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The Healthcare Information Technology Industry—Past, Present
And Future
Kim Slocum—AstraZeneca Pharmaceuticals
Randy L. Thomas—Eclipsys Corporation
February 9, 20032
Speaker background
Kim Slocum– Director, Strategic Planning &
Business Development, AstraZeneca
– BA, SUNY Geneseo, Graduate studies in business, Xavier University
– 28 years in healthcare (mostly biotechnology & pharmaceuticals, series of increasingly responsible positions in sales, training, marketing, new product development, managed care/strategic planning, healthcare consulting, corporate strategic planning, business development for a series of corporations)
Randy L. Thomas– Executive Vice President,
SunClinical Data Institute, a division of Eclipsys Corporation
– BA, Temple University– 27 years in IT, 16 years in
HIT (mostly IT vendors, series of increasingly responsible positions in training, implementation, software engineering, software design, product planning, customer support, sales support, marketing and corporate strategic planning)
February 9, 20033
Learning objectives
Provide background on the development of healthcare information technology in the US and its ties to the evolution of healthcare delivery and financingProvide attendees a chance to participate in scenario-based strategic planning for HITObtain perspective on future trends in healthcare and their potential effect on HIT
February 9, 20034
Healthcare information technology:a brief history
BirthdatePlayersFocusGrowthA language unto itself“Once more from the beginning…”
February 9, 20035
HIT: Birth date
1960s, as a separate industrySpawned by the “iron makers”– Burroughs– IBM
Regional companies
February 9, 20036
HIT: Early players
SDK (1961)
Lockheed Inserve (1968)
IDX (1969)
Meditech (1969)
Shared Medical Systems (1969)
HBO & Company (1974)
Cerner (1979)
February 9, 20037
February 9, 20038
HIT: More players
Amherst Associates (1973)
Sunquest (197?)
Transition Systems (TSI) (1985)
Emtek (1984)
February 9, 20039
February 9, 200310
HIT: “The disappeared…”
Amherst Associates (HBOC)Lockheed Inserve (multiple acquisitions, lately Eclipsys)SDK (Eclipsys)Emtek (Eclipsys)TSI (Eclipsys)HBO & Company (after “swallowing” over 30 other companies such as IBAX and ESI, acquired by McKesson)Shared Medical Systems (after acquiring a number of other companies such as GE Healthcare, acquired by Siemens)Sunquest (Misys)
February 9, 200311
HIT: “Here, gone, and maybe back again…”
IBMAmerican ExpressGE – back in it again!OracleMcDonald Douglas
February 9, 200312
HIT: Current players (in alphabetical order)
CernerEclipsys CorporationEpicGEIDXMcKessonMeditechSiemens Medical Systems
February 9, 200313
HIT: Critical criteria
1. “Think speed” - <1 second response time2. Input by selection - <5% typing3. Save time – e.g., order sets, direct communication4. Customized to user, place, time and circumstance5. Graphical presentation; logical workflow support6. Never a roadblock7. Tasklist support for nursing and ancillaries8. Table driven9. Consistent user interface10. 100% paperless medical record; imaging & voice the final
barriers
February 9, 200314
HIT: Critical criteria
11. 100% physician utilization – saves time, improves accuracy, supports decision making
12. Bi-directional, real time integration with departmental systems13. 100% data retention to support research14. 100% reliability and availability15. Test and training environments to mirror live16. 24x7 training for all users until proficient17. 100% data accessibility in customizable formats18. Efficient relational & hierarchical data storage and retrieval
February 9, 200315
HIT: Critical criteria
19. User configurable screens20. Eliminate communication errors21. System an extension of caregivers22. Used in office and home as well as hospital23. Anywhere, anytime access by authorized users24. Eliminate significant opportunities for error in
