Lessons from Meaningful Use: Implications for the UK

David W. Bates, MD, MScCQO, and Chief, General Internal Medicine, Brigham and Women’s

HospitalMedical Director of Clinical and Quality Analysis, Partners

Healthcare

London, 2013

Overview• Where U.S. is starting– Quality/Safety/Efficiency– Health care reform

• HIT policy in the U.S.– How important is this to organizations

• Evidence about HIT in the U.S. and electronic prescribing

• Conclusions

Question

• What are the chances of getting injured by the care you receive during hospitalization?– 1 in 100– 5 in 100– 10 in 100– 25 in 100

Harm is Ubiquitous: Rates of Adverse Events Around the World

• 3.7% of hospitalizations in New York– 58% preventable

• 2.8% Colorado-Utah• 16.6% in Quality in Australian Health Care study• Near 10% in Canada, New Zealand, Denmark

among others– Approximately 10% in UK

• Rate in most developed countries appears to be at least 10%– Recent study by Classen found adverse events in a

third of admissions in U.S. using trigger tool

Adverse Events are Expensive:Costs of Safety Issues in the U.S.

• JJJEvent Type Annual Costs (Billions)

Preventable ADEs $3.8

All hospital-acquired infections $5.8

Thromboembolic disease $3.1

Other adverse events $3.3

Total Preventable Adverse Events $16

Jha et al, Health Affairs 2009

Health Care Reform• Affordable Care Act– Provides access to all patients– Incentives to improve costs, quality, efficiency• “Accountable care organizations”• Bundling

• Many have questioned whether pressure on costs will be sufficient

• Still politically contentious• No strong movement to single payer

Electronic Medical Record Adoption by Country

Zimlichman, CMAJ 2011

Adoption in Hospitals: Jha et al. NEJM 2009

• By panel definition:– 1.5% have

comprehensive system

– 10.9% have basic system

– Installed across major clinical units

Another View of the Hospital Data

Percent of hospitals fully implementing:• Laboratory and radiology reports: 77%-78%• Drug allergy/interaction alerts: 45%-46%• Medication lists: 45%

President Obama’s First Weekly AddressSaturday, January 24th, 2009

“To lower health care costs, cut medical errors, and improve care, we’ll computerize the nation’s health records in five years, saving billions of dollars in health care costs and countless lives.”

HITECH will Advance the “Tipping Point”

TIME

Technology Adoption

2004 2012

National Coordination

EnhancedTrust

GrantPrograms

PaymentIncentives

2009 2011 2013 2015HIT-Enabled Health Reform

HITECH Policies

2011 Meaningful Use Criteria

(Capture/share data)

2013 Meaningful Use Criteria

(Advanced care processes with

decision support)

2015 Meaningful Use Criteria (Improved Outcomes)

Meaningful Use is Being Defined and Will Follow an “Ascension Path”

14

*Report of sub-committee of Health IT Policy Committee

Three Key Components for Higher-Performing Healthcare System

• Better information on what works and what doesn’t

• Ability to rapidly apply knowledge to practice• Changes in the financing and organization of

care that reward physicians for considering cost and quality in decision-making

Blumenthal, ONCHIT coordinator

Health IT Policy Committee• Required to make recommendations to the National

Coordinator on:• A policy framework for the development and adoption

of a nationwide health IT infrastructure• The areas in which standards, implementation

specifications, and certification criteria are needed• Working groups– Meaningful Use– Certification/Adoption– Interoperability and information exchange

Everything has been conducted in openStakeholders on group from many perspectivesRegulations have gotten much better after public

commentary, responseSometimes has been significant time pressureCan’t keep everyone happy, but highly successful

overall◦ Lately vendors and providers are asking to slow down,

consumer groups and insurers to keep going/move faster◦ Has been consensus about direction

Observations from HIT Policy

Health System IT Priorities

Integration of IT Medical Devices

Interoperability

Focus on Ambulatory Systems

Leveraging Information

Optimizing Current Systems

Focus on Clinical Systems

Meaningful Use

0 10 20 30 40 50 60

Percent

0%

2011 HIMMS Leadership Survey

2%

Health IT Standards Committee• Required to make recommendations to the National

Coordinator on standards, implementation specifications, and certification criteria for adoption by the Secretary.

