Saturday, February 28, 2009

Obama to Name Kathleen Sebelius to HHS

Kansas Governor Kathleen Sebelius will be tapped on Monday to be Secretary of Health and Human Services (HHS).

Barack Obama will highlight her bipartisanship, executive experience and independent-minded insurance experience. Unlike the previous nominee, Sebelius has not worked in Washington which will test her capacity to guide plans to overhaul the US health care system. And unlike the previous nominee, Sebelius will be nominated for Secretary of HHS only and not the health care role within the White House which is thought to be reserved for someone with the Washington background needed to drive Obama's health care legislation.

Sebelius has a Masters in Public Administration at the University of Kansas. For 8 years she served as a Kansas legislator. In 1994 she won election as Insurance Commissioner where she worked for the next 8 years. Sebelius developed a reputation for staying independent from the insurance companies and even halted a planned merger of the powerful Kansas Blue Cross and Blue Shield.

In 2002 Sebelius became the Democractic governor of a very red state. Her bipartisan appeal contributed to her re-election in 2006 by a wide margin. She remains a highly popular governor.

Thursday, February 19, 2009

Best Links to HITECH

To understand the implications of the stimulus legislation on health IT in 3 clicks or less, here are the places to turn:

Health Care and the American Recovery and Reinvestment Act. New England Journal of Medicine. 2/17/2009.

Stimulus Bill dramatically modifies HIPAA rules. Wisconsin Technology Network. 2/18/2009

A Shared Vision and Roadmap for Health IT. By the chairs of the National eHealth Collaborative, HITSP and CCHIT. 2/10/2009.

Monday, February 9, 2009

Reductions in Mortality, Complications and Cost Linked to Healthcare Technology

On January 26, the Archives of Internal Medicine published a study on Clinical Information Technologies and Inpatient Outcomes which found that greater automation of hospital information was linked with reductions in mortality, complications and costs.

The study was conducted in 41 Texas hospitals representing a cross-section of hospital types and sizes with data on 167,233 patients over the age of 50.

The key finding: “Hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.” The study does not conclude that there is any causal relationship from technology to outcomes and cost, but does describe the very strong correlation between them.

One of the study's authors, Dr. Ruben Amarasingham, Associate Chief of Medicine for Parkland Health and Hospital System, graciously agreed to sit down with Healthcare Technology News (HTN) to describe these results.

HTN: Congratulations on your study - - very compelling results, on such a large scale.

Amarasingham: Thank you very much. We think its one of the largest studies to evaluate the relationship between technology, clinical effectiveness and cost. We looked at this using a new framework for measuring health information technology, the Clinical Information Technology Assessment Tool (CITAT).

HTN: Can you explain CITAT? Please break it down for us.

Amarasingham: We started to develop the tool 5 years ago, starting in 2003. When we looked at HIS systems, we found that there was no good method to evaluate hospitals against each other. If hospitals say they've implemented an EMR, it's impossible to know if the definitions, functionality, usability and maturation are the same across hospitals. We therefore started with a universe of activities that physicians do in a hospital - - thousands of activities. If the activity is electronic, regardless of the specific software/technology, we asked physicians how would they respond to the following:

1) Do you have electronic support for this activity?

2) Do you know how to use the technology for this activity?

3) Do you choose to use the technology for this activity?

From that we created an instrument based on what we, and others, thought were the most important clinical activities and scaled a hospital based on whether its physicians are using the technology. We set a very high bar – the hospital needed to have the technology and the physician not only needed to know how to use the technology, but then had to choose to use it over other processes (like falling back to paper or having an assistant deal with the technology). It’s entirely possible for a hospital to spend millions and still fail on these criteria.

HTN: What piqued your interest in this?

Amarasingham: I'm an inpatient physician myself so it is a natural set of questions to ask. As a Robert Woods Johnson Clinical Scholar at Johns Hopkins, my mentors pushed me to define how to quantitatively measure information technology and the effect on clinical outcomes. Many of the technology studies were worrisome - it was not clear that the technology measure could be generalized. There was less attention to real usability. After studying the human factors research, particularly Vimla Patel's work at Columbia, it became clear that these three criteria of physician use were very important. We published an earlier study that described and validated the CITAT tool.

HTN: The data is so compelling regarding the reductions in mortality and complications. Do you have any sense for the key drivers?