caregiver environment25. 2 fold return in labor savings and medical errors
February 9, 200316
February 9, 200317
HIT: Focus
Clinical systems? – Absolutely!Rand studyEl Camino Hospital– Computerized physician order entry– 1969– 25 critical criteria
February 9, 200318
HIT: Focus
The great myth – only focus was “business transactions”Financial systems – yes– Hill-Burton Act (1970s)– Prospective payment (1983)
Cost plusFixed fee
February 9, 200319
February 9, 200320
Historical perspective on “billing”
Focus on Focus on billingbilling
IndemnityIndemnity DRGsDRGs ManagedManagedcarecare
Groupers Groupers & pricers& pricers
StandStand--alonealonesystemssystems
2121stst
centurycentury
Workflow Workflow focused,focused,
rulesrules--basedbased
Until 1983 1980s 1990s 2000s
February 9, 200321
February 9, 200322
GeneralGeneralAccountingAccounting PatientPatient
FinancialsFinancials
ManagementManagementInformationInformation
ClinicalsClinicals
HIT problem
February 9, 200324
Clinical system “roadmap”
Core CPR– Physician OE– Documentation– Pathways– Decision support– Results viewing
Context SystemsEMPIManagedCareRegistration
Context SystemsEMPIManagedCareRegistration
CooperativeSystems
SchedulingLaboratoryRadiologyPharmacy
CooperativeSystems
SchedulingLaboratoryRadiologyPharmacy
Subscriber SystemsBillingData warehouseEDI
Subscriber SystemsBillingData warehouseEDI
Source: ComputerPatient Record Institute
knowledge-workerfocused
ancillary and niche-product independent
patient centric
February 9, 200326
February 9, 200327
February 9, 200328
Five generations of clinical systems
Minimal
Functionality
Full
Availability of Products
First Generation:The Collector
Second Generation:The Documentor
Third Generation:The Helper
Fourth Generation:The Colleague
Fifth Generation:The Mentor
Gartner Group
February 9, 200329
February 9, 200330
February 9, 200331
February 9, 200332
February 9, 200333
Average AME annual costs: 400 bed hospital
$0$0 $2,500,000$2,500,000 $5,000,000$5,000,000 $7,500,000$7,500,000
AnesthesiaAnesthesia
FallsFalls
ReadmissionsReadmissions
DecubitusDecubitus UlcersUlcers
ADEsADEs
Nosocomial InfectionsNosocomial Infections
Procedural Complications
Patient safety initiatives are putting pressures on HCOs and physician groups to “overhaul the practice of medicine” in the U.S.
February 9, 200334
Source of errors – driving HIT
Provider Responsible for Primary Error (ADE)
56%34%
6% 4%
Physician Nurse Unit Clerk Pharmacy Staff
• Doctors and nurses (90%) are the primary source
• Focus on automating what they do:
– Clinician order processing
– Medication administration process
– Clinical documentation process
• Tightly integrate the entire system (pathways, orders, alerts, variance tracking)
February 9, 200335
Historical and projected HIT sales growth rates in dollars:
• Total HIT sales have expanded from an estimated $7.5 billion in 1993 to $20.4 billion in 2000.
Source: Dorenfest & Associates
$0.00
$5.00
$10.00
$15.00
$20.00
$25.00
$30.00 199319941995199619971998199920002003
February 9, 200336
Historical and projected HIT sales growth rates in percent:
0.00%2.00%4.00%6.00%8.00%
10.00%12.00%14.00%16.00%18.00% 1993
19941995199619971998199920002003
• The annual growth rate for HIT sales is currently the lowest it has been since 1993, and headed slightly downward.
February 9, 200337
“Overall the health care industry allocates about 2 to 3 percent of its budget to IT,
compared with between 5 and 10 percent for industries like financial services and retail.”
--Red Herring
HIT: Growth 2002
Gartner Group, 2001
February 9, 200339
Inhibitors to HIT growth
Over-promised, under-deliveredTrend of automating old processesLack of standards
February 9, 200340
February 9, 200341
HIT: A language unto itself
HITEHRCDREMRCPRCISFISRISEPI
LISEMPIHL7HTMLXMLEDICPOEE-I-E-I-O
February 9, 200342
February 9, 200343
February 9, 200344
HIT: “Once again, from the beginning…”
HIT as an industry is now old enough to begin to
repeat itself.
