The World of Informatics In 2020

Introduction to Medical Informatics MED-INF-403 Winter 2011 FOR Professor Gerasimos Petratos Northwestern University Evanston, Illinois

BY Amy M. Andrade, David Lee, Alan Zunamon

March 3, 2011

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The World of Medical Informatics in 2020

Focal Issue: How Will the World of Medical Informatics be in 2020 Drivers and how they will change Recent events and emerging trends that foretell where we are headed Strategic and tactical implications for Health IT decisions Ways to maximize success in whatever future we predict
We read the article entitled Gartners Vision for Health Care: the Next 10 years. We then met several times via telephone conferencing to brainstorm regarding the various topics assigned. We focused on the broad issue of how the world of medical informatics may look in 2020. We tried to understand how this future ultimately would be influenced by various drivers including: social, technology, economic, environmental, and political. We tried to identify these drivers in terms of predetermined elements and critical uncertainties as was done in the original paper. In addition we independently researched recent events and emerging trends and discussed our various perspectives with each other. We tried to bring our own personal knowledge and experience into the discussion. Eventually we divided the assignment into various sections so that we would each have some individual responsibility and perhaps develop a unique expertise regarding certain topics. We submitted our work to each other for critical review and editing. Finally we put all the pieces together to create our final document. Ultimately we realized that while it may be extremely difficult if not impossible to predict the future, a keen understanding of current forces will lead to an improved ability to weather uncertainty.

Recent Events and Emerging Trends

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Personalized Medicine Smartphones/Mobile Devices Telemedicine Patient Centered Medical Home Accountable Care Organizations Cloud Computing Impact of ARRA, HITECH, Meaningful Use, ACA Continued increased in medical costs Jobless recovery

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Personalized medicine includes things like gene profiling. Care can be tailored to each patient's specific needs and type of disease. Smartphones and new tablet computers particularly the devices that have been marketed by Apple (iphone, iPad) have led to thousands of applications with new ones being developed every day. Telemedicine which incorporates telecommunications technology is increasingly used to provide and support in-home and remote access health care. The Patient Centered Medical Home(PCMH) is an approach to primary care in which one practice takes the lead on coordinating all aspects of a patient's care. One key to its success will be successful sharing and integration of healthcare information. Accountable Care Organizations complement the concept of the PCMH and similarly will require robust data sharing and reporting functions. Cloud computing continues to offer increased availability of cutting-edge information technology at a lower cost by removing the need to house and service local hardware. Legislation including the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. This has led to the development of the so-called Meaningful Use incentives which provide a financial incentive for the "meaningful use" of certified EHR technology to achieve health and efficiency goals. Continued increase in health care costs and a struggling economy will result in continued pressure to find new and improved ways to deliver quality care at lower costs. In addition, the evolving field of informatics will provide new jobs.

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Economic Drivers

Escalating cost of care Shortage of providers Increased pool of patients requiring coverage Increasing demands for price controls on pharmaceuticals/devices/procedures State of economy including the jobless recovery Government-provided incentive payments

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Predetermined elements: The continued escalation in cost of care will put pressure on all stakeholders to find solutions that are innovative and fair. An increased pool of patients with healthcare coverage will be served by an inadequate pool of providers. Continue pressure will be placed on industry to price their products with adequate profit to recoup their investments but not to be perceived as gouging the public. 17 billion dollars will be used for incentive payments to physicians and hospitals that participate in Medicare and Medicaid programs. These incentives will be issued to current users and new adopters of certified Electronic Medical Record (EMR) systems, who use the system in a meaningful way. The expected increase in the number of patients with insurance coverage will put pressure on providers to see more patients. Information Technology (IT) leaders will be tasked with finding innovations that give providers efficient ways to see more patients in the same amount of time. That may involve mobile technology, telemedicine, and online care. Critical Uncertainties: The federal government could find itself unable to make good on financial promises made just as current pension programs are coming under attack as being insolvent. A potential increase in unemployment and/or decreased buying power for the consumer makes decision-making even more complicated. What will be considered basic care and what is consider extra will continue to be debated. Inadequate financing for information technology will slow the pace of adoption by private and public health care delivery systems.

