# Presentation: 449076

## 

HIT Return on Investment:
Evaluating Progress in a Sea of Change

John Hsu, MD, MBA, MSCE
AHRQ Conference
27 September 2007

- HIT Return on Investment:
- Evaluating Progress in a Sea of Change
- John Hsu, MD, MBA, MSCE
- AHRQ Conference
- 27 September 2007

## HIT Background

- Great potential for transforming clinical care, especially for patients with chronic diseases
- Adoption of HIT across the U.S. is limited but growing
- Actual benefits of HIT unclear:
- Initial benefits of HIT depend on how routinely and systematically clinicians use the HIT tools and resulting information
- Little information on HIT effects in the ambulatory setting with commercially-available systems
- Actual benefits and costs of HIT are difficult to quantify
- Comprehensive identification
- Methodological challenges

## Preliminary Results - IMPACT Study

- Impact of Information Technology on Clinical Care:
- An Evaluation of the Technology on Quality, Safety and Efficiency of Chronic Disease Care
- John Hsu, MD, MBA, MSCE (KP DOR)
- Ilana Graetz (KP DOR)
- Huihui Wang (KP DOR)
- Jie Huang, PhD (KP DOR)
- Mary Reed, DrPh (KP DOR)
- Bruce Fireman, MA (KP DOR)
- Joseph Selby, MD, MPH (KP DOR)
- Yvonne Zhou, PhD (KP)
- Jim Bellows, PhD (KP CMI)
- Naomi Bardach, MD (UCSF)
- Julian Wimbush (UCB)
- Tom Rundall, PhD (UCB)
- Robert Miller, PhD (UCSF)
- Richard Brand, PhD (UCSF)
- Funding: AHRQ R01HS015280

## Design: 
Longitudinal study with quasi-experimental changes in exposure to HIT, and using a pre-post analytic design with concurrent controls

Study Period: 2004-2008

Population: IDS Members with any of five chronic diseases in January 2004 (Asthma, CAD, DM, HF, Htn)

Data: 
Automated databases
Annual surveys

- Longitudinal study with quasi-experimental changes in exposure to HIT, and using a pre-post analytic design with concurrent controls
- Study Period: 2004-2008
- Population: IDS Members with any of five chronic diseases in January 2004 (Asthma, CAD, DM, HF, Htn)
- Data:
- Automated databases
- Annual surveys

- Overview

## Basic HIT Tools

|   | CIPS | eChart | eRx/eRefill | eConsult |  |
| --- | --- | --- | --- | --- | --- |
| First Available: | 1995 | March 2004 |  |  |  |
| Functions: |  |  |  |  |  |
| Data-Review |  |  |  |  |   |
| Documentation |   |  |   |  |   |
| Order-Entry |   |   |  |  |   |
| Communication |   |  |  |  |  |
| Paper-alternative: | No | Yes | Yes |  | Yes |
| Integrated: | Not integrated with other applications (i.e., need log onto each application separately) |  |  |  |  |
| Description:

  | Viewing lab results

Viewing medication list
 | Writing free-text visit notes

Using standard note templates | Viewing medication list

Viewing medication allergies

Entering orders for new prescription or refills | Requesting referrals or consultations

Sending messages to other providers |  |

## KP HealthConnect Ambulatory Suite

| First Available: | Staggered implementation (2005-2008) |
| --- | --- |
| Functions: |  |
| Data-Review |  |
| Documentation |  |
| Order-Entry |  |
| Communication |   |
| Paper-alternative: | No |
| Integrated: | Fully Integrated |
| Description:

  | Viewing medication list, allergies, lab results
Using standard note templates & writing free-text visit notes
Order new prescription or refills with decision support
Ordering Disease-specific sets (drugs and labs)
Sending messages to other providers & requesting referrals or consultations
Sending and receiving messages from patients
Point-of-care access to decision-support tools– including: 
Online references and resources for current treatment guidelines 
Care Management Institute protocols, and standard tests/screens |

