October 25, 2005

October 25, 2005

Robert M. Kolodner, MDChief Health Informatics Officer, VHA

Department of Veterans Affairs

Realizing the Financial Benefits of Electronic

Health Records: What do the Data Show?

The VA Experience

AMIA - S49 (Kolodner) October 25, 2005 2

Cost Savings and EHRs in VA

•20+ year history of computer use to support care in the Veterans Health Administration (VHA)

•Sometimes challenging to tease out effects of the Electronic Health Record from other major changes in VHA, especially since 1995

– Shift from Inpatient to Outpatient care– Reorganization to 22 (now 21) regional networks– Implementation of performance measures– Shift from facility-centric to veteran-centric


Transformational Strategies for VA Health Care

“In summary, electronic health records, performance management, and a patient-centric focus have been critical transformational strategies for the VA. They have been utilized to support achievement and are associated with measurable progress in each of the VA’s value domains.”

The American Journal of Managed Care, November 2004


2005: Who is “VHA” . . . Veterans Health Administration• 5.2 million patients, ~ 7.6 million enrollees

~ $30 Billion budget ~ 1,300 Sites-of-Care

– Including 171 medical centers or hospitals~ 870 clinics– 207 counseling centers & – long-term care programs

~ 197,500 Employees (~14,000 MD , 56,000 Nurses, 33,000 AHP)~ 150,000 volunteers• Affiliations with 107 Academic Health Systems

– 1,500 Health Professions Training Affiliations– Additional 25,000 affiliated MD’s; +35,000 residents & fellows in 14,000 slots~ 89,000 trainees in all disciplines– Nearly half US health professionals (>65% MDs) have some training in VA

~ $1.7B Research: Rehabilitation, Health Services, Clinical, Basic


VA’s Health Information System is VistA

•“CPRS” is the integrated EHR application•VA runs 128 VistA systems these sites

– Down from 172 VistA systems 10 years ago– ~180,000 PCs and thin clients

•Delivers a complete hospital information system, electronic health record, imaging, Bar Code Medication Administration

– Hardware, software, maintenance, upgrades, staffing

•For FY2004:– Cost per enrollee

$78 / enrollee– Average cost per hospital (n=158)

$3.6 million


And VistA Is Actively Used... Some National VistA Statistics (Total…Daily)

•Documents (Progress Notes, Discharge Summaries, Reports)

– 742,000,000…….. +576,000 each workday

•Orders– 1.48 Billion…….... +922,000 each workday

• Images– 385,000,000……… +587,000 each workday

•Vital Sign Measurements– 915,000,000……… +676,000 each workday

•Medications Administeredwith the Bar Code Medication Administration (BCMA) system

– 716,000,000……… +607,000 each workdayStatistics as of September 2005


Rate of Increase of VistA Data

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05

Date

Av

era

ge

Dai

ly I

nc

rea

se (

Wo

rkd

ays

)

Orders

Images

Documents

Medication Administration

Vital Sign Measurements

VistA Data Trend – Rate of Increase


Financial Benefits of EHR in VA

•Unable to provide overall benefits for the system since DHCP/VistA implemented and matured over 20 years and baselines were not taken

HOWEVER

•Many local examples with costs•Some local examples with implications without exact costs

•Some speculations•…not counting savings by not repeating tests / or avoiding hospital admissions


Myths: VA’s Different . . .

•“VA’s Command & Control”– Truth: Yes, 17,000 staff physicians, but 25,000 affiliated

faculty & 35,000 housestaff through affiliations with 107 academic health systems

•“VA has an appropriated budget”– True, but VA $1.5 of $25 B (FY03) was revenue from

billing, increased from $300 M, 3 years prior

•“VA’s patients are former military, thus overall healthier & follow instructions”

– VA patients define adverse selection

•Think of VA as “Living Laboratory”


Examples

•Medications – Inpatient– Bar Code Medication Administration

•Medications – Outpatient (local initiatives)– Drug Cost feedback

•Disease Management - Diabetes– HgB A1c– Outcomes

• Impact of Vaccinations– Pneumovax

•Not having to pull charts or maintain a chart room

Bar Code Med Administration (BCMA)

