1

Electronic Health Record (EHR) Adoption in Arizona:A View from the Frontlines

Scott Endsley MD MSc Medical Director, System Design

Health Services Advisory Group

http://www.ahcccs.state.az.us/eHealth/Presentations/Endsley.ppt

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Health Services Health Services Advisory GroupAdvisory Group

• Medicare Quality Improvement Organization (QIO) for Arizona

• Founded in 1979 by Arizona doctors and nurses, HSAG is one of the most experienced QIO’s in the nation.

• Dedicated to improving quality of care delivery and health outcomes through information, education, and assistance

• Partner with physicians, health plans, nursing homes, hospitals

3

Most Healthcare Comes from Small Practices

1460 primary care practices

92% 1-3 physicians

98% less than 8 physicians

4

Health Information Technology Use in Arizona

AzAFP/ACP/AOMA Survey (Jan-March 2005)

Harris Survey (Maricopa County Medical Society) Summer 2004

5

Key Findings 87% have high-speed

Internet access

13.5% currently using electronic health records

25% ready to purchase in next 2 years

29+ electronic health record vendors active in Arizona market

6

Office Practices are Saying….

Drug checking, reminders sound great, but can I afford this as a solo practitioner?

Will I be able to connect with my hospital?

Will the vendor be able to support my needs?

Will my patient’s information stay private?

Most of my colleagues still use paper, shouldn’t I wait till electronic medical records are the standard of care?

I have been using paper for 20 years, how will I ever get them all into my electronic medical record?

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The IT Adoption ‘Gap’

We are here

How do we get here

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Source: Ford et al. “Predicting the Adoption of Electronic Health Records” JAMIA, 2006, 13: 106

Tipping point in next 3 years

Interpersonal effect 20x more potent than mass marketing effect

PREDICTING THE FUTURE

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IT Market Failure: A Prisoner’s Dilemma

$1.6 billion in health care

Highly fragmented delivery and financing models

Asymmetric risk assumption and benefit sharing

12% DECLINE in proportion of pay for performance programs with IT incentives

IT incentives small = 4% of total incentive.

Are you locked behind your medical loss ratio?

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If HIT were a Gallon of Gas….

We spend 400X LESS than Great Britain

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Per “Average” Provider Annual Cost Saving Projections

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

Basic Rx Basic Rx-Dx Int Rx Int Rx-Dx Adv Rx-Dx

ADE Reductions

Laboratory

Radiology

Medication

$28K

$16.6K$12.3K

$2.5K$2.2K

Only 11% ($3080) accrues to physician

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The Market Opportunity

$200 Billion Market

13

Costs Highly

variable (e.g. $3,000- $134,000)

Components:o Hardwareo Application (both

primary and 3rd party)

o Trainingo Supporto Maintenanceo Interfaces

14

Bridging the GAPTen Key StrategiesTen Key Strategies

Demonstrate relative advantage Triability Observability Use multiple channels of communication Work with homophilous groups Stay tuned to changes Social networks Opinion leaders Compatibility Infrastructure

Source: Cain and Mittman, Diffusion of Innovation in Health Care, Institute for the Future, May 2002

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Barriers to Electronic Transformation

Financial High up-front cost Underdeveloped business

case High initial physician time

costs

Technical Inadequate technical

support Lack of standards Security and privacy

Behavioral Concerns about IT effect on office culture

Organizational ChangePatient-physician communicationWorkflow changesTechnical competenceStaff Training

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Hard Dollar Benefits

Hard DollarBenefits

Capture lost charges IF charges are now being lost

1% - 5% revenue gain

Reduce ‘defensive downcoding’

IF downcoding is prevalent

5% - 11% revenue gain

Reduce claims denials & delays

IF denials or delays are common

15 – 30 day A/R speedup

Increase preventive and management

services

IF new services are profitable AND capacity exists

5% revenue gain

Reduce transcription IF dictating AND willing to change

$5k - $15k/yr costs cut

Example Conditions Amount

ROI ~$33,000/provider starting at 2.5 years after investment, most of which accrues from better coding and charge capture

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3-year initiative of Centers for Medicare & Medicaid Services (CMS) focused on small to medium sized primary care practices

Aim: transformation of care through widespread adoption of electronic technologies in office practice

State Quality Improvement Organizations have developed technical assistance services