February 9, 200345
February 9, 200346
External compliance pressures
JCAHOJCAHO
HIPAAHIPAA
IOMIOM
LeapfrogLeapfrogGovernmental Governmental regulationsregulations
ConsumersConsumers
NHIINHII
February 9, 200347
Technology advances driving HIT
PCs
Genomics
Integrated Circuits
The Internet
February 9, 200348
SCENARIO: “The Triumph Of Reason”
February 9, 200349
February 9, 200350
February 9, 200351
SCENARIO: “Consumer Chaos”
February 9, 200352
February 9, 200353
February 9, 200354
SCENARIO: “Big Brother Takes Over”
February 9, 200355
February 9, 200356
February 9, 200357
Work group instructions
Elect a leaderRead and discuss the scenario assigned to your group
– What processes des HIT track?– Who are the customers for healthcare information?– Who buys and uses systems?– What percentage of healthcare resources is devoted to HIT?– Do you like this environment and do you think it is sustainable?
Present your conclusions to the entire group
HIT & Healthcare—Future Trends
Kim D. Slocum—AstraZeneca Pharmaceuticals
Randy L. Thomas—Eclipsys Corporation
February 9, 200359
Where are we headed?
Of the three scenarios you’ve just seen…Short-term— “consumer chaos” probably the best bet– Is it stable long term?
Concerns about lack of good consumer decision support toolsAdverse selection
Longer term ????
February 9, 200360
Forces that will shape healthcare…and HIT
“Pull” from consumers/payers/government– More “consumer directed healthcare”– The “quality” movement
New technologiesGenetic revolution
“Circles Of Influence”
Providers
Payers
-“What, me worry?”-Don’t see healthcare as “broken” -don’t see big it problem-Somewhat resistant to broad HIT
-“Healthcare isn’t perfect”-Connectivity would help-Mostly managing cost
-“Healthcare is a mess!!”-Large cost/quality issues-HIT critical to solutions
Managed Care
February 9, 200362
New Healthcare Models
Existingmanaged careofferings
CatastrophicplusMSA
Tierednetworks
Personalizedhealth plans
Openmarketpurchase
Definedcontribution
Consumer involvement
Consum
er incentives
“You are here”
February 9, 200363
“When will most US employers move to defined contribution?”
69%
17%
14%
Before 2010
After 2010
Not in forseeablefuture
SOURCE: “Healthcast 2010 Survey”—Price Waterhouse Coopers
February 9, 200364
“Consumer directed healthcare”
$1,000-$1,500 employer paid coverage(Subject to std. Co-pays/co-insurance)
$1,000-$1,500 employee “risk corridor”(Funded OOP or via FSA)
>$3,000—catastrophic coverage(Re-insurance)
Prev
enta
ti ve
c are
100
%
Emp l
o ye r
-cov
e re d
February 9, 200365
The “catch”
Consumer pays tiered rate for any/all carePhysician, hospital, charges vary widely within a geographic regionWill tiers be decided on cost considerations alone?Will consumers be willing to pay up?
February 9, 200366
The Quality “Avalanche?”
ACCESS/QUALITY/COST - CALPERS: PLANS TO SHIFT FOCUS TO QUALITY OF CARE
DJ News Clippings - Tuesday April 30, 2002CARE ISSUES
American Health Line - 04/30/2002
Facing 25% average increases in its health insurance premiums for next year, the California Public Employees' Retirement System "wants proof" that the higher costs will lead to better care for its 1.3 million members, the Sacramento Bee reports. CalPERS, which will spend $2.2 billion on HMO care next year, plans to spend another $15 million to develop a claims database that will allow its pension fund managers to track what happens each time a member visits a doctor or fills aprescription. CalPERS officials expect to use such data to determine which doctors, hospitals and treatments "best serve" its members, particularly those with chronic problems, and then to request that its contracted health plans "tailor" their benefits accordingly.
February 9, 200367
The new “rating game”
Sun, Mar. 10, 2002
For the last five years, treatment of stroke has been undergoing a revolution. But the revolution may not have come to your hospital. State-of-the-art stroke treatment, experts say, could save thousands of lives nationally and spare tens of thousands more from disability. But few hospitals in the Philadelphia region report having all the necessary people, equipment and procedures. And very few stroke victims are being treated with a drug that increases the chance of a normal life by at least 30 percent…
…The newspaper's survey of more than 70 hospitals in Southeastern Pennsylvania and South Jersey found that only eight reported meeting 11 key stroke-care standards outlined in 2000 by the Brain Attack Coalition, a group of national stroke experts that included the National Institutes of Health…
How You Might Avoid Disability After A StrokeBy Stacey BurlingInquirer Staff Writer
February 9, 200368
Government joins the rating game
Health: U.S. Begins Nursing-Home Rating PlanBy Jill Carroll and Bernard Wysocki Jr.
