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