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Information about Middleton

Published on January 15, 2009

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Evaluating the Value of Healthcare Information Technology: New Studies on Return on Investment from HIT Adoption from the CITL : 1 Evaluating the Value of Healthcare Information Technology: New Studies on Return on Investment from HIT Adoption from the CITL Blackford Middleton, MD, MPH, MSc, FACMI Chairman, Center for IT Leadership Corporate Director Clinical Informatics R&D Partners Healthcare Harvard Medical School Overview : Overview Highlights from CITL studies of HIT value Value of Ambulatory CPOE Value of Healthcare Information Exchange and Interoperability Value of IT-Enabled Chronic Diabetes Management Value of Physician-Physician Telehealth Value of PHRs Insights and Lessons learned Contributors to value, detractors/barriers, implications Conclusions/Q&A CITL Mission : CITL Mission Produce timely, rigorous market-driven technology assessments which: Help providers invest wisely Help IT firms understand value proposition Provide leadership for IT in healthcare Established at Partners Healthcare in partnership with HIMSS C!TL – Improving Healthcare Value www.citl.org The Value Proposition for HIT : The Value Proposition for HIT Headlines: Value of ACPOE suggest $28K savings per provider $44B savings potential nationally Value of Healthcare Information Exchange $78B year nationally Value of IT in Chronic Diabetes Management On average in excess of $5000/diabetic, or $20B for diabetes related care Value of Telehealth In press Value of PHRs TBD US Healthcare System Will Benefit with ACPOE : US Healthcare System Will Benefit with ACPOE National adoption of Advanced ACPOE systems would prevent… 2 million ADE/yr 190,000 ADE admission/yr 130,000 life-threatening ADE/yr Nationwide implementation of advanced ACPOE could: Save the US $44 billion annually www.citl.org Value of HIEI: Key Findings : Value of HIEI: Key Findings Standardized, encoded, electronic healthcare information exchange would: Save the US healthcare system $337B over a 10-year implementation period Save $78B in each year thereafter Total provider net benefit from all connections is $34B Net benefits to other stakeholders: - Payers $22B - Pharmacies $1B - Laboratories $13B - Public Health $0.1B - Radiology centers $8B Dramatically reduce the administrative burden associated with manual data exchange Decrease unnecessary utilization of duplicative laboratory and radiology tests Walker, J et al Health Aff 2005 Jan 19 Value of ITDM Key Findings : Value of ITDM Key Findings Many diverse approaches to chronic disease management in DM Considerable expenditure on both payer and provider side Evidence base weak Potential savings not as impressive as ACPOE or HIEI On average in excess of $5000/diabetic, or $20B for diabetes related care Diabetes in the US : Diabetes in the US US prevalence: 14.6 million diagnosed, 6.2 million undiagnosed Our research focuses on Type-2 diabetes 90-95% of all diabetics “Adult-onset” Impaired response to insulin to regulate blood sugar Tremendous annual incidence of co-morbidity Every day diabetics across the country suffer harm: 33 people become blind 118 begin treatment for kidney failure 225 undergo lower extremity amputations Estimated direct cost of $92 Billion in 2002 American Diabetes Association Potential to Manage Diabetes : Therefore, there are more opportunities for management and prevention of complications Potential to Manage Diabetes Improved understanding of diabetes risk factors Improved weight control lowers the risk of diabetes Earlier diagnosis and treatment Diabetes is diagnosed years earlier, providing opportunity to treat before complications occur Tight management of diabetes prevents disability Clinical trials show that tight blood sugar and blood pressure control prevent many complications, including stroke, heart attack and death Advances in treatment New drugs emerge to control sugar and prevent complications Clinical Care Failures : Clinical Care Failures McGlynn, et al: The Quality of Health Care Delivered to Adults in the United States: Appendix. RAND, July 2004 CITL ITDM Study Goals : CITL ITDM Study Goals Can IT-enabled disease management change the course of a chronic disease? Can it reduce the rate of complications? Can