1	Keynote: What Is Primary Care Informatics? David Bates, MD, MSc Chair, National Alliance for Primary Care Informatics Chief, Division of General Internal Medicine, Brigham and Women’s Hospital
2	Overview What are the needs of primary care and what is PC informatics? Why EHRs? International scene U.S. scene NAPCI Other developments Massachusetts plan Conclusions
3	Primary Care vs. Specialty Care Primary care is first, foremost, fundamental
4	Implications of This Both specialists and primary care clinicians need to use IT in provision of care But need is arguably greater for primary care physicians because of coverage breadth necessary Information needs in primary care differ from those of specialists Needs will not be met if we don’t have primary care informaticians and informatics
5	Some Specific Examples Decision support for chronic diseases Tools that let us manage masses of results Tools to help with delivery of preventive care Tools to help with management of panels of patients Better interaction with patients Many of these not unique to primary care but all extremely important in delivering excellent PC
6	Where Does Primary Care Fit in Informatics? Serious concern that primary care may not get enough attention in IT frameworks Particularly in the U.S. ? Less an issue in other countries though still not may be enough basic support to realize value
7	Key Domains of Benefit Availability Communication Operational savings Decision support Reducing errors Improving guideline compliance Reducing costs Quality measurement Satisfaction Efficiency
8	Costs of EHR vs. Benefits
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10	Quality and Safety Impact Safety Lots of room for improvement Quality Probably even more room than with safety
11	Ways IT Can Improve Safety Prevent errors and adverse events Facilitating a more rapid response after an adverse event has occurred Tracking and providing feedback about adverse events
12	Key Outpatient Safety Benefits Computerized prescribing Default doses Allergy, drug-drug, other checking Lab follow-up Tools to ensure that important results don’t get lost Monitoring Communication
13	Quality and IT in Outpatients Reminders increase compliance with prevention guidelines Probably also with chronic disease though more data needed Absolutely essential for measuring quality in populations across an array of conditions
14	Results Manager Home Page
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17	Monitoring Substantial evidence that in-office monitoring doesn’t get done today as well as it should New tools can help patients monitor Chronic diseases Trend detection Abnormal values
18	The “CPR Adoption Gap”: Variation in EHR Use by Country
19	EMR Use Internationally Harris Interactive - 2001 Use PCs Use EMR Australia 90% 53% Denmark 95% 62% Netherlands 95% 88% Sweden 95% 90% United Kingdom 95% 58%
20	EHR Use -2002 www.nhsia.nhs.uk-Bainbridge www.gpcg.org-Kidd Australia UK Use EMR 90% 99% Of Those: Prescrip 100% 80% Notes Unknown 45% Reminders Unknown 70% Clin Vocab 15% (ICPC) 100% (Read) Paperless Unknown 45%
21	National Strategic Plans for Primary Care Information Technology UK 1997 Government NHS An Info Strategy for NHS 1998-2005 NHS Partnerships Govern, Clinical Communities, Key Stakeholders, Social Care, and Suppliers 8 Billion Pounds Australia 1998 GPCG Strategic Framework for GP Info Manage and Technology Representatives RACGP, AMA, Div of GP, Rural MDs, Software, Dept Health 15 Million $A
22	IT in the UK: A Case Study Courtesy of Michael Bainbridge
23	Computerisation in UK FP 70 practitioners are not computerised 95 % of all prescriptions are produced electronically from clinical information systems Nearly ready to transfer the record between systems with semantic integrity
24	The New GP Contract
25	Basic Principles Practice based contract Emphasis on Quality Control of workload Low bureaucracy
26	Key Features 100% Funding PCO Ownership and liability Choice of systems Development, implementation, support Education & training Implementation
27	1 - Practice based contract Capitation based funding Formula intended to reward workload Carr-Hill formula: Age-sex + residential care List turnover ‘Standardised’ Illness Rates and ‘morbidity’ Costs (rurality, market forces) Guaranteed funding for IT
28	2 - Emphasis on Quality Clinical indicators (550 points) 9 exclusion criteria Organisational indicators (184) Additional services (36) Patient experience (100) Holistic care (100) Quality practice (30) Access (50) All Based on Clinical Evidence
29	3 - Control of workload Essential Services Enhanced Services National, Local Additional Services Minor surgery, Imms & Vaccs, Out-of-Hours Allocations
30	4 - Low Bureaucracy Items of Service “abolished” No separate staff budgets / rules Automated reporting of quality indicators IM&T support provided by the PCO
