how you can improve the health of populations

address the issue of how you can improve the patient experience, how you can improve the health of populations, and how to reduce the per capita cost..i also will upload some guest speakers presentations which you can use to help answer the question and discuss a little about what they talked about as well.here are some case studies and guest speakers that can help as well.. he also wants to you to talk about some of the stuff the guest speaker spoke on…you can also put your opinion on what you think should be done.. another big thing he really wants you to talk about is the triple aim which is in the powerpoint that i uploaded.http://www.ihi.org/engage/initiatives/tripleaim/Pa…
bill_todd.pptx

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The HITECH ACT and the
Rush to Meaningful Use
Margaret Wagner Dahl
Associate VP, Information Technology and Analytics
Office of Industry Collaboration
Oct 5, 2017
The Interoperability & Integration Innovation Lab
IHI* Triple Aim: National Taxonomy
• Improve the patient experience
• Improve the health of populations
• Reduce the per capita cost
*Institute for Healthcare Improvement. http://www.ihi.org
Triple Aim Alignment with the ACA*
Improve the patient experience
• Offer incentives and penalties such as:
? Meeting the value based payment patient satisfaction goals
and the consumer assessment of healthcare providers and
services measures.
(hint: patient satisfaction doesn’t always correlate with
evidenced based medicine)
? Supply patient portals
(hint: we are now “portaled out”)
*Affordable Care Act
Triple Aim Alignment with the ACA
Improve the health of populations
• Provide payment based on quality such as…
? achieving quality metrics and meeting pay for
performance/physician quality incentives
? Establish rewards for clinically integrated care (HIEs,
disease registries, ACOs, Medical Homes, patient
engagement, incorporate mobile apps for health goals etc.)
(Hint: requires interoperability be able to affect everyone’s
behavior, both patients and docs)
Triple Aim alignment with the ACA
Reduce the Per Capita Cost
• Make adequate health insurance coverage more affordable
and available to the public by:
? Offering incentives to expand coverage
? Regulating healthcare coverage
? Creating health insurance exchanges
• Reform delivery and payment systems (value based payment
using evidenced based medicine, clinical decision support,
institute employer penalties)
(Hint: requires pricing transparency, currently not there at all!)
Health Information Technology for
Economic and Clinical Health (HITECH)
Healthcare reform started with Nixon, but…
• “By computerizing health records, we can avoid
dangerous medical mistakes, reduce costs and
improve care.” President George W Bush, 2004
• Office of the National Coordinator created through
executive order to oversee EHR implementation
through a structure and process of incentives called
“meaningful use”.
How HITECH works:
•
Requires attestation annually by healthcare providers and certification by EHR vendors.
•
Funded Regional Extension Centers to help primary care providers achieve the substantive
use of their EHRs (GA HITEC is through Morehouse SOM, GT is their contractor and assists
practices throughout Georgia)
•
Meaningful Use set up in 3 stages to enable both vendors and providers to increase EHR
use & functionality
•
Both Medicare and Medicaid providers had incentive payments encouraging adoption. In
2015, CMS ended incentives for non-adopting Medicare providers and started penalizing all
Medicare providers via Meaningful Use in their claims payments (penalties increase each
year of non-compliance).
•
Since Medicaid is a state program, CMS has to rely on the incentives to encourage adoption
and the incentives continue for Medicaid providers until 2021.
The Three Stages of Meaningful Use
targeted the reduction of errors for medication orders,
populating the patient chart with important data when collaborating
with other providers, and securing the systems. Most providers see
limited value beyond e-prescribing and converting to an electronic
chart during this stage.
• Stage 2 began the start of electronic collaboration and patient
engagement. Recertification for the EHR vendors to show they could
import and export data according to standards and protocols was
required to meet attestation and receive funds.
• Stage 3 will set the baseline for a system that is able to assist
providers with clinical decision support, care collaboration, and
sharing of data. Incentives going away, now penalties.
Progress so far – 2016 data
? 3 out of 4 hospitals adopted at least a basic EHR system
(76% of hospitals)
? 97% reported a certified EHR technology (an increase of
35% since 2011)
? Delaware (100%), South Dakota (95%), Virginia (93%) had
the highest % of hospital EHR adoption
? West Virginia (50%), Hawaii (55%), Kansas (60%) had the
lowest % of hospital EHR adoption
Electronic Functions-Basic and
Comprehensive EHR attributes
• Clinical Information:
? Basic systems include demographics, problem lists, medication
lists, discharge summaries.
? Comprehensive systems include the above + physician notes,
nursing assessments, advanced directives.
Electronic Functions cont…
• Computerized Provider Order Entry:
? Basic includes medications
? Comprehensive includes lab reports, radiology tests,
medications, consultation requests, nursing orders.
• Results Management:
? Basic includes view lab reports, radiology images, radiology
reports
? Comprehensive includes the above + diagnostic results, images
and diagnostic report
Electronic Functions cont…
• Decision Support:
? Basic systems not in this at all
? Comprehensive include clinical guidelines, clinical reminders,
drug allergy results, drug-drug interactions, drug-lab interactions,
drug dosing support
Trends in advanced functionality
& market considerations
• Hospital adoption of comprehensive EHR systems
has increased eleven-fold since 2009 – 1/3 of U.S.
hospitals – 34.4% in 2014.
• US market size – $24B.
• Average cost of EHR systems and implementation:
? Small = about $5-8M (100 beds or less, critical access)
? Mid-Size = about $15-20M (100-300 beds, community)
? Large = $50-100M, and up (300 + beds, academics and integrated