The Wall Street Journal via Dow Jones
April 25,2002
WASHINGTON -- The U.S. government took a large step toward rating the nation's nursing homes, as it launched a pilot program in six states that allows consumers to compare nursing homes along nine separate measures of quality.
The Department of Health and Human Services is beginning the rating system with a blizzard of publicity, including an advertising campaign in 30 newspapers. Details of the ratings went up on the HHS Web site, covering more than 2,500 nursing homes in Colorado, Florida, Maryland, Ohio, Rhode Island and the state of Washington.
More than anything, the HHS rating system allows consumers to pinpoint deficiencies in care. Consumers in the six pilot states can now find out what percentage of patients at a nursing home have infections, have lost too much weight, or have been given inappropriate doses of drugs. While some digging and interpretation is required, consumers will also now be able to find out whether nursing-home staff didn't provide enough to alleviate pain among residents.
If the six-state pilot works well, the program could be expanded to the rest of the country. The government rating system may also be broadened to cover hospitals and physicians, eventually providing consumers greater access to information about their local hospitals, family doctors and specialists.
The nursing-home data will allow consumers to see how facilities stack up against each other, and against statewide and national benchmarksof performance. In addition, it is likely that the glare of publicity will pressure poor-performing homes to get better.
February 9, 200369
So who’s measuring quality?
• HealthGrades.com• HospitalProfiles.org• SelectQualityCare.com• DoctorQuality.com• Various local top 10, top 100 lists (often
consumer-focused)• Waiting in the wings—employer groups,
state and federal governments
February 9, 200370
“Dollars and cents” impact
“In some form or fashion, hospitals will be in a pay-for-performance mode by 2005.”--Scott Serota, CEO Blue Cross and Blue Shield Association
“Cost-sharing without quality indicators and consumer decision support may be like throwing a grenade over the wall”—Sam Ho, MD, Pacificare
(Cited in “HealthCast Tactics: A Blueprint For The Future” By PriceWaterhouseCoopers)
February 9, 200371
“So what” for HIT?
As consumers get more “skin in the game…”– Customer (aka patient) service gets more
important (immediately)– Quality/outcomes assessment tools become
critical to justify differential pricing (longer term)
February 9, 200372
What consumers want
• 90% of online population wants electronic communication with MD– 77% ask questions where no visit is needed– 71% fix appointments– 71% RX refills– 70% test results
• 37% are willing to pay (nominally) out pocket (either monthly fee or “per communication” charge”)
• Over one-third of consumers are willing to switch doctors to achieve connectivity
SOURCES: Harris Interactive and Manhattan Research
“The doctor’s modem will connect you now”
February 9, 200374
Whither managed care???
• In a more “consumer-directed” healthcare world, what is managed care’s added value?
• Managed care’s new role—the “concierge?”– Help enrollees through resource allocation process (co-pays
vs. premium, “what can I get for how much money?”)– Assist with creating/presenting “quality” data– Assist with creating/maintaining “personal health records”
Robust HIT is vital to managed care’s success in this new world
February 9, 200375
HEALTH PLAN ELEMENTS
Accelerated eligibility determinationExpanded search capability for:- Certificate of coverage- Provider directory- Pharmaceutical coverageClaims- Automated adjudication- Improved inquiry capabilities- Historical data availability
CONSUMER-CENTRIC CARE
• Personal health record• Health risk assessments • Patient care alerts• High quality health information
- Preventive care- Acute care- Alternative medicine
• Interactive health care
• Decision support tools
Web enabled consumer driven health plans
February 9, 200376
February 9, 200377
February 9, 200378
New technologies
Bandwidth—leading to new business models– Patients– Ambulatory care physicians
New input devices (mobile, wireless)– Better “form factors”– Improved battery life
February 9, 200379
Remote patient monitoring—an emerging frontier…
Study: e-Monitoring device helps cut debilitating asthma attacks
Health Hero's Internet-able Health Buddy interactive health-monitoring device caused asthma patients to have a 48% lower frequency of attacks. The finding comes from a Merck-sponsored study from Health Hero Network on the product's efficacy. The 90-day trial -- developed by doctors at University of California Berkley and Children’s Hospital of Oakland –- was funded in part by an unrestricted grant from Merck… The health-monitoring device relays information between patients and healthcare workers over phone lines to a website. Based on that input, the device provides patients with a daily personalized asthma care quiz to help manage symptoms and maintain free breathing. The study also showed that Health Buddy users were less likely to make urgent calls to hospitals …
Tuesday, March 26, 2002
February 9, 200380
…And it’s expanding
Exclusive: Roche Diagnostics to unveil handheld diabetes monitor
An official at Roche Diagnostics has told ePharmaceuticals that the unit plans to unveil a handheld platform for patients to manage their diabetes. Courtney Jinks, Roche Diagnostics' global marketing manager, Internet, says the handheld system is part of a three-pronged e-diabetes strategy that also encompasses software and the Web. Roche is developing the handheld system based on the Palm OS… Roche's goal is to provide "actionable" health information, not just data…
Monday, March 25, 2002
Technology futureTechnology future
Broadband and connectivity (2.5/3G Cellular WWANs, WLANs, Wi-Fi Wireless Fidelity-802.11b RF Networks, Bluetooth PANs, etc.)