Doctors Office Quality Information Technology (DOQ-IT) Initiative

Expand the Adoption Rate by 5-

6%

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Roadmap

AssessmentVendor

SelectionPlanning ImplementationCare

Management

ASSESSMENT – practice readiness, workflow analysis

PLANNING – make business case, prioritize needs, set goals

SELECTION – identify options, evaluate, decide, contract

IMPLEMENTATION – prepare, build interfaces, go-live, problem solve

CARE MANAGEMENT- chronic care redesign, report data, improve

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DOQ-IT Services

EHR UniversityOnsite consultationsWeb resources – www.azdoqit.org

Physician Champions Network IT Events/ Vendor Fairs

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DOQ-IT Support

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• Tools & Resources

• Consulting Services

• Arizona IT news & events

• Register for EHR University

• Complete Practice Readiness Assessment

Our Website – www.azdoqit.org

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Early Lessons from Frontlines

Cost and loss of productivity concerns

Huge disinterest on part of payers

Second wave of adoption

Free isn’t free enough

Waiting for the government solution

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University of Arizona implementing Allscripts systems across 22 site network

Arizona Community Physicians implementing Allscripts across 89 providers

Arizona State Physicians Association promoting Synamed to 900 practice network

Arizona Medical Clinic implemented GE Centricity, uses as basis for pay for performance

Canyonlands Community Health Centers rolling out NextGen across 5 clinics

…..and many more clinics and organizations engaging in electronic transformation

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Yuma Regional Center for Border Health

Administer a discount care program – Community Access Program of Arizona (CAPAZ)

52 providers, 500 patients

Exploring use of CCR-based technology to track patients (especially medications across Arizona/Sonora border)

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Our ChallengeDefine electronic health care as the standard

Close the technology gap-help small offices find ways to finance technology

Assist practices accomplish the practice redesign to effectively use new technologies, including use of data for improvement

Connect all parts of the healthcare system including consumers

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THANK YOU!

Email:

azdoqit@hsag.com

Website:

www.azdoqit.org

Scott Endsley 602.745.6342

sendsley@hsag.com

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Gary A. Christopherson, Senior Advisor to Under SecretaryVeterans Health Administration, Department of Veterans Affairs

May 13, 2003

Presentation to TEPR

1/7th of US Economy“Electrifying”

http://www.informatics-review.com/talks/TEPR-2003/max.ppt

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Birth Direct Care / Info/Prevention

Quality Assurance

National Health Policy

Health

RisksUS Health – Goals, Strategic Principles, Outcomes,

Leadership/Management, Benefits, Culture/Environment, Resources, Information, History

“Occu

pation

al” En

vironm

ent“C

omm

un

ity”

En

viro

nm

ent

Research & Development

US Health SystemUS Health SystemUS Health SystemUS Health System

DeathCare Episode /Chronic Care

H&ITBP/

Ideal

H&ITBP/

Ideal

Clinical Care Population,Person/Enrollee,

Episode

Maximize Health/Ability & Satisfaction

Status - Well, Acute Illness, Chronic

Illness, Custodial

Health Surveillance

Preventive Measures

Education

Evaluation/Diagnosis

In-/Outpatient Treatment

Community Treatment

Rehabilitation

Information

Health SurveillancePreventive Measures

EducationEvaluation/Treatment

RehabilitationInformation

Community Care (Home / Workplace)

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Drivers for health

• Maximize health/abilities• Maximize satisfaction• Maximize quality• Maximize accessibility/portability• Maximize affordability• Maximize patient safety (defects/errors to zero)• Minimize time between disability/illness &

maximized function/health (time to zero)• Minimize inconvenience (inconvenience to

zero)• Maximize security & privacy

312001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Standards• Data• Communications

---------------------

Health Info Systems• Electronic Health

Records Systems (EHRs)

• Personal Health Record Systems (PHRs)

• Info Exchange

Paperless (IOM)

Affordable, high quality, standards-based EHRs, PHRs & Info Exchange

Potential timetable to “paperless”

Adoption by health

organizations

Adoption by persons

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Toward standards & high performance info systems• HealthePeople Strategy:

•Move Federal & Nation to national standards & high performance health info systems – EHR, PHR, HIE – supporting ideal health systems

• HealthePeople Concept:•Collaboratively develop by public & private sectors•Support by consumers, providers, payers & regulators•Meet consumer, provider, payer & regulator needs •Achieve info standards for data, communications, security, systems & technical

•Build/buy & implement high performance systems •Public ownership/sharing of at least one high performance system for special needs populations

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Management & Financial System

Health Provider (including clinical Interface, e.g. CPRS, CHCSII, & RPMS) & Data System

Registration, Enrollment & Eligibility System

Database/Standards

“e” communications/ transactions

Billin

g System

Provid

er Paym

ent

System

Ph

armacy S

ystem

Lab

oratory System

Rad

iology System

En

rollmen

t System

Sch

edu

ling S

ystem

Blood

System

Outside health organizations

My HealthePeople[web site, virtual health

record, trusted information, self-reported information,

link to other health providers]

