of unique patients
2. E-RxMore than 10% electronic prescribing (eRx) of discharge medication orders
3. Imaging ResultsMore than 10% of imaging results are accessible through Certified EHR Technology
4. Family History Record family health history for more than 20%
5. Advanced DirectivesRecord advanced directives for more than 50% of patients 65 years or older
6. LabsProvide structured electronic lab results to EPs for more than 20%
Stage 2 Hospital Menu Objectives
HITPC: MU Workgroup Stage 3 Recommendations
25
HITPC Stage 3 MU Timeline
• Aug, 2012 – present draft preliminary stage 3 recs• Oct, 2012 – present pre-RFC preliminary stage 3 recs• Nov, 2012 – RFC distributed• Dec 21, 2012 – RFC deadline• Jan, 2013 – ONC synthesizes RFC comments for WGs review• Feb, 2013 – WGs reconcile RFC comments• Mar, 2013 – present revised draft stage 3 recs• Apr, 2013 – approve final stage 3 recs• May, 2013 – transmit final stage 3 recommendations to HHS
HITPC: MU Workgroup Stage 3 Recommendations
26
Guiding PrinciplesMU Objectives
• Supports new model of care (e.g., team-based, outcomes-oriented, population management)• Addresses national health priorities (e.g., Million Hearts) • Broad applicability (since MU is a floor)−Provider specialties (e.g., primary care, specialty care)−Patient health needs−Areas of the country
• Promotes advancement -- Not "topped out" or not already driven by market forces • Achievable -- mature standards widely adopted or could be
widely adopted by 2016
April – By the NumbersApril 2013
12.77%
87.23%
Registered Eligible Hospitals
5,011 Total HospitalsRegistered Hospitals
27
April – By the NumbersApril-2013
22.57%
77.43%
Paid Eligible Hospitals
5,011 Total HospitalsHospitals Paid
28
Hospital 1st vs. 2nd yearCore Objective Performance
29
2011 2012
Number of Attestations 833 746
CPOE for Medication Orders 86.9% 85.2%
Maintain Problem List 95.7% 95.2%
Active Medication List 97.6% 97.7%
Medication Allergy List 97.9% 97.8%
Record Demographics 97.0% 96.9%
Record Vital Signs 94.0% 92.5%
Record Smoking Status 94.9% 93.6%
Electronic Copy of Health Information 95.0% 96.9%
Electronic Copy of Discharge Instructions 95.0% 94.9%
Hospital 1st vs. 2nd yearMenu Objective Performance
30
2011 2012
Advance Directives 96.1% 95.8%
Clinical Lab Test Results 96.1% 95.6%
Patient-Specific Education Resources 74.1% 72.3%
Medication Reconciliation 87.5% 84.7%
Transition of Care Summary 80.2% 81.8%
Immunization Registries Data Submission 51.9% 58.2%
Reportable Lab Results to Public Health Agencies 17.6% 13.8%
Syndromic Surveillance Data Submission 18.7% 16.8%
• Much of innovation has come from a few sites• Vendor systems now being implemented• Need support for innovation in future• Essential to look at what is implemented, not just potential• Links with external incentives will be pivotal
• How fast to go?• What are most effective things to ask for?– What should be included in terms of clinical decision
support?• How should people qualify?• What about core vs. menu?• How do you prevent gaming?• How do you know if the criteria are actually
improving care?
Looking Forward
Predictions
It’s tough to make predictions, especially when they are about the future
We always overestimate the change that will occur in the next two years, and underestimate what will occur in the next 10
Yogi Berra
Bill Gates
Where Will the U.S. Be in 2016?• National adoption rate will be over 90% in
hospitals– Essentially universal in big hospitals
• National adoption rate will be over 90% in practices– Universal in large practices– Most of holdouts will be small practices– There will have been a lot of consolidation
• Certain areas like nursing homes will still be behind• Data exchange will still be a major challenge
Who Will Be Struggling?• Small hospitals, and disproportionate share hospitals– Especially if they don’t have relationships with larger
entities• Small practices– Evidence shows that many practices actually become less
efficient after conversion, especially if they don’t adapt their workflow
• Regional health information organizations– Think they need public support and right now no plan to
give it to them
Remaining Gaps:EHRs and Care Coordination
• Continuity within team• Documentation of information• Referrals issues• Sharing care plans with other providers• Assisting with transitionsToday’s EHRs do most of these things poorly
Safety Results of CPOE Decision Support Among Hospitals
• 62 hospitals voluntarily participated• Simulation detection only 53% of orders which
would have been fatal• Detected only 10-82% of orders which would
have caused serious ADEs• Almost no relationship with vendor
Metzger et al, Health Affairs 2010
Copyright ©2010 by Project HOPE, all rights reserved.
Jane Metzger, Emily Welebob, David W. Bates, Stuart Lipsitz, and David C. Classen, Mixed Results In The Safety Performance Of Computerized Physician Order Entry, Health Affairs, Vol 29, Issue 4, 655-663
Conclusions (I)• US healthcare has huge room for improvement in
efficiency, safety, quality• Overall HIT policy direction taken so far has been
terrific– Early returns very positive
• Information technology will become ubiquitous in healthcare—near a tipping point– Electronic prescribing is a big early win– Yet adoption is just the beginning
• EHRs and HIT more broadly can provide major benefits with respect to safety, quality, efficiency
• Safety is perhaps most straightforward– Checklists, reliable processes
Conclusions (II)• Quality improvement is achievable with HIT in many
domains• Efficiency benefits least well-demonstrated and
linkages with incentive key• Lots to be learned about how to get benefits– HIT is simply a tool—part of a program– But nearly every other effort to improve
safety/quality/efficiency will rely on HIT
• Getting right decision support in place is central
Implications for UK
• Incentive approach has worked well• Adoption rate has climbed very rapidly– Still uncertain though about to what extent will
improve quality, safety– Need some post-implementation checking
• Secondary care applications are ready now for implementation– Electronic prescribing, medication administration
records ready in particular– Integrated ePrescribing applications are universal
“Insanity is doing the same things the same way and expecting different
results”
Albert Einstein