Political Drivers

American Recovery and Reinvestment Act(ARRA) Health Information Technology for Economic and Clinical Health Act(HITECH) Meaningful Use regulations Patient Protection and Affordable Care Act(PPACA) Control of Congress since November 2010 State government control since November 2010

On February 17, 2009 a $787 Billion, the American Recovery and Reinvestment Act of 2009 was signed into law by the federal government. Included in this law is $19.2 Billion which is intended to be used to increase the use of Electronic Health Records (EHR) by physicians and hospitals; this portion of the bill is called, the Health Information Technology for Economic and Clinical Health Act, or HITECH Act. The HITECH Act provides Health and Human Services with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health information technology (HIT), including electronic health records and private and secure electronic health information exchange. Two regulations have been released, one of which defines the meaningful use objectives that providers must meet to qualify for the bonus payments, and the other which identifies the technical capabilities required for certified EHR technology. Incentive Program for Electronic Health Records: Issued by the Centers for Medicare & Medicaid Services (CMS), this final rule defines the minimum requirements that providers must meet through their use of certified EHR technology in order to qualify for the payments. In March 2010, the Patient Protection and Affordable Care Act (PPACA) passed promising extensive reforms including ending lifetime limits on benefits, increasing the population of covered patients, ending pre-existing condition denials, providing Health Insurance Exchanges. Critical Uncertainties: The elections of November 2010 included a change in the control of Congress which raised questions as to whether some or all of the recently passed measures would be overturned or held unconstitutional. Various states as well have challenged much of what is included in the PPACA.

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Technology Drivers

Inefficiency, redundancy, passive records, savings, incentives. Medical errors, CDSS, CPOE. Patient-centric; single-entry points, evidence-based medicine Data warehousing, data mining. Bandwidths, speed, storage, lag time. Consumerism, Internet, empowered consumers. Genomic medicine, personalized.

Inefficiency, redundancy, and passive nature paper-based records will promote implementation EMRs. Demand for systems important for analysis and strategic planning, potential cost-savings, Medicare and Medicaid incentives will also motivate increased adoption of EMRs. There are probably lack of short term financial benefits, but the ROI long term 5-7 year are probably generally significant. From 2004 through 2006, medical errors resulted in 238,337 potentially preventable deaths of U.S. Medicare patients and cost the Medicare program $8.8 billion. The rise in iatrogenic medical errors promote implementation of CDSS such as CPOE, information management, and diagnostic support. HCIS and single-entry points that provide tools for clinical, administrative, financial, research, and education will promote integrated workstations. The goal of patient-centric care promote adoption of integrated intranets, and encourage HCOs to practice evidence-based medicine, robust data warehousing, and increased data mining for quality control. In 2010 more than $670 million was funded to RECs. Federal programs such as RECs helping with meaningful use will increase phase 3 and 4 EMRs. Requirements for integrated systems and interapplications will bring higher bandwidths, speed, storage availability, and decreased lag time. Use of wireless devices such as hand-helds and tablets will continue to increase. Consumerism and self-help will promote consumer health informatics. E-health and access to the Internet will empower educated consumers to expect more from their providers. Telemedicine with the potential cost savings and reduced travel delays will gain a wider support. Computational analysis will continue to increase in the fields of public health, administrative, and research (especially genomic and proteomic). Genomic medicine and highly personalized healthcare will be increasingly important. Many are digitizing patient data, and information processing for diagnosis and therapy continue to increase. Privacy and security legislations will be important to organizations such as HITECH and HIPPA. The demand for robust sharing of patient data for medical, research and educational purposes will motivate multiple stakeholders such as HIE and RHIO to push for standardizations and integrated information exchange.