HealthePeople - High Performance Information Systems Components/Links/Standards

Database/Standards

Database/Standards

S

S

S

S S

S

S S

SS

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Management & Financial System

Health Provider (including clinical Interface, e.g. CPRS, CHCSII, & RPMS) & Data System

Registration, Enrollment & Eligibility System

Database/Standards

“e” communications/ transactions

Billin

g System

Provid

er Paym

ent

System

Ph

armacy S

ystem

Lab

oratory System

Rad

iology System

En

rollmen

t System

Sch

edu

ling S

ystem

Blood

System

Outside health organizations

HealthePeople - High Performance Information Systems Components/Links/Standards

Database/Standards

Database/Standards

S

S

S

S S

S

S S

SS

Personal Health Record

My HealthePeople[web site, virtual health

record, trusted information, self-reported information,

link to other health providers]

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Other health organi-zations

My HealtheVet / My HealthePeople

My HealtheVet / HealthePeople[Personal Health Record System]

“health in a box” on PC & web site via community, health, non-health, government

S

Electronic Health Record System (e.g. VistA)

Database/Standards

S

Primary healthprovider

Software & Hardware

Person

Health Record•Access to health records•Sharing health records•Self-entered health record

Services•Checking/filling prescriptions•Checking/confirming/making appointments•Checking/paying co-payments•Participating in support groups•Health decision support•Health self-assessment•Messaging with health provider•Diagnostic/therapeutic tools•Reminders•“Checking in”•Safety services/tools•Links to other health sites

Information•Trusted information

Electronic Health Record System

Database/Standards

Software & Hardware

SS

S

S

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• Phase 1• Presentation framework• Health education content• VA developed content (e.g., seasonal health bulletins, health tip of the day,

Veterans Health Initiatives, interactive chat)• Portal personalization features

• Phase 2• Rx Re-fill • Self Entered Data (excluding self entered metrics)

• Phase 3 • View Co-pay balance • View Appointments • Self Entered Metrics

• Phase 4 (Electronic Health Record) • eVAult• VistA extracts• Delegate function• User and system administration functions

My HealtheVet Phasing

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• Summer 2003• Foundational online environment with VA-developed

content, health education information, and self-assessment tools

• Fall 2003• Prescription refill and self-entered data*

• Winter 2004• View total co-payment balance, view next scheduled

appointment**• Spring 2004

• Electronic patient record data and migration from pilot to national system***

* Requires proofing solution in place ** Requires Secure Web Transaction Architecture; otherwise, reduced-capability service still possible.*** Requires Secure Web Transaction Architecture implementation

My HealtheVet Timeline

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Potential of “Best Practices” / Ideal Systems

Veteran (and their families) not receiving care currently

20+ million veterans not receiving VHA care currently can benefit via My HealtheVet getting trusted info, keep a personal health log, store their non-VHA health record, do internet dialogue with health advisor, help family & friends get care, form peer-to-peer support groups, be notified of benefit & care site info, be notified of service-related illness information (e.g. SHAD, Gulf War Illness), register/apply for benefits & arrange for first appointment. Ideal – Via My HealtheVet, veterans entering VHA for care have already established/trusted relationship & VHA already has basic info on which to base care; veteran is strong partner in health.

Family of veteran not yet receiving care

Via My HealtheVet, can assist veteran with accessing care or benefits, get trusted info, do an internet dialogue with a health advisor with their veteran family member, form peer-to-peer support groups, be notified of benefit & care site info, be notified of service-related illness information (e.g. SHAD, Gulf War Illness), register/apply for benefits & arrange for first appointment for their veteran family member. Ideal – veterans families feel VHA cares & can be trusted; family is strong partner in health.

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Potential of “Best Practices” / Ideal Systems

Person (and their families) not receiving care currently

People can benefit via My HealthePeople where they get trusted info, keep a personal health log, store their health records, do internet dialogue with health advisor, help family & friends get care, form peer-to-peer support groups, be notified of benefit & care site info, be notified of work-related illness information, register/apply for benefits & arrange for first appointment. Ideal – Via My HealthePeople, people entering for care have already established/trusted relationship & provider already has basic info on which to base care; person is strong partner in health.

Family of person not yet receiving care

Via My HealthePeople, can assist person with accessing care or benefits, get trusted info, do an internet dialogue with a health advisor with their family member, form peer-to-peer support groups, be notified of benefit & care site info, be notified of work-related illness information, register/apply for benefits & arrange for first appointment for their family member. Ideal – persons’ families feel health provider cares & can be trusted; family is strong partner in health.