INFORMATION TECHNOLOGY – SAFETY

Inpatient Medication Error Rate per 10,000 doses

1.571.49

0.97 0.96 0.93

0.73

1.3

0.82

0.41

1.09

0.921.01

0.48

1.03

0.87

0.61

0.13

0.33

0.53

0.73

0.93

1.13

1.33

1.53

1.73

1st Qtr01

2ndQtr 01

3rd Qtr01

4th Qtr01

1st Qtr02

2ndQtr 02

3rd Qtr02

4th Qtr02

1st Qtr03

2ndQtr 03

3rd Qtr03

4th Qtr03

1st Qtr04

2ndQtr 04

3rd Qtr04

4th Qtr04


What is the AssociatedCost Avoidance or Cost Savings?

INFORMATION TECHNOLOGY – EFFICIENCY

Drug Costs

are listed in the order menu

Using Technology to Manage Drug Costs



Here Fluoxetine is listed as

the preferred

drug, costs are also listed


SSRI Total Costs for 30 Day Equvalent Rx's

$173,938

$90,955

$174,989

$91,101

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

$180,000

$200,000

12/1

5/20

04

12/2

2/20

04

12/2

9/20

04

1/5/

2005

1/12

/200

5

1/19

/200

5

1/26

/200

5

2/2/

2005

2/9/

2005

2/16

/200

5

2/23

/200

5

3/2/

2005

Date

Co

st


Conversion from

Citalopram to Fluoxetine


Diabetes Mellitus (DM)

•Prevalence of DM among VA patients is 20% – Substantially higher than in the general population– More than 1 million patients per year– Nearly all are male (2.4% women)– Largest group is >65 years old


Performance MeasurementSetting the U.S. Benchmark for 18 Comparable Indicators

Clinical Indicator VA 2003 Medicare 03 Best Not VA or Medicare

Advised Tobacco Cessation (VA x3, others x1) 75 62 68 (NCQA 2002)

Beta Blocker after MI 98 93 94 (NCQA 2002)

Breast Cancer Screening 84 75 75 (NCQA 2002)

Cervical Cancer Screening 90 62 81 (NCQA 2002)

Cholesterol Screening (all pts) 91 NA 73 (BRFSS 2001)

Cholesterol Screening (post MI) 94 78 79 (NCQA 2002)

LDL Cholesterol <130 post MI 78 62 61 (NCQA 2002)

Colorectal Cancer Screening 67 NA 49 (BRFSS 2002)

Diabetes Hgb A1c checked past year 94 85 83 (NCQA 2002)

Diabetes Hgb A1c > 9.5 (lower is better) 15 NA 34 (NCQA 2002)

Diabetes LDL Measured 95 88 85 (NCQA 2002)

Diabetes LDL < 130 77 63 55 (NCQA 2002)

Diabetes Eye Exam 75 68 52 (NCQA 2002)

Diabetes Kidney Function 70 57 52 (NCQA 2002)

Hypertension: BP < 140/90 68 57 58 (NCQA 2002)

Influenza Immunization 76 P 68 (BRFSS 2002)

Pneumocooccal Immunization 90 P 63 (BRFSS 2002)

Mental Health F/U 30 D post D/C 77 61 74 (NCQA 2002)

INFORMATION TECHNOLOGY – QUALITY

CLINICAL REMINDERS


Effect of Clinical Reminders at 1 VAMC

HEMOGLOBIN A1cLower is Better

16

19 20

13

00

5

10

15

20

25

FY01 FY02 FY03 FY04 1st Qrt FY05

Perc

en

t

Implementation


HEMOGLOBIN A1cLower is Better

16

19 20

13

00

5

10

15

20

25

FY01 FY02 FY03 FY04 1st Qrt FY05

Perc

en

t

Implementation Education and Focus

Effect of Clinical Reminders at 1 VAMC


Highest Quality of Care For Patients with Diabetes in VA

“Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care.”

