Wednesday, December 8, 2010

Healthcare IT implications of Healthcare Reform

I'm often asked how Healthcare Reform will impact IT planning and implementation over the next few years.

First, some background.  The Patient Protection and Affordable Care Act (HR 3590) and Health Care and Education Reconciliation Act (HR 4872)  were passed to to address several problems with healthcare in the US.    We're spending 17% of our Gross Domestic Product on healthcare, yet we have worse population health outcomes than many other industrialized societies spending half as much.  Healthcare costs are rising faster than inflation.   We have significant variation in practice patterns that is not explained by patient co-morbidities nor justified by comparative effectiveness evidence.    We want to expand access to health insurance to 95% of the population, lower our spending growth rate, and incentivize delivery system change.

How will we do this?

Health insurance reform expands coverage, makes features and costs of plans transparent, and removes the barriers to enrollment created by pre-existing condition considerations.  

Payment reform transforms the Medicare payment systems from fee-for-service to Value Based Payment - paying for good outcomes rather than quantity of care.    Pilot projects will test new payment methods and delivery models.  Successful innovations will be widely implemented.

Let's look at the payment reform details that will lead to delivery system reform.

Medicare Initiatives include
*Medicare shared savings program including Accountable Care Organizations (ACOs)
*National pilot program on payment bundling
*Independence at home demonstration program
*Hospital readmissions reduction program
*Community-Based Care Transitions Program
*Extension of Gainsharing Demonstration

Medicaid Initiatives include
*Health Homes for the Chronically Ill
*Medicaid Community First Choice Option
*Home and Community Based Services State Plan Option
*Hospital Care Integration
*Global Capitation Payment for Safety Net Hospitals
*Pediatric ACOs

I believe that Accountable Care Organizations will be the ideal place to host several of these innovations including bundled payments, the medical home, and an increased focus on wellness.

All of this requires innovative IT support.  

Here are my top 10 IT implications of healthcare reform

1.  Certified EHR technology needs to be implemented in all practices and hospitals which come together to form Accountable Care Organizations.   EHRs are foundational to the capture of clinical and administrative data electronically so that data can be transformed into information, knowledge and wisdom.
2.  Health Information Exchange among the PCPs, Specialists, and Hospitals is necessary to coordinate care.   Data sharing will start with the "pushed" exchange of patient summaries in 2011 and evolve to just in time "pulls" of data from multiple sources by 2015.
3.  Health Information Exchange to Public Health registries is necessary to  measure population health across the community.
4.  Quality data warehousing of key clinical indicators across the ACO is necessary to measure outcomes.   2011 will be about measuring practice and hospital level quality, 2013 will be about measuring quality throughout the accountable care organization, and 2015 will be about measuring patient-centric quality regardless of the site of care.
5.  Decision support that occurs in real time is needed to ensure the right evidence-based care is delivered to the right patient at the right time - not too little or too much care, but just the right amount of care to maintain wellness.
6.  Alerts and Reminders are critical to elevate the overwhelming amount of data about a patient to action that a caregiver (or the patient) can take to maintain wellness.
7.  Home care is needed to prevent hospital readmissions, provide care that is consistent with patient preferences, and to enlist families as part of the care team.  Novel IT solutions range from connected consumer health devices (blood pressure cuffs, glucometers, scales) to wireless telemetry informing clinicians about compliance with treatment.
8.  Online access to medical records, secure communication with caregivers and customized patient educational materials are needed to enhance workflow, improve coordination, and engage patients.
9.  Outcomes are challenging to measures and we'll need new innovative sources of data such as a patient reports of wellness, exercise, and symptoms.
10. Revenue Cycle systems will need to be significantly modified as we move from fee for service models to value-based payment and gainsharing when ACOs deliver higher quality care for less cost.

So there you have it - find the PCPs, Specialists and Hospitals you want to form an ACO then fully implement EHRs, PHRs, Quality Data Warehouses, Health Information Exchange, Decision Support Systems with alerts and reminders, homecare support including consumer healthcare device interfaces, and new revenue cycle systems.  Luckily this is well aligned with Meaningful Use Stages 1,2, and 3, so you'll be doing it anyway.

For IT professionals, we truly live in interesting times.


Donald Green MD said...

You have mentioned that many industrialized countries have half the cost and significantly better outcomes. Have they adopted any of the proposals you outlined to achieve their success?

Yesterday you wrote on negativism as a stymying force but it should not exclude healthy skepticism and in depth investigation in solving our problems.

You also didn't mention the role of medical schools in producing physicians prepared to enter primary care fields or bolstering the doctor patient relationship or improving work flows in physician offices.

Further payment reform is necessary to lower the administrative costs of negotiating fees and entering claims and making the risk pools broader. Much of the difference in cost between this country and the others mentioned lies in bureaucratic overhead, not payout for medical expenses to care for patients.

Our senior citizens on Medicare have better or similar outcomes at reasonable expense(3% overhead) than nations in the same comparisons. For sure the technological era has not reached this group of patients. However they all have insurance and can appropriately access and form therapeutic relationships with their professional caregivers without cost being a barrier.

PBBrady said...

The other IT application I'd add is real time enterprise logistics platforms that support process improvement methodologies and facilitate patient throughput across the entire hospital. This systems based approach will help PI to achieve total hospital efficiency rather than the siloed based efforts so common today.

Anonymous said...

Another point of view with EHR adoption rate is that most are poor value. The lack of interoperability may be due to lack of initiative on the part of an industry that is loathe to innovate unless they have a large group of users organized forcing their hand.

The reality is that most physicians don't need an EHR. What they need is access to structured data they can use for reports and analysis. They need the same structured data (based on proper use of the right code systems, such as SNOMED-CT for clinical findings, diagnosis, problems and the like) so they can take advantage of CPOE/eRx automation (aka CDS!)

They need software which does a good job of keeping track of problems in patients and which can link individual diagnosis, labs, and drugs to problems. There are a lot of things physicans need and the market of EHRs isn't full of "need."

Most available EHRs do a poor job of providing analytics, reporting, making problem lists useful (rather than yet another alert "you forgot to..."), and otherwise making life of a harried clinician better, let alone saving lives, reducing risks, improving public health or lowering costs.

Most physicians who don't use EHR, I wager, have done a good job assessing the state of the art, and are reasonably adept small businesses. They have weighted the cost/benefit/risk/alternatives and opted to put off EHR until there was a compelling reason.

We spend too much time lambasting these Docs as Luddites and not enough listening to them tell us they have heard the panacea story before (although from another industry), similarly making unrealistic claims based on a few studies in some academic medical center.

What we need to do first, is get the value proposition right, based on multiple uses of information. Which means it is going to have to be computable. If we want to get data from others we can understand, we better be sure we can return the favor. So rigourous standards are required.

Then come push EHR and it will be a different story. Until then, you are trying convince people with a good horse and cart they need a wood-fired steam powered car with solid iron wheels because "automobiles are the future".

Miguel Vilaplana said...

It is kind of weird to read many things that are just happening in the US about the healthcare reform (as Spanish in Boston).

Most of the attributes that an EHR should have to be certified and accomplish "meaningful use" (not just for 2011, but for what I may be in 2015 too) are a rather usual practice among Family physicians in Spain.

Several solutions that are going to be implemented here, already have been deployed elsewhere under another name too (in Spain some of them too).

The shift towards PCP and what I understand is called home office... have deep roots in other countries as well.

And yet, many people still conceive the whole Healthcare reform as a personal attack.
I truly hope they will start focusing on the "full half glass" soon... for healthness sake!