Amarasingham: We suggest some possibilities in our paper. Smaller earlier studies found similar reductions and specifically examined in qualitative ways how technology might mediate these outcomes. I think that hospital medicine is extraordinarily complex with ever more studies and more innovations. Every day physicians are presented with multiple choices of treatment and diagnostics. Which parameters should be monitored? How do we track an illness over time? Information systems help manage all the information that is available in terms of decision support.

On top of the knowledge explosion, care is increasingly fragmented. There are multiple teams of physicians and para-physicians, shift work, etc. - - a growing and large number of actors just within the theater of medicine. A good IT system may help coordinate care; becoming perhaps a member of the team by helping to facilitate communication among staff who are working different shifts and schedules. In my opinion, the coordination of care makes an enormous difference in an increasingly fragmented medical system.

Good information systems also possess a certain degree of artificial intelligence. Physicians may not track the small trends in the patient’s condition. Presenting alerts and information in an objective way that may help physicians know where to look is so important. Conversely, poorly constructed systems have the potential to be harmful.

HTN: Why wasn’t Length of Stay related to use of technology?

Amarasingham: Length of Stay (LOS) is probably at the lowest it could be in American hospitals. A 2005 National Discharge Survey examined LOS over 30 years. It has been systematically driven down by a number of pressures, including attention by payers and regulators. Given the very small lengths of stay, it's possible that information technology provides efficiencies but not enough to change an already low LOS.

HTN: You published a report earlier this year which found that academic affiliation and larger IT operating, capital, and staff budgets are associated with more highly automated clinical information systems. Basic conclusion: more investment, more highly automated systems – simple. So why in this study do you find that higher levels of automation of test results, order entry and decision support are all contributing to lower costs? It seems almost contradictory.

Amarasingham: Great question. We found the hospitals that had better use of information technology had lower cost per hospitalization, adjusted for patient severity of illness. It may be that you need a certain economy of scale to implement these systems. Once you have those systems in place your per hospitalization costs are reduced - - overwhelmingly lower. We adjusted for a lot of the characteristics that are typically associated with the higher costs that makes this a robust finding. When you are seeing a patient and have a breadth of options - if you have really sophisticated decision support that is easy to use - - that tool may become an effective agent to help physicians make clinically sound choices that also control costs.

HTN: How much does the effective and extensive use of automation relate to the degree to which physicians are employees of the HCO?

Amarasingham: We didn't look at that particularly. We did look at the hospital organization. We found that the benefits cut across all hospital types. Regardless of the physician practice model, these benefits accrue to the hospital. It’s clearly a challenge for hospitals to ensure that training is provided and protocols followed. If the physicians aren't motivated and engaged with design and training, there’s the potential for very poor outcomes. We didn't look at nursing in our study, but the same applies there as well.

HTN: The stimulus package includes the HITECH Act which includes provisions for federal payments by Medicare and Medicaid for the “meaningful use” of EHRs. As I listen to you talk about CITAT, it strikes me that is exactly what CITAT is measuring.

Amarasingham: Great point. Measuring the presence of technologies would be an inadequate measure. CITAT evaluates whether the 1) technology is present in the organization, 2) the physicians have the know-how to use the technology and 3) the physicians choose to use it over other methods. Government will need to measure some sort of effectiveness outcome like this. Our research suggests that investment in healthcare technology is a wise investment. But it needs to be adopted properly. If it is rushed, not focusing on the socio-technical environment that we discuss in the paper, it could be ineffective. By setting a standard around meaningful use, I think HITECH would be headed in the right direction.

Monday, February 2, 2009

$23 Billion HITECH Stimulus: Senate Debate Kicks Off

The Senate debate kicks off today on the Superbowl of stimulus packages including HITECH, the Health Information Technology for Economic and Clinical Health Act.

It will take a carefully calibrated bi-partisan 60% to get past any Senate filibuster. So what will "careful calibration" look like? Imagine the Steelers' blockers making way for James Harrison's explosive 100 yard interception return. Or imagine the ballet of Santonio Holmes hauling in the winning pass in the far corner of the end zone with 35 seconds to go.

If it passes the Senate, it goes to conference committee to finalize the legislation. We can expect that no changes would be made that risk a Senate challenge to the final bill, like the challenge to a Roethlisberger apparent TD that fell short by 2 inches.