3G ???? 3G Wireless Has Arrived (Finally!) This week, Verizon rolled out America's first "third-generation" wireless network. Will consumers sign up? That's the billion-dollar question.
By Matthew Maier, February 01, 2002
Device convergence
Casio Adds Life to Mobile Devices New fuel cell generates power through chemical reaction, keeping notebooks running for 20 hours.
Battery life
Battery technology advances
Processing power efficiencies will limit drain
February 9, 200382
Adoption issues
Battery life
Weight
Portability/size
Cost
Microsoft Tablet PC
Tablet PCs?Tablet PCs?
February 9, 200383
“So what” for HITCost currently a major factor limiting physician adoption of clinical connectivity3G networks open possibility of “real time” response from ASP-type modelsReduces upfront expense of software purchase/maintenance“Pay per use” model becomes feasibleBetter mobile platforms allow connectivity to exam roomsNear-real time patient-centric information collected, analyzed, used to assist in measuring quality of care
• Formulary control• Switch potential
Payor
Additional applications
• Charge capture• Lab results• Dictation/transcription• EMR
• Convenience• Safer prescriptions
Physician
Pharmacy
Patients
eRx
• Access to information• Efficiency tools• Fast, legible prescriptions
• Automated data entry• Speedier reimbursement • Improved accuracy and safety
Rx -Compliance monitoring
“Frankenrecord”“Frankenrecord”Building physician use of clinical computing one step at a time.Building physician use of clinical computing one step at a time.
Pharmaceutical sponsorship
• Messaging at point of care• Clinical programs• Relationship management
Rx
Handheld healthcare evolution
Most HIT, Practice Mgmt. Vendors
Leading eHealth VendorsHealthcare PDA VendorsAvailable From
500,000 MDs, Many Other Health Care Professionals
300,000 MDs100,000 MDsAdoption
Computerized Patient Record, Hospital Info.System
Practice Mgmt. SystemLabs
PBM, Pharmacy, PayerIntegration
Clin.Decision SupportBenefits,Referrals,Clinical Trials
Lab ReportsOrder EntryDictation, AlertseMail
Medical ReferenceRx WritingCharge Capture
Applications
Broadband WirelessDigital WirelessCradled/Synchronized
Connectivity
2003-20082001-20022000Function
SOURCE: Gartner Group
February 9, 200386
The “new science”
Genetics/genomics/pharmacogeneticsPredictive testing to determine individual susceptibility to diseaseTesting to determine likelihood of individual response to particular (existing) therapyUse of aggregated genetic information to design/develop new therapies for population subsets
February 9, 200387
Genetic progress
CN: DV Canada NwsWir - Friday May 31, 2002Canada News-Wire via Dow Jones
Researchers use microarray technology to discover genetic patterns in lung cancer patients
TORONTO, May 31 /CNW/ - New research from Toronto's Princess Margaret Hospital identifies the genetic fingerprint for lung cancer that may eventually help determine which patients are at high risk for cancer recurrence after surgery. The findings, published in this month's edition of the international scientific journal Cancer Research, come after scientists at Princess Margaret Hospital's research arm, Ontario Cancer Institute (OCI), examined over 19,000 genes in a group of 39 lung cancer patients. The scientists discovered unique genetic differences between lung cancer patients that had high likelihood of failing standard treatment compared to those with a better prognosis. Generally, about 50-60 per cent of lung cancer patients treated by surgery will have their cancer reoccur.
