1. The Value of Healthcare Information Technology in Clinical Practice Blackford Middleton MD, MPH, MSc, FACP, FACMI, FHIMSS Corporate Director Clinical Informatics R&D Chairman Center for Information Technology Leadership Partners HealthCare System, Inc. Assistant Professor of Medicine, Brigham & Women’s Hospital Harvard Medical School

8. The “CPR Adoption Gap”: The United States vs Others Primary Care Physician Office CPR Use by Country, 2002 Source: "European Physicians Especially in Sweden, Netherlands, and Denmark, Lead U.S. in Use of Electronic Medical Records." Harris Interactive Health Care News 2(16).

9. Dilbert Wisdom…

11. Wang SJ, Middleton B, Prosser LA, et al. Am J Med 2003; 114:397-403.

14. Per “Average” Provider Annual Cost Saving Projections $28K $16.6K $12.3K $2.5K $2.2K

15. 5 Yr Net Cost-Benefit for 25 Providers In Thousands Costs Benefit

17. National Cost Savings to Providers and Other Healthcare Stakeholders In US Millions

21. Flow of Healthcare Information Clinical Encounter Diagnosis Treatment Claims and Billing Public Health Other Provider Referral Request Chart Request Prescription Pharmacy Order Results Imaging Center Order Results Lab Local Public Health Dept . Disease Reports, Vital Statistics Payer Remittance advice Eligibility, Referrals, CSI Claims attachments, Claims submission, Coordination of benefits

22. HIEI Taxonomy No PC/information technology Fax/Email Structured messages, non-standard content/data Structured messages, standardized content/data Secure e-mail of free text or incompatible/proprietary file formats, HL-7 message Machine-organizable data 3 PC-based and manual fax, secure e-mail of scanned documents Machine-transportable data 2 Mail, phone Non-electronic data 1 Automated entry of LOINC results from an external lab into a primary care provider’s electronic health record Machine-interpretable data 4 Examples Description Level

23. HIEI National Net Cost-Benefit Level 2 Level 3 Level 4 Value of HIE standards is the difference between Level 3 & 4 $22B $24B $78B Annual Net Return after Implementation $141B -$34B $337B Net Return over 10-year Implementation

24. 10-Year Cumulative Net Return by HIEI Level Level 4 in billions $(200) $(100) $- $100 $200 $300 $400 0 1 2 3 4 5 6 7 8 9 10 Years Level 1 Level 2 Level 3

29. Partners Geography Towns With PCHI Primary Care Care Physician Practices Orleans MGH McLean Salem & Shaughnessy Kaplan Union BWH Faulkner Newton- Wellesley Spaulding Partners Acute Hospitals Partners Specialty Hospitals RHCI Go Red Sox!

32. Partners IT Statistics, ca. Q4 2004 3,669,665 Immunizations 2,287,706 Health Maintenance items 580,781 Prescriptions faxed 4,195,900 Prescriptions printed (new and refills) 2,661,475 Medications 9,937,947 Notes in LMR 2,600 Telemedicine consultations annually 26,000 Orders entered daily through inpatient CPOE 20,000 Patient users of the patient-provider portal 2,700 Physician users of CPOE 3,300,000 Total number of patients 18,951,058 Web Sessions 51,392,709 Patient Sessions 6,094,474 Vital Signs ~300,000 Web pages generated: Average per day ~65,000 Web Sessions: Avg./day (Average patient sessions per web session = 3) ~220,000 Patient Sessions: Avg./day ~ 10,000 Edits to Notes: Avg./day ~ 15,000 New Notes: Avg./day ~ 17,000 Appointments: Avg./day 11,960,444 Patient Visits including phone call encounters

38. Informatics Innovators Vanderbilt Medical Center Massachusetts General Hospital Brigham & Women’s Hospital Stanford Hospital Kaiser Permanente … a recent systematic review in Annals of Internal Medicine found that 25% of all studies took place at the above institutions.

39. Intuitive Chart Summary Automatic Reminders Summary Flowsheets Coded Clinical Data Customizable Desktop Secure Clinical Communication And Notification of Results

40. Automatic Alerts in the Clinical Workflow

41. KnowledgeLink in the Workflow

42. Results Management and Patient Communication Patient Name Patient Name

43. Checking results, writing letters Paragraphs, letter templates Add turbo letter Tickler

44. Information Access  Knowledge Linking

45. Patient Disease Management

47. CAD Quality Dashboard – Summary Page

48. CAD Quality Dashboard – All Measures Graphical Screen

49. CAD Quality Dashboard – Apply Filters (Patient Lists View)

50. SmartView: Intelligent Data Review (template driven) SmartNote: Free text and Coded Clinical Documentation (template and rule driven) SmartOrders: One-click disease specific order recommend-actions and workflow support

54. LMR DSS logic General info

56. FHx Checklist Enter Relatives

57. Discrepancy Details

58. Patient-centered Care Management

61. The Future: Shared Data, Knowledge, and Logic Common ‘Shell’ or Clinical Portal Shared Logic, Dictionaries, and Rules ( Enterprise Clinical Services, Medication Services and Knowledge Management) Enterprise Repository (s) Problems, Meds, Allergies, Labs, Orders, Notes, etc. Dictionaries And Rules Data (Knowledgebases) Future clinical applications will take advantage of shared repositories of enterprise data, knowledge, and logic, in a services-oriented architecture LOGIC (Services) MGH OE BWH OE LMR

63. Compare Content Across Organizations Keyword search

64. Multi-Clinician Collaboration on a 300 x 5 Decision Table

65. From Clinic to IDN to RHIO to NHII Hospital A Internet Regional Network Hospital Backbone State/Federal Health Authority Hospital B Clinic Home Employer

66. Where Are We?

67. “ I conclude that though the individual physician is not perfectible, the system of care is, and that the computer will play a major part in the perfection of future care systems.” Clem McDonald, MD NEJM 295:1355, 1976 Thank you! Blackford Middleton, MD [email_address]