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National standards & high performance systems

Convergen

ce

Convergence

DoD CHCS II

IHS (upgraded RPMS)

Public/Private (CMS, VA, health providers/ payers/regulators, private sector vendors)

Standards – Jointly develop/set/use.Systems – Develop/enhance/use high performance, interoperable.Exchange – Develop two way with computable data.

Standards – Nationally accepted.Systems – High performance, interoperable.Exchange – Two way with computable data.

2001 2010

HealthePeople(Fed)

HealthePeople

VA HealtheVet-VistA

National Health

Information Standards

Exchange/ Sharing

High Performance

Health Info Systems

Personal Health Record

Systems

VA, DoD, IHS individual/joint adoption

Public/Private•Individual (e.g. Kaiser Permanente)•Joint (Connect. Health, eHealth, NCVHS, SDOs, …

HealthePeople(Fed)

HealthePeople

Consolidated Health Informatics (CHI)

Hea

lth

In

form

atio

n

Sys

tem

s

Sta

nd

ard

s

41

Back-up Slide

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This & Next Generation Strategy

HealtheVet-VistA• Operate current generation VistA• Develop, implement & operate HealtheVet-VistA,

incl. My HealtheVet• Develop, implement & operate Next Generation

HealtheVet-VistA as open source, componentized high performance system with partners

HealthePeople, including HealthePeople-VistA• Push development & adoption of health information

standards• Push availability & use of public/private sector high

performance health information systems, including NextGen HealtheVet-VistA used externally as HealthePeople-VistA, and personal health records

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MAINTAINING SECURITY AND PRIVACY OF PATIENT INFORMATION

September 2, 2006

Frank E. Ferrante, MSEE, MSEPP

President FEFGroup, LLC

Past Chair, Medical Technology Policy Committee

IEEE-USA, Washington, DC

Presented at28th IEEE EMBS Annual International Conference

Aug 30-Sept. 3, 2006, New York City, New York, USA

http://www.ieeeusa.org/volunteers/committees/mtpc/documents/EMBC06-NYC-Panel.ppt

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Outline

• Why Electronic Medical Records? • Software Sample/hardware samples • Barriers/Standards for EHR• HIPAA Security and Privacy Regulations • Medical data transmission requirements• Wireline and Wireless Telecommunications

Services Security• Security of Patient Medical Records• References

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Why Electronic Medical Records (EMRs)

• Time spent filing and pulling patient charts, searching for charts

• Time re-creating records if destroyed by natural disaster or accident

• Cost of supplies to maintain charts• Cost of facility space for records (can better use of space

be made?)• Storage and Backup Cost • Transcription services cost• Cost of doing nothing today• Better Security/Privacy Maintainable

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Software/Hardware Supporting Digital Medical Records

• Electronic Medical Record (EMR)Software– Soapware - check it out $300 Starting Price see: http://soapware.com/

– e-MDs Electronic Medical Record Support Software http://www.e-mds.com

– a4Healthsystems EMR and Access systems http://www.a4healthsystems.com

• Companion Technologies http://www.companiontechnologies.com

• Security and Privacy - all EMRs must be protected– Sample approach: indigenous authentication of digital information (US

Patent 6,757,828 B1 of June 29, 2004) by Signa2 http://www.gjtdc.com

– Backup routinely onto remote servers or storage offerings

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What are the Barriers to EHR and e-Health Implementation?*

• Lack of a Unique Personal Identifier• Lack of HIPAA Compliant Middleware• Lack of Incentives• No Paradigm or “First Mover” for Some System

Components• Evolving Standards• Disincentives• Lack of an NHIN Architecture• [Fear of Cost/Benefit]

* [Corr 06]

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Barriers and SolutionsIdentifiers and Middleware

HIPAA compliantIdentification,

Authentication, and Access

Lack of a Unique Personal Identifier:• Solutions:

•Voluntary Personal Healthcare Identifier (IEEE-USA Voluntary Healthcare Identifier Position Statement, 17

June 2004)•Center for Certification of Health Information Technology Multiple ID Approach (Provider ID + Provider Unique Personal ID)•DOD Common Access Card Model

Lack of HIPAA Compliant Middleware:•Solutions:

•RHIO Contracts•Marketplace Solutions

•Shortcomings:•Public Health and Research Interfaces may not be included

* [Corr 2006]

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EHR Standards Evolution*

• International Statistical Classification of Diseases and Related Health Problems (ICD) from ICD-9 to ICD-10

• ASCI X12 Version 4010 to ASCI X12 Version 5010 (HIPAA Business Transactions)

