health information technology: ehrs and beyond thomas sequist, md mph

Health Information Technology:

EHRs and Beyond

Thomas Sequist, MD MPH

The Structure of Our Discussion

• What is Health IT and how is it used to improve care?

• What are the health policy strategies around Health IT?

The Structure of Our Discussion

• What is Health IT and how is it used to improve care?

• What are the health policy strategies around Health IT?

What is Health IT?

“Health information technology (IT) refers to technologies and tools that allow health care professionals and patients to store, share, and analyze health information”

- Office of the National Coordinator for Health IT

Is This The Role of Health IT?

Health IT and Healthcare Innovation

Health Information Technology

Advanced Data Analytics

Patient Engagement

New Approaches to Care Delivery

Value-Oriented

Financing

What do Consumers Want From Health IT?

• Only 56% feel US healthcare uses the most up-to-date IT

Deloitte Survey of Healthcare Consumers, 2012

Practical Applications of Health IT

• Provider-facing▫ Electronic health record▫ Health Information Exchange

• Patient-facing▫ Personal health records▫ Virtual visits and telemedicine▫ Internet▫ Text messaging▫ Mobile apps▫ Self monitoring devices

Provider-Facing Health IT

A Common View of EHR Implementation

But Perhaps This is the Truth…

Physician Perceptions of EHR Implementation

50

60

70

80

90

100

1 3 6 12

% C

lin

ciia

ns

Agr

eein

g

Months Since Implementation

Improves overall care Improves MD communication

Reduces medication errors Improves result Followup

It Was Not All Positive!

Have EHR tools Been Beneficial?

• Overall, the answer is yes▫Focus on EHR decision support▫Less robust on health information exchange,

patient reminders and patient portals

• Focus is on clinical quality ---- preventive care

• Cost data are not conclusive

• 20% - 25% of studies come from 4 institutions▫More recently, >50% of studies on commercial

systems Chaudhry B. et al, Ann Intern Med 2006

Buntin, M. et al, Health Aff 2011

Jones, S. et al, Ann Intern Med 2014

Can Health IT Improve Patient Safety?

• Increase accessibility of information

• Communication

• Standardize operations (e.g. prescriptions)

• Real-time calculations (e.g. dosing)

• Decision support

Bates and Gawande, NEJM 2003

Does Health IT Improve Patient Safety?

• EHRs and decision support effective in reducing adverse drug events▫Bar coding▫Drug-disease checking▫Drug-allergy checking

• No data on errors in diagnosis▫Leading cause of ambulatory malpractice

• Are there unintended consequences?

Health Information Exchange

• Promote care coordinationReduce inefficiencyImprove safety

• Nearly 2/3 of hospitals and ½ of physicians participating

• Lack of rigorous data to demonstrate above benefits

Rahurkar S et al. Health Aff 2015

Patient-Facing Health IT

What is a Personal Health Record?

“An electronic record of an individual’s health information by which the individual controls access to the information and may have the ability to manage, track, and participate in his or her own health care”

- Dept of Health and Human Services, Office of Civil Rights

How do Patients Use Patient Portals?

• View laboratory results (53%)• Request medication refills (38%)• Email messages (37%)• Appointment scheduling (15%)

Relatively consistent finding that lower SES and minority patients less likely to use portals

Sarkar, et al. JAMIA 2011

Patient Access to Physician Notes

Delbanco T, et al. Ann Intern Med 2012

Patient Access to Physician Notes

Delbanco T, et al. Ann Intern Med 2012

Virtual Visits and Telemedicine

Pearl R. Health Aff 2014

The Internet

Current Use of the Internet• General use▫59% of adults look online for health

information

• Diagnosis▫ 35% of adults go online to diagnose a medical

condition

• Social connection▫ 16% searched to find others with similar condition

Pew Internet 2013

What Are We in Search of?

Topic %

Specific disease/condition 55

Certain treatment/procedure 43

Weight loss 27

Health insurance 25

Food safety/recall 19

Drug safety/recall 16

Drug seen in advertisement 16

Medical test results 15

How to reduce your health care costs

11

Pew Internet 2013

Leading Health-related Google Searches 2013

1. Flu2. Cold3. Labor4. Diarrhea5. Balance6. Diet7. Back pain8. Allergies9. Rash10.Lupus

Zeitgeist Google 2013

1. Pregnancy2. Influenza3. Diabetes4. Anxiety5. Thyroid6. HIV7. Mono8. Lupus9. Herpes10.Pneumonia

Health Issues Symptoms

The Internet as Health IT

•What we know▫The most ubiquitous form of health IT▫Diagnosis is a common reason for use▫Information is variable, not trusted, and not

free

•What we don’t know (…a lot)▫Impact on health care outcomes▫Impact of patient experiences▫Impact on health utilization

What’s Next: The Promise of Text?

Stockwell MS, et al. JAMA 2012

•Urban, low SES population•Weekly text message x 5 weeks

What’s Next: Activity Monitoring?

• Ability to monitor health-critical lifestyle features

• What will this mean for health improvement?

The Structure of Our Discussion

• What is Health IT and how is it used to improve care?

• What are the health policy strategies around Health IT?

EHR Adoption in 2008

Ambulatory Hospital0

10

20

30

40

50

60

70

80

90

100

4 2

137

83

91

Comprehensive Basic None

% A

dop

tin

g E

HR

DesRoches et al NEJM 2008, Jha et al NEJM, 2009

Major Barriers to Adoption

Jha et al NEJM, 2009

Inadequate Capital

Maintenance Cost

Physician Resistance

Unclear ROI Inadequate IT Staff

0

10

20

30

40

50

60

70

80

90

100

73

44

3632 30

% R

ep

ort

ing

The Policy Response

•HITECH▫Meaningful Use of Health IT▫Target incentives to Hospitals and Physicians▫ Implemented via CMS

•Define Meaningful Use▫Stage 1 – data capture and sharing (2011-

2012)▫Stage 2 – advance clinical processes (2014-

2015)▫Stage 3 – improved outcomes (2017-)

Increasing Use of Ambulatory EHR

Furukawa MF et al. Health Aff 2014

2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

80

90

100

13

22 25

3540

48

% W

ith

Basi

c E

HR

Incentives Begin

Increasing Use of Hospital EHR

2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

80

90

100

9 12 15

27

45

59

% W

ith

Basi

c o

rC

om

pre

hen

sive

EH

R

Incentives Begin

Adler-Milstein, et al. Health Aff 2014

And Meaningful Use?

Adler-Milstein, et al. Health Aff 2014

The Structure of Our Discussion

• What is Health IT and how is it used to improve care?▫ It is more than an EHR▫ Care has improved in focused areas▫ We have much to learn and leverage

• What are the health policy strategies around Health IT?▫ HITECH has dramatically improved adoption▫ What is ‘meaningful use’ of the EHR▫ Adoption and use are all in the details