## Potential Benefits of HIT

- Improved information availability (value of information)
- Clinical benefits
- Financial benefits: e.g., greater efficiency, lower administrative costs, better coding

- Benefits predicated on clinician use of HIT tools

## HIT Use

## HIT Implementation and Use

- * Among office visits in department of Medicine or Family Practice

## CPOE Implementation and Use

- * New prescriptions are defined as new prescriptions doctor wrote, can be refills for existing drugs or completely new drugs

## HIT Use

- Implementation ≠ use
- Use of one type of HIT ≠ use of all HIT tools

## Information Quality

## Data Availability: Diagnoses Completed on Visit Date

- * Among office visits in department of Medicine or Family Practice

## Clinical Benefits

## Methodological Challenges for Assessing Clinical Benefits

- Measures of use
- Temporal trends - concurrent control groups
- Patient- and physician-level differences
- Reliable pre-implementation clinical data - differentiating documentation vs. care
- Multi-level effects
- Adequate power

## Methods 

**Study Period: **04/2004-12/2006
**Study Population**
- Active KPNC members who continuously enrolled during the study period
- 18 years and older as of 04/01/2004
- In diabetes registry as of 1st quarter of 2004
- Members in 5 medical centers  where KPHC implemented before 07/2006 during the study period
- In teams which existed all the time during the study period
- With at least one LDL measurement in pre-HIT period and one in post-HIT period
**Predictor Measures: **Presence of HIT (HealthConnect)
**Model:** Mixed model with random effects at PCP and Patient level, adjusted for patient age, gender, race/ethnicity, neighborhood SES, time of measurement and Medical centers

## Definitions of Presence of HIT 

- Definition 1: Medical center level KPHC rollout schedule
- HIT=0: before KPHC was implemented at the first team in the medical center
- HIT=1: within six months after KPHC was implemented at the first team in the medical center
- HIT=2: six months after KPHC was implemented at the first team in the medical center
- Definition 2: Primary care team level actual use
- HIT = 0: low use (<80% at team level) of eChart or KPHC
- HIT = 1: starting from the first month when eChart used >=80%
- HIT = 2: starting from the first month when KPHC used >=80%

## Mean LDL in Each Month in KPNC

## Association between HIT and LDL 

|   |   | Estimate | 95% CI |  |
| --- | --- | --- | --- | --- |
| 1. Implementation at Medical Center (roll-out schedule)

  | Before KPHC  | 1.00 | ref. group    |  |
|  | First 6 months of KPHC  | -0.50 | -1.15 | 0.15 |
|  | 6+ months of KPHC  | -0.64 | -1.58 | 0.30 |
| 2. Actual use by Primary Care Team 
(% of total visits)

  | Low HIT use (<80% of visits)  | 1.00 | ref. group    |  |
|  | EChart used in >80% of visits  | -0.89 | -1.55 | -0.23 |
|  | KPHC used in >80% of visits | -1.72 | -2.68 | -0.76 |

## Costs

## Investment

- Investment costs
- Equipment
- Personnel/productivity
- Training
- Maintenance costs
- IT support staff
- Future upgrades
- Continued training

## Other Relevant Features

## Dynamic Environment

- Changes in HIT
- Decision support
- Information use
- Changes in Care Delivery
- Clinical coordination
- Delivery system
- Changes in Medical Therapy
- Information on effectiveness
- Dissemination of new knowledge
- Changes in the Market
- Payment features, e.g., risk adjustment, reporting, performance incentives
- Payment mix

## Conclusions

- Benefits
- Some potential clinical benefits related to better information at the point-of-care
- Unclear benefits associated with improvements in clinical information at the system level
- Transaction benefits perhaps easiest to quantify
- Financial benefits depend market and reimbursement mix
- Costs
- Investment costs beyond equipment costs can be difficult to quantify
- Maintenance costs also important
- Dynamic/changing systems and markets....

## Summary: Need for Better Empirical Studies

## HIT as Basic Infrastructure