• Three workgroups: – Clinical quality– Clinical operations– Privacy and security

Payment Incentives and Meaningful Use

• A hospital or eligible provider must be a meaningful user to receive payment incentives

• Changes the focus from technology potential to clinician behavior

• By law, a “meaningful user” must:1. Use a certified EHR2. Exchange health information3. Report quality measures

• Primary care vs. specialty– Superspecialty

• Big practices vs. small• Big hospitals vs. small• What do you include/exclude?– Emergency departments– Psychiatric hospital

Issues in Setting Up Criteria

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Eligible hospitals must meet all 16 core objectives:Core Objective Measure

1. CPOEUse CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology

2. Demographics Record demographics for more than 80%

3. Vital Signs Record vital signs for more than 80%

4. Smoking Status Record smoking status for more than 80%

5. InterventionsImplement 5 clinical decision support interventions + drug/drug and drug/allergy

6. Labs Incorporate lab results for more than 55%

7. Patient List Generate patient list by specific condition

8. eMAReMAR is implemented and used for more than 10% of medication orders

Stage 2 Hospital Core Objectives

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Eligible hospitals must meet all 16 core objectives:Core Objective Measure

9. Patient AccessProvide online access to health information for more than 50% with more than 5% actually accessing

10. Education ResourcesUse EHR to identify and provide education resources more than 10%

11. Rx ReconciliationMedication reconciliation at more than 50% of transitions of care

12. Summary of Care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

13. Immunizations Successful ongoing transmission of immunization data

14. LabsSuccessful ongoing submission of reportable laboratory results

15. Syndromic Surveillance

Successful ongoing submission of electronic syndromic surveillance data

16. Security AnalysisConduct or review security analysis and incorporate in risk management process

Stage 2 Hospital Core Objectives

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Eligible Hospitals must select 3 out of the 6:

Menu Objective Measure

1. Progress NotesEnter an electronic progress note for more than 30% of unique patients

2. E-RxMore than 10% electronic prescribing (eRx) of discharge medication orders

3. Imaging ResultsMore than 10% of imaging results are accessible through Certified EHR Technology

4. Family History Record family health history for more than 20%

5. Advanced DirectivesRecord advanced directives for more than 50% of patients 65 years or older

6. LabsProvide structured electronic lab results to EPs for more than 20%

Stage 2 Hospital Menu Objectives

HITPC: MU Workgroup Stage 3 Recommendations

25

HITPC Stage 3 MU Timeline

• Aug, 2012 – present draft preliminary stage 3 recs• Oct, 2012 – present pre-RFC preliminary stage 3 recs• Nov, 2012 – RFC distributed• Dec 21, 2012 – RFC deadline• Jan, 2013 – ONC synthesizes RFC comments for WGs review• Feb, 2013 – WGs reconcile RFC comments• Mar, 2013 – present revised draft stage 3 recs• Apr, 2013 – approve final stage 3 recs• May, 2013 – transmit final stage 3 recommendations to HHS

HITPC: MU Workgroup Stage 3 Recommendations

26

Guiding PrinciplesMU Objectives

• Supports new model of care (e.g., team-based, outcomes-oriented, population management)• Addresses national health priorities (e.g., Million Hearts) • Broad applicability (since MU is a floor)−Provider specialties (e.g., primary care, specialty care)−Patient health needs−Areas of the country

• Promotes advancement -- Not "topped out" or not already driven by market forces • Achievable -- mature standards widely adopted or could be

widely adopted by 2016

April – By the NumbersApril 2013

12.77%

87.23%

Registered Eligible Hospitals

5,011 Total HospitalsRegistered Hospitals

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April – By the NumbersApril-2013

22.57%

77.43%

Paid Eligible Hospitals

5,011 Total HospitalsHospitals Paid

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Hospital 1st vs. 2nd yearCore Objective Performance