it improve quality of life? Can it reduce care costs? Identify long term value of IT Enabled Diabetes Management that reflects: Program costs Patient turnover Changes in care processes Changes in disease progression Evidence Gathering : Evidence Gathering Literature review Over 800 academic and general/trade sources Market research Phone interviews with 50+ organizations DMAA partner in surveying vendors, plans, and providers on DM program and IT costs Expert panel Day-long meeting, ongoing consultation and feedback Expert Panel : Expert Panel Madhu Agarwal, MD, Acting Deputy Chief Officer of Patient Care Services, Veterans Administration Brian Austin, Deputy Director, The Improving Chronic Illness Care Program, Group Health Cooperative, Seattle Stephen J Brown, President and CEO, Health Hero Network Lawrence P Casalino, MD, PhD, Assistant Professor, University of Chicago Tim Ferris, MD, M.Phil, MPH, Director of Pediatric Quality Improvement, Mass General, Partners HealthCare, Boston Jeremy M Grimshaw, MBCHB, PhD, FRCGP, Director, Centre for Best Practice, University of Ottawa Karen Kuntz, ScD, Associate Professor, Harvard School of Public Health John A Merenich, MD, Regional Director, Kaiser Permanente Colorado David Wennberg, MD, President and COO, Health Dialog Data Services Special thanks to the Disease Management Association of America (DMAA) and Karen Fitzner, Director Research and Program Development DM Program Components May Target Patients and/or Providers : DM Program Components May Target Patients and/or Providers Some common DM program interventions: Personal Health Risk Assessment Patient self-management support (education from certified diabetes educator, nurse case manager) Electronic and paper-based guidelines Care teams (MD, CDE, RN, others) Physician education Feedback to providers on guideline compliance, care quality (care audit) Orders support (CPOE) ITDM Taxonomy : ITDM Taxonomy Technologies used by payers Technologies used by providers Disease registries Clinical decision-support systems Technologies used by patients Self-management Remote monitoring Integrated provider-patient systems ITDM Model Overview : ITDM Model Overview Yr 0 Yr 5 Yr 10 Diabetic Population Input: Output: ITDM Impact ITDM Cost NET VALUE Financial and Clinical Benefit Diabetes Simulation Model minus = ITDM Impacts: Positive Example : ITDM Impacts: Positive Example 7.33 7.60 Evidence suggest payer interventions can improve control of blood sugar ITDM Impacts: Negative Example : ITDM Impacts: Negative Example 44.9% 44.9% No published evidence to suggest self management improves foot screening rates Disease Burden Engine : Disease Burden Engine Based on a CDC-RTI diabetes disease model Simulates the progression of Type-2 diabetes in a population ages 25-94 Markov model projecting progression in five major diabetic complications: Cardiovascular Cerebrovascular Renal Ocular Neuropathic Modified to show the impact of improved care processes on clinical outcomes * HOERGER TJ, RICHTER A, BETHKE AD, GIBBONS CB: A MARKOV MODEL OF DISEASE PROGRESSION AND COST-EFFECTIVENESS FOR TYPE 2 DIABETES. 2002. NO. RTI PROJECT NUMBER 6900.016. Evidence Impacts in the Model : Change In HbA1c Rate of Eye exams Rate of Foot Exams Change in Cholesterol Rate of Microalbuminuria Screening Change in Systolic BP Available Evidence Evidence Impacts in the Model Complications Projecting Impact on Disease Progression : Projecting Impact on Disease Progression We rely on benchmark clinical trials to project the impact of process improvements on disease progression Kendrick DC, Bu D, Pan E, Middleton B. Crossing the Evidence Chasm: Building evidence bridges from process changes to clinical outcomes. J Am Med Inform Assoc. 2007 May-Jun;14(3):329-39. Epub 2007 Feb 28. Cost Model Approach : Cost Model Approach Collect cost data for ITDM programs described in academic literature Challenges Not published Proprietary Varied implementation approaches Solution With support from the Disease Management Association of America, contacted member organizations to share cost data anonymously Conducted over 50 cost interviews Synthesized results into scalable model that mirrors payer and provider taxonomies ITDM Costs : ITDM Costs from over 50 interviews with DMAA member organizations Adler-Milstein J, Bu D, Pan E, Walker J, Kendrick D, Hook JM, Bates DW, Middleton B. The cost of information technology-enabled diabetes management. Dis Manag. 