Social Drivers

Social Networking Mobile Connectivity Generation Y Working Poor Population Increasing 45 Million People Uninsured Health Disparities

Communications has had a paradigm shift in the last five years with the contribution of Social Media, Social Networking and Mobile Connectivity. No longer will waiting for a returned phone call be acceptable, no longer waiting for more than 15 minutes for a communication from a friend, colleague or health professional be acceptable. No longer is it acceptable that personal information (financial, health or otherwise) is not obtainable instantly and through the internet onto a handheld device. Generation Y has demanded that their information be accurate and accessible 24/7. As this paradigm shift in communication and connectivity to the internet has taken place with more information now accessible 24/7, the underserved, uninsured, underprivileged have continued to escalate, with no end in sight for the near future. According to Business Week, 2004 article, the working poor are now estimated to be 25% of the US population, approximately 21.8 million citizens. The working poor families would qualify for federal healthcare assistance as they remain under 200% of the poverty level. However, we still have an estimated 45 million citizens who are above the poverty levels, thus not qualifying for federal assistance for healthcare insurance, who do not have access equity to obtain healthcare insurance. Many of the reasons are due to high costs, pre-existing condition, self-employed or working for small business who cant offer health insurance as a cost effective benefit to the employees due to risk pools low, thus raising premiums for the health insurance. Another social driver is health disparities. The American Medical Association (AMA) states recent studies have shown that despite the steady improvements in the overall health of the United States, racial and ethnic minorities experience a lower quality of health services and are less likely to receive routine medical procedures and have higher rates of morbidity and mortality than

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non-minorities. Disparities in health care exist even when controlling for gender, condition, age and socioeconomic status.

Environmental Drivers

Diversity Consumer Quality Epidemiology

The environmental drivers in all aspects of healthcare delivery system will shift the paradigm on how healthcare delivery is actually delivered and to whom it is being delivered to. Diversity and Consumer driven will be the environmental drivers in the next decade. According to an article, Healthcare Environment Drivers in March 2011, it states that by mid-century the population will be about 30% Hispanic, 13 % Black, 8% Asian and about two-third non-Hispanic White. Perhaps more importantly race, ethnicity and nationality seem to be less important for individual identity, but still are a significant factor for health outcomes and access to care. Diversity in the healthcare profession is another environmental driver which also with the passing of the Patient Protection and Affordable Care Act (PPACA), a large portion of this act is to empower the consumer with access to information in order to make well informed, self-determined decisions about their individual healthcare. Quality is another driver to be reckoned with in the US healthcare system. In the US, we were comfortable with the idea we had the best healthcare system in the world. In recent years this has been shown not to be the case. There are issues across the continuum of care and in all populations, leading one important assessment to conclude that "there are large gaps between the care people should receive and the care they do receive, according to Ed ONeil author of Healthcare Environment Drivers article in March 2011. As the baby boomer generation is aging, and we are moving from managing acute episodes to chronic disease management, this driver must be addressed as we try to reduce cost of managing chronic diseases away from the expensive acute facilities.

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Strategic & Tactical Implications for HIT

Meaningful Use Strategy Focuses on New Payment Models Accountable Care Organizations (ACOs) Charge Capture Systems Need Overhaul HIEs & RECs HIT Professionals

Meaningful Use (MU) began this decade as a strategic effort as the C-suite was trying to get their arms around what it was and how were they going to deal with it. Meaningful Use has set into motion the way we look at collecting health information, distributing this information to the consumer and how this information is used in evidence based medicine and development of decision based systems. Moving forward through the next several years, MU has transitioned into the tactical mode. Only C-Suite people concerned about MU are CIOs and CMIOs. The C-Suite has moved to the next strategy to develop Bundled Payments. The train has left the station when it comes to bundle payments and Accountable Care Organizations (ACOs). EMRs are at the center of a successful ACO in that they allow a more streamlined way to present medical information across an enterprise. For the purposes of an ACO, EMRs are critical in supplying data in a consolidated format. The EMRs required for an ACO must be MU compliant and must be integrated into a health information exchange (HIE). The C-Suite in Health Care Organizations is working overtime in developing a strategy. Moving from a fee for service model to a bundled payment model will require a number of changes in current charge capture systems. These systems will need an overhaul to capture the information required for this new payment model. Health Information Exchanges and Regional Excellence Centers will continue to run into conflict among private and state entities. The HIEs need to focus on smaller pods of networks, that will connect together, which will then create a large state HIE. Instead, the HIE initiatives are trying to build one very large network for the state which will become way too large to manage or be effective. HIT resources continue to be difficult to obtain across the private and public sectors. If HIEs are having difficulties in locating excellent talent, then what kind of talent will be left for the state agencies?

