Heatlh Informatics (Georgia Tech) Week 1 cont'd

SYSTEMATIC ISSUES (explained by IOM)

Institute of Medicine
 - theres a quality gap
REASON  - too few ppl trained
REASON 2 - fragmented


Network view of primary care (georgia tech developed)
Average patient treated see average 14 different care provider
Interact with 229 providers
--> Paper records not good

Multiple conditions
Poor coordination: multiple conditions has 25-40% has greater odds of reporting errors
50% who seen 4 more physicians report error. --> laspe in communication during care transitions

Part of the Solution
Information Technology (IT) is not fully utilized.

IOM created a vision
Adoption - interoperability - analytics
>> creates learning health system


FEDERAL PROGRAMS:
OVERVIEW
Medicare and Medicaid.

HIT adoption historically low @ 1.5% hospitals, 4% of physicians (2008 and 2009)
2004 George Bush - raised the HIT issue as national priority "reduce cost, improve care". Goal to hit universal adoption by 2014.
President Obama - move incentives toward create better results (value based health care)
30B set aside for HITECH - to spur adoption of electronic records.
- 20B create medicare/medicaid incentives
- 2B office of the national coordinator

ONC - Office of National Coordinator
Key Programs: EHR Certification
- meaningful use
- health info exchange
- regional extension centers
- standards and interoperability
- research and demonstration projects

Programs to spur adoption
 - Vendors have to show qualification: EHR certification
 - Meaningful use
 - incentive payments (medicare and medicaid)

EHR CERTIFICATION

Quality improvement
- electronic prescribing, drug-drug,drug allergy interaction check, medication reconciliation
- provider order entry, patient reminder, patetient specifci education resources, automated measure calculation
- calculate and submit care quality

Need to show key qualities of care coordination
- electronic copy of health information
- timely access
- clinical summaries
- exhange information & patient summary record

Public health
 - submission to registries (cancer, reportable disease)
- electronic surveillance (epidemics, bioterrism)

EMR certification - how many certified?
 - professional's office
 - hospitals


All the systems designed by different standards - interoperability issue (how to make them talk to each other)

Meaningful Use
/eligible providers/
- physicians
- nurse practitioners
- certified nurse - mid-wife
- dentists
- physicians who practice in federally qualified health center, rural health center, led by physician assistant
- doctors of optometry


Meaningful Use - 3 stages
Stage 1: 14 core, 5 menu items - almost all have it
Stage 2: priority for now
Stage 3: still deciding

Healthcare Quality
(defined IOM)
The degree to which health service for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge"

One of most diagnosed disease is diabetes
1. process: did the doctor do the test?% of diabetics having the test
2. outcome: adequate control? % of diabetics above threshold

Chronic disease - incurable

Stage 1: at least half of patients must have online access to view record
Stage 2: 5% patients actually do that.
Stage 3: e-prescribing, clinical decision support (computer help physician avoid msitakes), computer-based physician order entry. Health information exchange, public health and clinical data registry reporting


INCENTIVE PAYMENTS

Two systems: medicare (no threshold) US care pay for 65+ citizens - carrot and sticks,
Medicaid (30% of patients, 20% for pediatricians) poor or disabled - just carrot

Medicaid no penalty - already among poorest providers, underserved. Mutually exclusive

carrot and stick. Better for early adopters, penalize late adopters. 

INCENTIVE REFORM

Value based reimbursement --replace-- number of procedures completed

What's wrong with financial incentives: The forces that have led to a global epidemic of over testing, over diagnosis, and over treatment are easy to grasp. Doctors get paid doing more, not less. We're more afriad of doing too little than of doing too much. And patients often feel the same way. They're likely to be grateful for the extra test done in the name of "being thorough" - and then for the procedure to address what's found. - Atual Gawande MD

Affordable care act (2010)
Medicare shared savings program will allow providers who voluntarily agree to work together to coordinate care for patients and who meet certain quality standards to share in any savings they achieve for the program.

Proof of concept
- 10 advanced sites
- 4 earned $29.4million reimbursement
- Marshfield Clinic earned half - health information technology

Accountable Care Organization (ACOs)
 - similar to Health Maintainence Organization
- potential savings

Pioneer ACOs - high performing sites
- 2 years of shared savings and shared losses
- successful program can move in year 3 to a population-based model

Value based care - not just the government
Anthem's Joe Swedish said it's value-based contracts include "enhanced payments for performance and shared risk or bundle payment arrangements."

Data matters!