Emerging HIT Incentive Programs: Physician Responses Health Information Technology Summit March 8,...

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Emerging HIT Incentive Programs: Emerging HIT Incentive Programs: Physician ResponsesPhysician Responses

Health Information Technology SummitMarch 8, 2005

Peter Basch, MD David Kibbe, MDMedical Director, eHealth Director, AAFP’s Center for MedStar Health Health Information Technology

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Bio’sBio’s

Peter Basch, MD General internist Medical Director, eHealth –

MedStar Health Co-Chair PEHRC Co-Chair of the Small Practice

Workgroup of eHI

David C. Kibbe, MD, MBA Family physician Director, Center for Health

Information Technology Co-Chair PEHRC Co-Chair of the Small Practice

Workgroup of eHI

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OverviewOverview

Barriers to HIT adoption Why are incentives necessary? Responses to key HIT incentive programs

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Risks / barriers to HIT adoption?Risks / barriers to HIT adoption?

Physicians are not computer phobic Physician culture is pro-quality / safety Computers are affordable / reliable Connectivity is affordable / reliable Software is reliable, and often affordable

Why haven’t physicians accelerated adoption of HIT?– Risks / barriers to adoption– Risks / barriers to “interconnectivity”– “Questionable” (negative to very negative) business case

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Lowering Risks / Barriers to Lowering Risks / Barriers to EHR AdoptionEHR Adoption

Barrier Solution Current WorkConfusion about product and company

EHR product certification

Certification Commission on HIT (CCHIT)

Not knowing which EHR is best for which type of practice

Trusted specialty-specific EHR guidance

AAFP, ACP, other medical specialty societies; KLAS, HIMSS, others

High prices Affordability and transparency

Buying collaboratives - Medical professional and specialty societies

Risk of implementation failure

Trusted technical advice

AAFP’s CHiT, ACP’s PMC, QIOs

Wide variability in contracting and business practices

Standard contracting language, RFP guidance

AAFP’s Partners for Patients, ACP’s PMCeHealth Initiative

Difficult and expensive access to external information

Standards-based solutions for labs, imaging centers, etc

California Health Care Foundation, eHealth Initiative

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Lowering Risks / Barriers to Lowering Risks / Barriers to EHR AdoptionEHR Adoption

Barrier Solution Current WorkConfusion about product and company

EHR product certification

Certification Commission on HIT (CCHIT)

Not knowing which EHR is best for which type of practice

Trusted specialty-specific EHR guidance

AAFP, ACP, other medical specialty societies; KLAS, HIMSS, others

High prices Affordability and transparency

Buying collaboratives - medical professional and specialty societies

Risk of implementation failure

Trusted technical advice

AAFP’s CHiT, ACP’s PMC, QIOs

Wide variability in contracting and business practices

Standard contracting language, RFP guidance

AAFP’s Partners for Patients, ACP’s PMCeHealth Initiative

Difficult and expensive access to external information

Standards-based solutions for labs, imaging centers, etc

California Health Care Foundation, eHealth Initiative

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Lowering Barriers to Lowering Barriers to InterconnectivityInterconnectivity

Barrier Solution Current Work

Information overloadInformation out of contextCare confusion

Potential for ↑duty and risk in an interconnected environment

Potential for ↑duty and risk with use of clinical decision support

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Lowering Barriers to Lowering Barriers to InterconnectivityInterconnectivity

Barrier Solution Current Work

Information overloadInformation out of contextCare confusion

New clinical protocols for interconnectivity

Potential for ↑duty and risk in an interconnected environment

Dialog and clarity with legal / policy communities

Potential for ↑duty and risk with use of clinical decision support

Dialog and clarity with legal / policy communities

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Lowering Barriers to Lowering Barriers to InterconnectivityInterconnectivity

Barrier Solution Current Work

Information overloadInformation out of contextCare confusion

New clinical protocols for interconnectivity

CCR

Potential for ↑duty and risk in an interconnected environment

Dialog and clarity with legal / policy communities

???

Potential for ↑duty and risk with use of clinical decision support

Dialog and clarity with legal / policy communities

???

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Creating the Business CaseCreating the Business Case

Barrier Solution Current WorkNo money available for IT investment

Access to capital eHealth Initiative Financing Working Group

Questionable business case for IT adoption

Pay-for-IT use National Group for the Advancement of HIT

Negative business case for quality

Pay-for-performance National Group for the Advancement of HIT, eHI, DOQ-IT, BTE, Leapfrog

Negative business case for information management

Pay-for-activities of information management

National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB

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Creating the Business CaseCreating the Business Case

Barrier Solution Current WorkNo money available for IT investment

Access to capital eHealth Initiative Financing Working Group

Questionable business case for IT adoption

Pay-for-IT use National Group for the Advancement of HIT, ACP

Negative business case for quality

Pay-for-performance National Group for the Advancement of HIT, eHI, DOQ-IT, BTE, Leapfrog

Negative business case for information management

Pay-for-activities of information management

National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB

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Creating the Business CaseCreating the Business Case