• National Council for Prescription Drug Programs Telecommunication Standards from version 5.1 to version D.0

• Conversion of all standards to XML* [Corr 06]

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HIPAA Security and Privacy Regulations

• Health Insurance Portability Assurance Act (HIPAA)– Security - Required stronger and more focused

provision of security around medical information (supports maintaining of information privacy)

– Privacy - Enforces increase in privacy protections for medical information (Not just speaking privacy- required under penalty if failure occurs)

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Electronic Medical Record (EMR) Data Requirements

• Page of text for entering and storing non-image information– Less than 64 Kbytes(large file)

• Image Data– (Refer to estimate table)

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Medical Images Data Transmission Requirements*

*Source: Ferrante, F.E.,“Evolving Telemedicine/eHealth Technology,” Telemedicine and e-Health, Vol 11,

Number 3, June 2005, Mary Ann Liebert, Inc Publisher, ISSN-1530-5627.

I mage Type I mage resolutionI mageSize

Spatial Size(bits/pi xel)

lessControl &error bits

Ultrasound 512x512 x8 256 KbytesOther (Angiography,Endoscopy, Nuclear Med.,Cardiology, Radiology) 512x512 x8 256 KbytesComputed Tomography 512x512 x12 384 KbytesMagnetic Resonance Imaging 1024x1024 x12 1.5 MbytesDigitized (Scanned) X-Ray 1024x1280 x12 1.9 MbytesDigital Radiology 2048x2048 x8 4 Mbytes “ “ (high quality) 2048x2048 x12 6 MbytesMammography 4096x4096 x12 25 Mbytes

53

Wireless Telecommunications Services

– Broadband Services• 802.11n• WiMax

– Security• PKI• VPN• Secure ID• WEP/WPA/WPA2 (802.11i)

54

How New Technologies Stack UpD

ata

Rat

e(m

egab

its p

er s

econ

d)

Source: Technology Review, October 2005Established Emerging

Actual performance will vary depending on factors such as how the technology is deployed, the user’s distance from base stations, and interference.

1,000

-1

1

10

100

WPANWPAN WLANWLAN WMANWMAN WWANWWAN

Bluetooth 1.2

Bluetooth 2.0

Ultrawideband

Wi-Fi (802.11b)

Wi-Fi (802.11a/g)

Wi-Fi (802.11n)

WiMax (802.16)

WiMax mobile(802.16e)

2G cellular

2.5G cellular

3G cellular

3.5G cellular

4G cellular

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Security of Patient Records• Wireline Communications/Computer Access

– Database Encryption– Public Private Key access control– Routine Password Control and Management– Isolation of Database Server from outside access

• except via Virtual Private Network (VPN) and Secure ID hand-held devices or Secure Private Key system

• Wireless Communications– Wire Equivalent Privacy (WEP)

• Poorly designed, vulnerable

– Wireless Protocol Architecture (WPA)& WPA2• Improved Security Encoding • Enterprise Security Offering(Both WPA and WPA2 now available for Wireless

operations as alternate to WEP)

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References

• [Corr 2006] Corrigan, Mike (Current Chair MTPC), “Consumer-Centered Electronic Health Records and e-Health - Roadblocks and Opportunities,” presented to GEIA Roundtable, June 29, 2006 -

Available at: http://www.ieeeusa.org/volunteers/committees/mtpc/index.html

• [IEEE-USA]IEEE Medical Technology Policy Committee Web Site - ttp://www.ieeeusa.org/volunteers/committees/mtpc/index.html

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Backup Slides

58

Other HealthcareSystem Records

Payer Recordsor Payer EHRs

Healthcare Provideror

Clinical EHRs

Top Level EHR Components

Glue

Personal Health Record(PHR)

orPersonal EHR

59EMT Records

RadiologicalRecords

LaboratoryRecords

PharmacyOffice Records

DentalOffice Records

PhysicianOffice Records

HospitalRecords

PersonalHealth Record

Health Insurance PayerRecords

Per

sona

l EH

RP

rovi

der

EH

Rs

Car

rier

EH

R

PersonalHealth Record

Per

sona

l EH

R

Uncertified• Demographics• Allergies• Medications•Inoculations

Certified• Demographics and Identity• Links to other EHR components

Limited PHR Full PHR

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PersonalHealth Record

Lifetime Full PHR

Prenatal and Pediatric Records

Medicare Records

Employer and SelfInsuranceCarrier Records

Military and VARecords

ResearchRecords

Public HealthRecords

Anonymized Links with Trusted Reverse Channel

EnvironmentalRecords

GenomicRecords

Links

Death Certificateand AutopsyRecords