2007;10(3):115-28. Detailed ITDM Model Overview : Detailed ITDM Model Overview Yr 0 Yr 5 Yr 10 Diabetic Population Mortality Morbidity Medical Costs QALY ITDM Impact Input: ITDM Costs NET VALUE minus = Output: ITDM Model Architecture : ITDM Model Architecture Care Processes Results: 10th Year Screening Rates : Care Processes Results: 10th Year Screening Rates Bu D, Pan E, Walker J, et al.: Benefits of Information Technology-Enabled Diabetes Management. Diabetes Care 10.2337/dc06-2101. Physiology Results:10th Year Average Value : Physiology Results:10th Year Average Value Bu D, Pan E, Walker J, et al.: Benefits of Information Technology-Enabled Diabetes Management. Diabetes Care 10.2337/dc06-2101. n/s denotes a statistically non-significant result at alpha=0.05. Mortality Results: Reduction in 10 Year Cumulative Incidence : Mortality Results: Reduction in 10 Year Cumulative Incidence Bu D, Pan E, Walker J, et al.: Benefits of Information Technology-Enabled Diabetes Management. Diabetes Care 10.2337/dc06-2101. Financial Results: 10 Year Cumulative Net Present Value : Financial Results: 10 Year Cumulative Net Present Value * Cost of care savings results published in: Bu D, Pan E, Walker J, et al.: Benefits of Information Technology-Enabled Diabetes Management. Diabetes Care 10.2337/dc06-2101. Key Lessons (1) : Key Lessons (1) All forms of ITDM can improve the lives of diabetics All forms of ITDM improves care processes Improved care process results in improved quality of life Technologies used by providers have the greatest potential for benefit Diabetes registries showed the greatest improvements in clinical outcomes CDSS showed the next greatest improvements in clinical outcome Diabetic registries are cost beneficial over ten years National adoption of registries saves money Registries are cost beneficial for all size organization except single physician practices Key Lessons (2) : Key Lessons (2) For other technologies, national adoption costs more than it saves National adoption of all other technologies cost money in net CDSS achieves positive cost-benefit for practices with more than six physicians Economies of scale vary widely CDSS show strong economies of scale, due to the high cost of knowledge management Payer technologies show strong economies of scale, due to negotiating leverage of large organizations Patient technologies show weak economies of scale, due to high patient associated costs (e.g. individual devices) Implications (1) : Implications (1) Market inefficiencies may foster suboptimal solutions Payers reap most cost savings Many diabetes-management programs are implemented by payers Our research suggests provider technologies may be more effective overall Research points to the benefit for public clinical knowledge repositories Most of CDSS associated costs stem from knowledge management (KM) Public knowledge repositories may allow small practices to benefit by defraying the large fixed costs of KM Implications (2) : Implications (2) Implementation cost control and careful targeting of interventions be important All technologies provide benefit, but in only some cases do the benefits exceed the costs Cost containment should not be overlooked when looking for high benefit solutions Careful targeting, through severity stratification or predictive modeling, may play an important role Limitations : Limitations Strength of evidence Future studies may show more or less potential of ITDM to improve care Our methodology selected a study that showed a negative effect of CDSS on blood pressure Only one study showing the effect of foot screening on amputation was identified Severity stratification Severity stratification and predictive modeling, techniques often used to increase the efficiency of disease management, were not included in the analysis Scope of benefits ADA estimate approximately 2/3 of diabetic costs due to utilization that was not modeled (general medical utilization and indirect economic costs) Cross-applicability of studies Diabetes-management programs vary widely in salient features (population under study, programmatic components) Thank You! : 35 Thank You! More information www.citl.org Blackford Middleton, MD bmiddleton1@partners.org

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