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6 Approaches to Improving Value - Organization and Structure of Care
Pages 173-200

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From page 173...
... Electronic health records (EHRs) , discussed by Douglas Johnston, are considered a key piece of infrastructure for overall health system improvements.
From page 174...
... Yet, he asserts, to achieve these "home runs," the design of medical homes -- a model of delivering primary care that engages individual patients in forming partnerships with their personal physicians in an accessible, continuous, comprehensive, patient-centered, coordinated, compassionate, and culturally effective manner (American Academy of Family Physicians et al., 2007) -- must explicitly incorporate the lessons learned from these successful examples before they can improve quality while lowering total costs of care in a sustained fashion.
From page 175...
... The Center for IT Leadership's (CITL's) own projections suggest that millions of avoided medication errors and hundreds of billions in avoided costs are possible from widespread adoption of EHR-related functions such as order entry, decision support, and electronic healthcare information exchange (Bu et al., 2007; Walker et al., 2005)
From page 176...
... 8. Reporting and population health management: aggregation, reporting, and analysis of data across patients for multiple purposes including monitoring and managing chronic conditions, tracking key quality indicators, and reporting disease statistics.
From page 177...
... Used consistently and appropriately, EHRs containing these functions are postulated to produce significant value in the form of the following: • Improved quality -- decision support may result in increased adher ence to care guidelines; • Improved patient safety -- interaction and allergy checking at the time of drug orders may decrease rates of medication errors; • Improved outcomes -- decreases in the morbidity and mortality associated with acute and chronic conditions; • More integration and better care coordination -- improved avail ability of patient data at the point of care and communication among caregivers and patients; • Improved efficiency -- decreases in the frequency of unnecessary and duplicative care and in the costly manual exchange of clinical data; • Decreased costs -- both in administrative costs to support clinical operations (maintaining paper medical records) and in the costs of care; • Increased provider revenues -- from improved coding and documen tation; and • Better research data -- creating longitudinal data stores on patient's conditions, histories, and outcomes.
From page 178...
... . Other studies have suggested that in some care settings, the use of EHR functions such as computerized physician order entry (CPOE)
From page 179...
... In addition to payment systems, the sophistication of an EHR system, the settings in which this system is adopted, the size of the organization, the presence or absence of strong leadership and quality improvement programs, and other dimensions impact the type and amount of value EHRs may produce and to whom this value ultimately accrues. Table 6-1 provides a summary of many of the key characteristics that impact EHR value creation and capture.
From page 180...
... • EHR adoption and maintenance costs • Workflow and practice patterns Care process variation • Level of EHR adoption and "meaningful" use • Populations served Pediatric, geriatric, or condition-specific Changing a few characteristics in this example would change the dynamics of EHR value creation and capture. If this same practice added order entry and robust decision support capabilities to its EHR, most medication orders would now be entered electronically.
From page 181...
... We present data from review articles that included studies examining EHRs as well as key EHR capabilities contained in the IOM definition above. Research Studies Related to EHR Impacts on Quality, Safety, and Efficiency In 2006, researchers at RAND published a systematic review on the impact of health information technology (health IT)
From page 182...
... Specifically, they examined the degree to which hospital use of many EHR functions -- including clinical documentation, order entry, results reporting, and decision support -- was associated with mortality, complications, costs, and length of stay for patients with four medical conditions: myocardial infarction, congestive heart failure, coronary artery bypass grafting, and pneumonia. Patients at hospitals who had adopted and used systems with EHR functions more intensively had lower rates of hospital-based fatalities and lower risk of complications.
From page 183...
... . In inpatient care settings, acquisition costs for clinical information systems with order entry and decision support capabilities -- a proxy for EHR costs -- ranged from $2.8 million to $4.1 million for a 200-bed hospital to $9.7 million to $14.7 million for a 1,000-bed hospital; support costs ranged from $174,000 to $468,000 annually for a 200-bed hospital, and $747,000 to $1.5 million for a 1,000-bed hospital annually (Birkmeyer et al., 2002)
From page 184...
... CITL has projected the potential impacts of several key EHR functions, including the following: • Order entry with decision support in outpatient care settings (ambulatory computerized provider order entry, or ACPOE) ; • Electronic communication and connectivity between providers and other healthcare stakeholders (health information exchange and interoperability, or HIEI)
From page 185...