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2011 2012

Number of Attestations 833 746

CPOE for Medication Orders 86.9% 85.2%

Maintain Problem List 95.7% 95.2%

Active Medication List 97.6% 97.7%

Medication Allergy List 97.9% 97.8%

Record Demographics 97.0% 96.9%

Record Vital Signs 94.0% 92.5%

Record Smoking Status 94.9% 93.6%

Electronic Copy of Health Information 95.0% 96.9%

Electronic Copy of Discharge Instructions 95.0% 94.9%

Hospital 1st vs. 2nd yearMenu Objective Performance

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2011 2012

Advance Directives 96.1% 95.8%

Clinical Lab Test Results 96.1% 95.6%

Patient-Specific Education Resources 74.1% 72.3%

Medication Reconciliation 87.5% 84.7%

Transition of Care Summary 80.2% 81.8%

Immunization Registries Data Submission 51.9% 58.2%

Reportable Lab Results to Public Health Agencies 17.6% 13.8%

Syndromic Surveillance Data Submission 18.7% 16.8%

• Much of innovation has come from a few sites• Vendor systems now being implemented• Need support for innovation in future• Essential to look at what is implemented, not just potential• Links with external incentives will be pivotal

• How fast to go?• What are most effective things to ask for?– What should be included in terms of clinical decision

support?• How should people qualify?• What about core vs. menu?• How do you prevent gaming?• How do you know if the criteria are actually

improving care?

Looking Forward

Predictions

It’s tough to make predictions, especially when they are about the future

We always overestimate the change that will occur in the next two years, and underestimate what will occur in the next 10

Yogi Berra

Bill Gates

Where Will the U.S. Be in 2016?• National adoption rate will be over 90% in

hospitals– Essentially universal in big hospitals

• National adoption rate will be over 90% in practices– Universal in large practices– Most of holdouts will be small practices– There will have been a lot of consolidation

• Certain areas like nursing homes will still be behind• Data exchange will still be a major challenge

Who Will Be Struggling?• Small hospitals, and disproportionate share hospitals– Especially if they don’t have relationships with larger

entities• Small practices– Evidence shows that many practices actually become less

efficient after conversion, especially if they don’t adapt their workflow

• Regional health information organizations– Think they need public support and right now no plan to

give it to them

Remaining Gaps:EHRs and Care Coordination

• Continuity within team• Documentation of information• Referrals issues• Sharing care plans with other providers• Assisting with transitionsToday’s EHRs do most of these things poorly

Safety Results of CPOE Decision Support Among Hospitals

• 62 hospitals voluntarily participated• Simulation detection only 53% of orders which

would have been fatal• Detected only 10-82% of orders which would

have caused serious ADEs• Almost no relationship with vendor

Metzger et al, Health Affairs 2010

Copyright ©2010 by Project HOPE, all rights reserved.

Jane Metzger, Emily Welebob, David W. Bates, Stuart Lipsitz, and David C. Classen, Mixed Results In The Safety Performance Of Computerized Physician Order Entry, Health Affairs, Vol 29, Issue 4, 655-663

Conclusions (I)• US healthcare has huge room for improvement in

efficiency, safety, quality• Overall HIT policy direction taken so far has been

terrific– Early returns very positive

• Information technology will become ubiquitous in healthcare—near a tipping point– Electronic prescribing is a big early win– Yet adoption is just the beginning

• EHRs and HIT more broadly can provide major benefits with respect to safety, quality, efficiency

• Safety is perhaps most straightforward– Checklists, reliable processes

Conclusions (II)• Quality improvement is achievable with HIT in many

domains• Efficiency benefits least well-demonstrated and

linkages with incentive key• Lots to be learned about how to get benefits– HIT is simply a tool—part of a program– But nearly every other effort to improve

safety/quality/efficiency will rely on HIT

• Getting right decision support in place is central

Implications for UK

• Incentive approach has worked well• Adoption rate has climbed very rapidly– Still uncertain though about to what extent will

improve quality, safety– Need some post-implementation checking

• Secondary care applications are ready now for implementation– Electronic prescribing, medication administration

records ready in particular– Integrated ePrescribing applications are universal

“Insanity is doing the same things the same way and expecting different

results”

Albert Einstein