CHAOS
C
Non-Integrated delivery system & bundled payments At the extreme, all services paid to an entity rather than individual. Lack of standards in terms of quality, outcomes, and performance Lobbying for best payment increases likelihood for corruption and in-fighting Physicians & Hospitals in fact do not have aligned incentives as each game the system

Bundle Payments

Non-Integration

This quadrant is characterized by bundled payments and lack of integrated healthcare information technology and delivery systems. While a strong case can be made for bundled payment in theory, implementation presents very real challenges in a community where hospitals do not employ physicians and information technology is not integrated. Challenges include: Persuading physicians and other providers to adopt changes and alter behavior. The collaboration that is necessary may occur more readily in integrated systems, where bundled payment is likely to gain a foothold first. The growing employment of physicians by hospitals will help. Current organizational models of disparate stakeholders will pose challenges for bundled payment, especially in community based care. Physicians may distrust a hospital to be in charge of administering their payments. The biggest challenge, though, is putting in place the contracting and claims infrastructure to handle a new payment model. Patient care would likely suffer as physicians may cherry pick and avoid sicker patients. Clinical research will be compromised as well. Providers will try and court the various payers without substantive ability to back up their claims. Distribution of resources to areas most in need will not be fair. Ultimately in the absence of integration, various coalitions will form that will in fact not deliver the desired quality of care in the most efficient manner, rather a chaotic mosaic that will continue to be an obstacle to accomplishing the nations goals. This is a quadrant that is best avoided if at all possible.

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UTOPIA
Standardization & full Integration nationally Clinical pathways promote evidence based medicine & patient centric medicine Increased bandwidth, speed, storage & decreased lag time Robust data sharing ideal for governmental, clinical, public health and biomedical research Reduced cost is shared by consumers, consumers negotiate price Incentives for cooperative work, efficiency & reliability

There is integration of patient data with clinical, financial, and administrative data resources. Clinical pathways promote evidence based guidelines, and CDSS and CPOE increase quality of care. This will allow patient-centered decision making at the point of care, reducing redundant data capture and manual input. The intranet will be integrated regionally and nationally. The sharing of data will be supported by HITECH and HIPPA compliant policies, and standards in vocabulary and data transmission. Under HITECH, $677 million was allocated to RECs to implement meaningful use to EMRs. Vendors will compete and ensure standardization. Bandwith, speed, and storage will increase with decreased lag time. A robust system of Internet integrated with EHRs provide opportunities for clinical, public health, and research. HIE and RHIO continue to remain active and ensure integration of HCIS. The creation of National Information Infrastructure (NHII) support shared research, surveillance databases, and even business operations (online submission of claims and invoices). Episode-based payment creates incentives for multiple providers to eliminate unnecessary services and reduce costs. There is reduction in unnecessary services, more judicious use of resources, postdischarge costs, unnecessary postacute care services, and avoidable readmissions. Providers are financially accountable if costs of care exceed the bundled payment. Consumers have more say and negotiate discounted rates, quality standards will be met to minimize reduction in necessary care. This creates incentives for physicians and hospitals to work together and improve efficiency, reliability by improving outcomes, reducing complications, and improving coordination. Pay-for-performance and adherence to national guidelines will also increase reliability. Integrated delivery systems will significantly make implementation of bundled payments easier. Medicare Payment Advisory Commission (MedPAC) will propose recommendations and strategies for implementing this system.