systems)
Vendors
• Hospital environment: Top 3 hold the vast majority
of market share
• Independent Practices: Over 50 vendor systems,
physicians in small practices seem to like their EHR
systems better than do larger practices affiliated
with hospital systems.
Trustee Perspective
This is “the job:”
“As fiduciaries, board members must act at all times in the
corporation’s best interest, ensuring that the organization’s
resources are used in a reasonable, appropriate and legally
accountable manner. Although the board does not generally get
involved in the day-to-day operations of an organization, it remains
responsible for overseeing management and making key strategic
decisions. These decisions include authorizing major financial
transactions, hiring and firing the organization’s senior officers and
high-level employees and ensuring that the organization adheres
to its mission and values.”
AHA Institute for Healthcare Governance
Trustee governance structure
• Depends on type of hospital:
? Non-profit community (usually volunteer though trend changing)
? Healthcare system (executive board with lots of working
committees)
? For-profit boards (usually paid, national)
? Academic Medical centers (advisory capacity)
• No matter what, most boards are responsible for hospital or
hospital system finances.
EHRs and Trustees
• Remember how much these systems cost?
• Trustees generally have significant business
experience
• Trustees understand IT systems; they work with
their hospital executive leadership to make informed
decisions on procurement
• So why are many Trustees frustrated?
Issues: “My doctor pays more attention to
the computer than me.”
• Usually not enough clinical engagement so the EHR
becomes an IT solution, NOT a clinical too.l
• Unrealistic expectations as to what it will take to properly
implement a new system – translates to the never- ending
sense of HIT as a “money pit” without clear ROI.
• Unintended consequences (reduced time for patientclinician interaction, new/burdensome data entry tasks
pushed to front line clinicians, longer workdays, trade-offs
between safety and efficiency).
Trustee reaction
• Why did we spend so much money and our doctors
hate us?
• Two real stories of implementation: Bad/Good
?Hospital A: community nonprofit, 350 beds.
?Hospital B: community nonprofit, integrated system of
several hospitals.
?Conclusion: Never underestimate the degree of leadership
and financial resources it will really take to get the job done
and clinicians will make or break it, literally.
Interoperability
What it is: The ability for disparate information systems
to exchange information with each other
• Typical industry examples: ATM machines, airlines
• Why it matters in healthcare: We cannot accomplish the
Triple Aim without it, AND it is much harder than money and
travel. Just sayin’.
• Enables predictive/precision medicine, machine learning,
learning health systems, health consumerism.
Vendor Reaction
Physicians Reaction: Let Doctors Be
Doctors
• Check out You Tube EHR State of Mind!!
So where are we?
• Commercial EHR products generally do NOT
encourage interoperability.
• EHR evolution has been difficult as originators of
innovation (academic medical centers) have
switched to commercial products that are closed
source.
• We are almost in a “too big too fail” moment with
some commercial vendors.
Movement to open source and
standards-based approaches
• “EHR vendors should become more open to both extracting data
from the EHR as well as well as creating novel ways to interact with
externally defined applications.”
• “We need APIs, data element standards and other ways to
efficiently extract data and interact with commercial EHRs.”
• “We need a broader ecosystem of innovators to help solve workflow
and functionality gaps faced by current EHR users, with opportunities
attractive to venture capitalists, academicians, private equity firms
and entrepreneurs with creative ideas and willingness to take risks in
the market place.”
-Payne, U of Washington/AMIA
Fast Healthcare Interoperability
Resources = FHIR!
• Developed through the Health Level 7 consortium and Harvard
Medical School/Boston Children’s Hospital
• New specification based on emerging industry approaches, but
informed by years of lessons around requirements, successes and
challenges gained through defining and implementing HL7 versions
and other precedent standards
• GT was the first academic center training students on FHIR starting
in 2015. We want our students to never live in a non-interoperable
world! GT ON FHIR!
The EHR 2020 Vision
“EHRs will be integrated into the full social context of
care, moving between acute care and clinic settings to
include all areas of care: home health, specialist care,
laboratory, pharmacy, pop health, long term care, physical
and behavioral therapies. The ability to incorporate data
from different sources is essential. Including, patientgenerated data, pop data, community contexts in an
EHR will spur development of new care delivery
models, improve pop health, aid in the development
of precision medicine and support other healthcare
transformations.”
-Payne et al
Let’s talk about careers
There are not enough highly qualified personnel to enable
all of this. Areas of need:
• Technical (data scientists, informaticists, coders, CTO, CIO)
• Healthcare (Clinical-CIMO, navigators, clinical decision
support experts)
• Industry (same as technical, innovators, marketing/sales,
entrepreneurs, investors)
• Academia (analytics, informatics, pop health experts,
visualization, enterprise simulation/modeling expertise)
Sources:
• Office of the National Coordinator. ONC data brief. No 23, April 2015.
• ONC Data brief. No 24, April 2015.
• Journal of the American Medical Informatics Association. Report of
the AMIA HER 2020 Task Force on the Status and Future Direction of
EHRs. Payne et al May 28, 2015.
• American Hospital Association Institute for Healthcare Governance.
http://www.americangovernance.com/resources/fiduciary-duties/.
• Triple Aim. www.healthcatalyst.com/how-analytics-achieve-triple-aim.
• Colleagues: Dr. Mark Braunstein, Prof of the Practice CoC; Rudy
Snyder, I3L GA HITECH representative

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