Genetic Fingerprint of Lung Cancer Predicts Treatment Outcome
February 9, 200388
“So what” for HIT?
Currently—average MD knows/frequently uses 20-25 drugsWhat happens to information requirements if those 20-25 become 100 due to genetic “market fragmentation?”How does MD store, array, use combinations of diagnostic and therapeutic information without significant clinical automation?New customers for medical histories aggregated with genetic data
“Carbon and silicon”
Custom-Tailored Medicine --- Mayo Clinic Plans Database Of Every Patient's History, Including Genetic Makeup--By David Hamilton
Monday, March 25, 2002The Wall Street Journal via Dow Jones
ROCHESTER, MINN. -- Piet de Groen is a large man in a small office with a big plan -- so big, in fact, that it could revolutionize medical research and health care.
A gastroenterologist here at the Mayo Clinic, the 6-foot-7 Dr. de Groen heads a project to electronically warehouse the medical records of every patient who passes through the doors of the world-famous medical center. The project is in its infancy; but if all goes according to plan, the computerized database will ultimately contain not only patients' medical records, but eventually detailed genetic information as well.
"This," says Dr. de Groen, holding up a clear plastic folder packed with color-coded patient records, "is going there." He points to one of the four computers in his narrow office, a converted examination room now lined with filing cabinets and packed with electronic equipment. "We are basically planning for the ability to have everyone's complete genome in there," he says.
That database would be an unusually comprehensive resource for physicians and researchers hoping to understand how an individual's genetic makeup can influence the course of disease and the success of the treatment. Such "personalized medicine" is one of the major benefits expected from the sequencing of the human genome.
Tomorrow’s pharmaceutical products
PrescriptionDrug(Plus package Insert)
Today
Rx
Databases Diagnostics Geneticprofiling
Patient info. & counseling
20??
solutions
Where HIT needs to be
I/P LabSystem
RadiologySystem
Hosp. BillingSystem
Pt. RegistrationSystem
HospitalInterface
I/P PharmacySystem
O/P PharmacySystems
Home HealthSystem
O/P LabSystem
Elec. Med.Record
Office BillingSystem
MD OfficeInterface
Pt. ReportedData
(On-Line Dx)(QOL Data)(Compliance)
MasterInterfaceEngine
February 9, 200393
The “Holy Grail”
At Kaiser, A Vision Of The Connected Future: From Exam Room To RadiologyMedical Economics - 02/08/2002
"Say I'm seeing a child who's had countless ear infections," says pediatrician Eric E. Brody. "I may ask the mother, 'What worked well in the past?' but she's likely to respond, 'Oh, the white stuff: which doesn't really help me. With our electronic medical record, I don't have to dig through a file looking for a piece of paper to see what's worked best for this kid. I can pull up a complete list of the drugs he's had and all his office visits, and immediately see what worked." Brody is health care team director and lead physician at the newest Kaiser Permanente Northwest (KPNW) clinic, which opened in October 2000 in Tualatin, OR. Physicians there can access electronic medical records on a flat-screen computer in every exam room. This gives them immediate access, not only to their own visit notes, prescriptions, and lab results, but also to all of the other patient information throughout the KPNW system. …
…"Everything on the patient is electronically available," explains internist Homer L. Chin, assistant regional medical director for clinical information systems at KPNW. "Whatever happens to the patient, including referrals, lab tests, and other orders, isentered in the system." …
…Meanwhile, the electronic medical record is already an essential part of practice in KPNW's clinics and affiliated hospitals. Where the terminal is not in the exam room, it's available elsewhere at the site, usually in physician offices. Doctors can alsodial up the information system from home. …
February 9, 200394
The new combination...
Healthcare IT people tend to be like drunken lovers at a bar: big talk, modest follow-through.
-- Uwe ReinhardtPrinceton Univ.
February 9, 200395
A closing thought
“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.”
– Alvin Toffler