Fully Integrated

Bundle Payments

TODAY
Fee for Service Non-Integrated
Clinical Data Located in Paper Charts Silos of Data Sets Fee for Service no incentive for less Lack of Continuum of Care Continue High Cost of Healthcare Delivery

Today we are located in this quadrant: Non-Integrated and Fee for Service. Currently, small physicians group practices are charting medical information in paper charts. If the mid-size and larger physicians group practices are charting medical information electronically, this information is kept in lone silos of data sets. There is no connectivity between the ambulatory setting and the acute setting. There is no sharing of data between the family physician and the hospital or vice-versa. Physicians are continually running blind in many emergency situations in making life threatening decisions quickly without the needed information at their fingertips. Today, the current model of payment is fee for service. Services provided by specialty physicians are charged at a higher rate of compensation, thus family medicine physicians are almost a rarity to locate as this model of payment doesnt incentivize family medicine practices. This is a contributing cause to the high cost of healthcare in the United States. Fee for service breeds the overuse of procedures, digital imaginary and prescriptions. There is no incentive for continuum of care coverage, maintaining health status of chronically ill patients and is discouraging for family physicians to choose to do less in the way of prescribing a solution. Today, we are doing little to practice evidence based medicine, developing decision support software applications to assist physicians with better information at the point of decision making. The turnaround time for a physician to place an order, to the point of this order being executed is slow and is costly in terms of financial and sometimes in terms of mortality. This is the quadrant we want to move out of in the next ten years and move towards a more fully integrated, bundled payment financial model.

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ORGANIZED
Fee for Service Fully Integrated
Fully Integrated Systems Nationally Robust Data Sharing Amongst Clinical, Public Health, and Research Consumer Driven Healthcare Prevention and Self-Care Incentives for quality, cost effectiveness, value and performance

O
There is full integration information systems and standardization of data sharing and terminologies regionally and nationally. Single entry point workstations provide clinical, administrative, financial, research, and educational resources. CDSS and clinical pathways promote evidence-based medicine. National network infrastructure allows providers from diverse practice settings to access EHRs. Surveillance databases are used in developing standards for prevention and treatments. [[RECs and meaningful use increase implementation of phase 3, 4 EMRs. Vendors compete and ensure standardization. Integrated systems and interapplications require increased bandwith, speed, and storage with decreased lag time. The increase in data transmission and sharing will motivate HITECH and HIPPA to push for security and privacy. HIE and RHIO continue to remain active and ensure integration of HCIS. Robust data sharing provide huge opportunities for governmental, clinical, public health, and research. NHII will create a national network and link providers to clinical data from all HCOs and private settings.]] This will allow point-of-care not limited to time or place. Increased deductibles and premiums create consumer incentives for self-care and prevention practices. MCO compete for cost-conscious consumers and customize coverage to match customer demands. ACOs offer an attractive way to manage, reduce costs, and increase accountability. ARRA and consumer interest groups lobby for lower costs. Advertising and branding are major drivers for insurance and pharmaceutical companies. Health providers are driven to provide information about quality, costeffectiveness, and indicators of value and performance. The flexibility of fee for service will provide convenience to consumers who will expect higher quality of care.

Summary

As we relook at the four quadrants, and recognize where we are today as non-integrated and fee for service as the reimbursement model for payment, we predict that we will be moving towards the Utopia quadrant over the next ten years. As there are many discussions today centered around Healthcare Reform and how this is all going to play out in the end. However, there are two trains which have already left the station and that is 1) moving to full integration of clinical data in order to have better quality outcomes; and 2) moving from a fee for service to bundled payments. This is evident with the embarking on Accountable Care Organizations and Patient Centered Medical Homes, the important continuum of care. With that stated, the debate remains open as to predict that we will be fully integrated with bundled payments in 2020. To be truly integrated, full interoperable with orders both sending and receiving, sharing data amongst the HIEs and RHIOs is quite a stretch of the imagination that this will all be accomplished in the next nine years. The HIEs and RHIOs are state funded, working within the State bureaucracy and politics which can be very volatile environments and not environments one can base a prediction. We all agree we want to be moving towards Utopia, hoping to get there by 2020, but not sure if all the factors will be aligned in order to make this a reality.

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