With that in mind, if it passes the Senate we can expect to see many of the following elements in the final bill:

Legislative endorsement for key National Health IT organizations
  • Office of National Coordinator for HIT (ONCHIT)
  • HIT Policy and Standards Committees through the National eHealth Collaborative (aka AHIC Successor) subject to ONCHIT endorsement.
  • Standards and certifications bodies: While unnamed, the Health Information Technology Standards Panel (HITSP) and the Certification Commission for Health Information Technology (CCHIT) are likely beneficiaries in support of standards and certification requirements.
ONCHIT Strategic Goals
  • Electronic exchange and the enterprise integration and use of health information, including establishment and governance of the nationwide health information network (NHIN)
  • Utilization of an electronic health record for each person in the United States by 2014.
  • Privacy and security protections for the electronic exchange of personally identifiable health information
  • Security methods for authorization, authentication and encryption of health information
  • Use of health information technology in improving the quality of health care, reducing medical errors, reducing health disparities, improving public health, and improving the continuity of care among health care settings.
  • Evaluation of open source health information technology systems for "federal safety net providers".
Meaningful Use

Financial incentives are tied to "meaningful use" of certified EHR's by physicians and hospitals. "Meaningful use" is defined somewhat circularly in the criteria:
  • Use of "EHR technology in a meaningful manner" (which for physician incentives shall include the use of e-prescribing).
  • Electronic exchange of health information to improve the quality of care such as promoting coordination of care.
  • Reporting on clinical quality measures (which shall become more stringent over time).
Physician Incentives for Adoption and Meaningful Use of Certified EHR Technology
  • The Carrot: $41,000 in Medicare payments per eligible physician: Year 1 - $15,000; Year 2 - $12,000; Year 3 - $8,000; Year 4 - $4,000; Year 5 -$2,000. If Year 1 for a professional is 2011 or 2012, then the Year 1 payment is $18,000. No incentive payments if first adopting in 2015. No incentive payments after 2015. Exceptions for rural physicians and later adopters are also specified.
  • The Stick: Fee schedule reductions will apply to physicians not using certified EHR technology starting in 2015, with fee schedule reductions of 1% in 2015, 2% in 2016 and 3% in 2017 and beyond.
  • These incentives do not apply to hospital-based physicians
  • For a summary of this, HISTalk just published a table of bonuses and penalties.
Hospital Incentives for Adoption and Meaningful Use of Certified EHR Technology

Medicare incentives to hospitals (both carrot and stick) are set up in a similar model as physicians, with a more complex calculation and bigger dollars tied to their meaningful use of certified EHR's. Incentives are calculated based on an initial amount ranging from $2 - 4.6 million (based on number of discharges) multiplied by a Medicare share and a declining "transition factor" for each of four years (1, .75, .5, .25).

Medicaid Incentives

100% federally funded Medicaid incentives are included in the legislation, without back-end reduction in Medicaid fees for non-compliance. Eligible Medicaid physicians are non-hospital based with 30% Medicaid patient volume. Eligible hospitals include 1) children's hospitals, 2) acute care hospitals receiving at least 10% Medicaid patient volume and 3) health centers or rural health clinics with at least 30% Medicaid patient volume.

News Analysis - HITECH's Impact

In a look at the slightly smaller house version of this bill, the Congressional Budget Office (CBO) estimates that $19.8 billion will be spent on HITECH which will, among other things, accelerate adoption of EHR's. The acceleration will deliver US health system net savings of 0.3% betweeen 2011 and 2019, or greater than $60 billion in savings. While this is a good return, 0.3% won't by itself substantially dampen the trajectory of health care spending (see Health Care Costs: A Principal Driver of Long-Term Deficits).

The CBO projects that without the stimulus package "about 45% of hospitals and 65% of physicians will have adopted qualifying health IT in 2019. CBO estimates the incentive mechanism would boost these adoption rates to about 70% for hospitals and about 90% for physicians."

CBO's savings estimates are based on the acceleration of benefits including "reducing the number of inappropriate tests and procedures, reducing paperwork and administrative overhead, and decreasing the number of adverse events resulting from medical errors. Health IT could also improve the quality of care provided to patients by improving the information available to clinicians at the time of treatment, by encouraging the use of evidence based medicine, and by helping physicians manage patients with complex, chronic conditions. The use of health IT could also increase some costs because improved adherence to treatment protocols could increase the amount of care provided."

John Glaser has pointed out that "meaningful use" will need to be clearly spelled out in 2009, leaving only one year for implementation in order for physicians and hospitals to realize the full benefit of the incentive programs. "This is a tall order. And it means that providers should start moving now (if they aren’t already) even though the dust has yet to settle on the specifics."