... Regarding ACPOE, CITL projected the impact of increasing levels of order entry and decision support sophistication on the reduction of adverse drug events, ADE-related hospitalizations and visits, and finally ACPOE adoption costs and financial benefits. Nationwide adoption of advanced ACPOE systems has the potential to eliminate more than 2 million ADEs and avoid more than 190,000 hospitalizations per year.
From page 186...
... However, given the limited evidence base, these analyses have not been able to account for every characteristic that may impact EHR value. Nonetheless, cost-benefit projections provide an important component in 7The definition of electronic medical records in the RAND cost-benefit analysis largely overlaps the IOM definition of EHRs.
From page 187...
... Adoption of fully functional EHRs that include the key functions and characteristics of the IOM's definition is even lower: at most, 4 percent of outpatient providers and less than 2 percent of hospitals have EHRs with broad functionality, such as clinical documentation, electronic data sharing, and order entry for drugs, as well as lab tests, image studies, and robust decision support.8 There are many reasons behind low EHR adoption, including the relatively high cost of purchasing and maintaining EHRs (Hersh, 2004) and provider's limited access to capital.
From page 188...
... Moreover, new forms of EHR value, such as enabling comparative effectiveness research and biosurveillance through aggregation of electronic patient data, have yet to be studied. What the existing evidence has not been able to determine and what is not well understood are which combinations of characteristics are able to achieve relatively greater value from EHRs and which interactions are most important in creating and sustaining EHR value.
From page 189...
... Medical homes that fail to substantially reduce total per capita health spending will also find it difficult to persuade public and private sector purchasers to support substantial new medical home fees. Lower-income adults and employer, union, and government health benefit program sponsors need the medical home to be a "medical home run" -- a care delivery innovation that substantially reduces near- and longterm total healthcare spending while improving quality of care.
From page 190...
... equally zealous concentration of referral care to highquality medical specialists who are sparing in their use of "supply-sensitive services," as defined in the Dartmouth Atlas. Personal Zealotry in Preventing Unplanned Hospitalization for Chronic Illness All four primary care medical home runs operate as de facto "hospitalization prevention organizations" for their chronically ill patients; they make prevention of unplanned hospitalization of these patients a primary objective; and they redesign their practice models accordingly.
From page 191...
... Concentrating Referral Care with High-Quality, Conservative Medical Specialists Current methods of comparing specialists on quality and total spending per episode of acute illness care and per year of chronic illness care are imperfect. Nonetheless, each of the four primary care medical home runs used available performance assessments of specialists on quality and total cost of care in order to concentrate specialist referrals with one wellperforming specialist or specialist group per specialty.
From page 192...
... Population health improvement in its many forms -- prevention, wellness, chronic disease management, and others -- offers important direction for this task by demonstrating how good health often is simply a matter of good timing. Population health improvement learned long ago that keeping people healthy and identifying risk, rather than waiting for hospitalization or diagnosis of chronic disease, brings greater rewards than reactionary care -- the all-too-common approach.
From page 193...
... However, this question overlooks the long-term value of sustaining and improving health status and, again, assumes that disease management is a one-size-fits-all, monolithic process that can serve any population in any setting regardless of the resources or the training required. A much better question reformers must consider is: Do population health improvement programs improve quality and deliver value?
From page 194...
... It also reflects the broader industry shift toward keeping people healthy with extensive new work on measuring success in wellness programs, an area DMAA will continue to develop in a fourth phase of the project. With this tool in hand, we can look critically at those relevant questions for population health discussed earlier and narrow our focus on programs that produce the results we seek, based on industry consensus, evidence-based approaches to evaluation.
From page 195...
... Illinois initially engaged nearly 2 million beneficiaries for primary care case management and disease management and provided disease management for 220,000 chronically ill Medicaid recipients. Working with nurses, social workers, and physicians to support patients and reduce admissions, Illinois realized a net savings in 2007 of $34 million through an 8.5 to 20 percent reduction in admissions and a 13 percent drop in emergency department visits.
From page 196...
... Population health's prospects for a central place in the medical home appear strong, particularly given its ability to provide the health information technology infrastructure that small practices often cannot afford and to dovetail well with medical home certification requirements. As we look to the continued influx of baby boomers to our healthcare system, population health improvement becomes an increasingly important component of coordination and collaboration with physicians and other medical providers.
From page 197...
... 2005. Unexpected increased mortality after implementation of a commer cially sold computerized physician order entry system.
From page 198...
... 2003. Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review.
From page 199...
... 2006. Lessons from "Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system." Pediatrics 118(2)


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