Annals of Internal Medicine, August 17, 2004


VA-TRIAD Adjusted Intermediate Outcomes

VA, % CMC, %

A1C level (proportion <8.5%)* 83 65

A1C level (proportion <9.5%)* 92 80

LDL level (proportion <100)* 52 36

LDL level (proportion <130) * 86 72

BP level (proportion <130/80) 28 29

BP level (proportion <140/90) 53 52

*P<0.001

Kerr et al – Annals of Internal Medicine 2004

October 25, 2005 AMIA - S49 (Kolodner) 23

FY99-04 Changes in Total, Major and Minor Age-Adjusted Amputation Rates Among

Patients With Diabetes

0

1

2

3

4

5

6

7

8

9

Overall 7.94 6.24 5.42 4.53 4.4 4.04

Major 3.61 2.78 2.4 1.95 1.84 1.72

Minor 4.33 3.46 3.03 2.59 2.55 2.32

1999 2000 2001 2002 2003 2004

Am

puta

tions

per

100

0 pa

tien

ts




Pneumococcal Vaccination Rates in VHA

0

20

40

60

80

100

FY 95 4th Qtr97

4th Qtr98

FY 99 FY 00 CHG FY01* FY02 FY03

Perc

ent

Vaccin

ate

d

VHA Healthy People 2000 Iowa 99* NHIS

`

•Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz•HHS: National Health Interview Survey, >64

--BRFSS--

--BRFSS 90th--


Pneumonia: Acute InpatientImproving Efficiency by Reducing Excess Health Care Utilization

104.0

100.5

94.5

16.0

15.5

15.2

14.614.8

1515.215.415.615.8

1616.2

FY1999 FY2000 FY2001

Th

ou

sa

nd

s

To

tal D

isch

arg

es

(be

dse

ctio

n)

889092949698100102104106

Th

ou

sa

nd

s

To

tal D

ays

(b

ed

sect

ion

)

Acute Days Discharges

9,500 fewer bed days

8,000 fewer discharges

• DRG89-90; Unadjusted for Pt. Population (up 20%, FY99-01)


Vaccine Cuts Pneumonia Risk in High-Risk Patients*

• 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine.

– VA Medical Center study of 1,900 elderly patients with chronic lung disease; 2/3 vaccinated against pneumonia.

• Pneumococcal vaccination:– 43% reduction in hospitalizations for pneumonia and

influenza, and a 29% reduction in the risk of death. • Pneumonia and Influenza vaccination:

– 72% reduction in hospitalizations for these two diseases and an 82% reduction in deaths from all causes.

• Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period.

*Archives of Internal Medicine 1999;159:2437-2442Dr. Kristin Nichol, VAMC / Minneapolis


Extrapolating from Dr. Nichol’s Study:

Between 1996 and 1998, Increased Rates ofPneumococcal Vaccination Averted 3914Excess Deaths Nationally in VHA Patientswith Chronic Lung Disease…Today, over 6,000 lives have been saved.




Priceless




Paper versus Electronic – Elimination of Processes

•Without an EHR– Paper charts were pulled & delivered to clinic locations for

scheduled appointments– Also involved re-filing – Resulted in a 60% average chart availability rate

•One VA Medical Center– Budget of 1% of the entire VHA– Closed file room - cost avoidance estimated at $600,000

•VERY Conservative estimate – $1 per pull, delivery and re-file

Some estimates in private sector as high as $10/pull– Eliminating this for VA’s 50 million outpatient encounters

estimated $50 million cost avoidance in staff resources


Home Telehealth

And what savings might we see from Home Telehealth?

October 25, 2005October 25, 2005 AMIA - S49 (Kolodner)AMIA - S49 (Kolodner) 3535

Home-Telehealth Technologies

Flexible Sensor Connectivity

Blood sugarBlood sugar

Blood pressureBlood pressure

ThermometerThermometer

StethoscopeStethoscope

ECGECG

Pulse O2Pulse O2

CameraCamera

Digital ScaleDigital Scale

October 25, 2005October 25, 2005 AMIA - S49 (Kolodner)AMIA - S49 (Kolodner) 3636




This presentation is available on the VHA internet at:

www.va.gov/vha_oi

Select “Office of Information Document Library” on the left hand bar

Presentation is Titled

“AMIA 2005 - Presentation by Robert M. Kolodner M.D.”

http://www1.va.gov/vha_oi/docs/AMIA_2005_Panel.pps

http://www1.va.gov/vha_oi/docs/AMIA_2005_Panel.pps