Barrier Solution Current WorkNo money available for IT investment

Access to capital eHealth Initiative Financing Working Group

Questionable business case for IT adoption

Pay-for-IT use National Group for the Advancement of HIT, ACP

Negative business case for quality

Pay-for-performance National Group for the Advancement of HIT, ACP, eHI, DOQ-IT, BTE, Leapfrog

Negative business case for information management

Pay-for-activities of information management

National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB

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Creating the Business CaseCreating the Business Case

Barrier Solution Current WorkNo money available for IT investment

Access to capital eHealth Initiative Financing Working Group

Questionable business case for IT adoption

Pay-for-IT use National Group for the Advancement of HIT, ACP

Negative business case for quality

Pay-for-performance National Group for the Advancement of HIT, ACP, eHI, DOQ-IT, BTE, Leapfrog

Very negative business case for information management

Pay-for-activities of information management

National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB

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No money available…No money available…

For physicians – access to loans is not a problem… But willingness to borrow money for an uncertain ROI is. Nevertheless – may be important for some doctors

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Case for IT adoption (Case for IT adoption (per se)per se)

Successful IT adoption by itself has not been shown conclusively to improve quality or safety (except where quality has been specifically incented)

Without further specifying process / outcomes measures as a requirement of reimbursement – it is clear that HIT will be used to further the existing business case = ↑ volume and “right coding”

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The business case for quality and The business case for quality and information managementinformation management

Computers are affordable Networking is affordable Broadband is affordable EHR software is affordable Interconnecting to all necessary sources of information is

affordable

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The business case for quality and The business case for quality and information managementinformation management

Computers are affordable Networking is affordable Broadband is affordable EHR software is becoming more affordable Interconnecting to all necessary sources of information will

hopefully become affordable (perhaps free) – and may (if we are lucky) improve quality and safety, and not result in information overload, “cookbook medicine,” and/or care confusion

Quality care = (information) (knowledge) (context) Quality care = “micro-tasking” Quality care = ↑ time, cost, complexity

Activities of quality care = the above, and population and disease management, non-visit based care, and care coordination

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Basic EHRBasic EHR

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Decision support for patientDecision support for patient

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Integrated registry – proactive Integrated registry – proactive use by clinicians and staffuse by clinicians and staff

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Advanced EHR + Registry + eVisitsAdvanced EHR + Registry + eVisits

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Advanced EHR + Registry + eVisits + HIEAdvanced EHR + Registry + eVisits + HIE

CDE

Security / MPI

Decentralized model

Imaging Centers

Labs

Community Hospitals

Tertiary Care Hospitals

PBMs

Payors Public Health

PCPs and Specialists

Patients

• Patient info• Visit list• Prob list• Med list• Allergy list• CCR

• Patient info• Visit list• Prob list• Med list• Allergy List• Discharge Sum • ED Reports• CCR

• Reports• Images• Med lists• Formulary

• Bio-surveillance• Safety, quality, efficiency indicators

• Diagnosis• Claims History• Eligibility• Referrals• Authorizations• Claim Submission• Claim Status• Claim Remittance

• Personal Health Record

Long-term Care Home Health

Outcomes Measures

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The business case for quality and The business case for quality and information managementinformation management

Computers are affordable Networking is affordable Broadband is affordable EHR software is becoming more affordable Interconnecting to all necessary sources of information will

hopefully become affordable (perhaps free) – and may (if we are lucky) improve quality and safety, and not result in information overload, “cookbook medicine,” and/or care confusion

Quality care = (information) (knowledge) (context) Quality care = “micro-tasking” Quality care = ↑ time, cost, complexity

Activities of quality care = the above, and population and disease management, non face-to-face care, and care coordination

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Existing P4P initiatives Existing P4P initiatives

Pros Cons

Free software / devices

Paid eCare

Use of administrative data for P4P

Use of administrative + clinical data for P4P

= bad, to = bad, to = completely meets goals= completely meets goals

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Preferred P4P initiatives Preferred P4P initiatives

= bad, to = bad, to = completely meets goals= completely meets goals

Pros Cons

Care coordination / management fee

Paid eCare*

Staged pay-for-use → data submission →

performance

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SummarySummary

There are many risks and barriers to HIT adoption that can and should be lowered

Interoperability only sets the stage – meaningful clinical interconnectivity will determine its value

Payers must create a sustainable positive business case for adoption and optimal use (recognizing the implications to the practice)

HIT adoption per se may add little or no net cost to a practice, and may produce little or no net value for the patient – may require a “jump-start,” but will not require ongoing incentives

Integration of HIT into some practice settings can lead to ↑ quality/safety/efficacy/access (↑ HIT value), and doing so will ↑ provider time/cost/complexity (↑ practice costs) – requires ongoing structural reimbursement changes

Incentives should not just be based on numerical targets, as healthcare transformation enabled thru HIT includes other key elements, such as meaningful care coordination / management, collaboration with patients, and optimal use of non face-to-face care (none of which will occur without fundamental reimbursement reform)