31	Benefits for Patients 33% increased resources over 3 years Needs based allocation Investment in IT / premises Improved GP / nurse recruitment More services. More choice Increased quality of care
32	Benefits for GPs 33% increased resources over 3 years Fairer resource allocation All NHS income pensionable Improved seniority pay Control over workload Salaried options
33	Australian Experience Very high levels of use Most providers use one EHR (although other options available) Paid for through pharmaceutical advertising When providers prescribe see diagnosis-specific ads Relatively little decision support so far
34	U.S. Picture: EHRs Finally Getting National Attention! “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” George W. Bush, State of the Union 1/2004
35	The “CPR Adoption Gap”: Large versus Small MD Offices
36	NAPCI Vision Statement “Every primary care provider will use information technology that includes electronic health records with the ability to access and communicate needed clinical information to achieve high quality, safe, and affordable health care.” Endorsed by all participants and the organizations Agreed to move forward
37	NAPCI Members AAP—American Academy of Pediatrics ACP—American College of Physicians AMIA—American Medical Informatics Assn ANA—American Nursing Association NAPCRG—North American Primary Care Research Group NONPF—National Organization of Nurse Care Research SGIM—Society of General Internal Medicine STFM—Society of Teachers of Family Medicine
38	Overall Objectives of NAPCI: I Promote creation of an NHII that: Identifies and supports the unique needs of primary care providers Provides incentives for primary care providers to participate in NHII Document and report of use of informatics and IT in primary care, and promote primary care IT research Educate primary care providers in use of informatics and IT
39	Overall Objectives of NAPCI: II Facilitate work within NAPCI and between NAPCI and other organizations to present a unified coalition representing the interests of primary care To take part in and sponsor meetings, publications and other forums for the purpose of advancing the mission of NAPCI and its member organizations
40	Achievements of NAPCI to Date Incorporated this spring “White paper” on case for EHRs in primary care (JAMIA) Paper describing NAPCI in Primary Care Informatics Meeting bringing together many state leaders at Spring AMIA Sponsorship, participation in many meetings including NHII, this one, etc.
41	Backdrop in U.S. Rate of EHR adoption appears to be increasing, but not as rapidly as it should be Many of concerns about making transition still not addressed
42	EMR Use at Partners
43	Misaligned Incentives
44	Physician Perspectives: Recent MMS Survey Data Physician Attitudes 84% agree that computers improve quality 78% think computers have beneficial effect on interactions within the health care team Attitudes vs. Intentions 85% believe doctors should computerize writing prescriptions, yet 49% do not intend to do so 89% believe doctors should computerize recording patient summaries, yet 48.5% do not intend to do so 83% believe doctors should computerize recording treatment records, yet 48.7% do not intend to do so
45	DOQIT National program sponsored by CMS to promote increased use of IT in ambulatory care California has lead role Other states are participating No financial incentive yet NAPCI would like to work with this group
46	IOM Recommendations Regarding EHR Content Developed in June, 2003 General format what EHRs should include at specific time Readily accessible, well received
47	HL7 EHR Standard Passed on second round! Still being digested/fleshed out But represents major progress
48	AHRQ RFAs $50 million for research on IT Planning, implementation, value Got >1000 letters of intent, >600 proposals Awards recently made Suggests need for more support in this area!
49	Single Individual in HHS for Health IT David Brailer named to role on 5/5/04 by Secretary Thompson Also announcement that remainder of CHI standards have been adopted Second NHII meeting held this summer Form of NHII still taking shape Need to get funding Need to ensure primary care needs represented!!!
50	Continuity of Care Record Developed by MMS Started with plan to automate paper form used at time of transfer HIMMS, AAFP have partnered Adopted as standard by ASTM, working now with HL7
51	Expanding Electronic Health Record Use in Massachusetts Proposal Current status Next steps General implications
52	MassSafe Goal: To improve the safety of patient care in every ambulatory provider office in Massachusetts Approach: Develop partnership among key stakeholders
53	Specific Aims Build a stakeholder coalition Collaborate with state and federal lawmakers around legislation Identify sources of Hardware Software Identify and recruit internists and physician groups Assist providers in acquisition and implementation through educational and support programs
54	Key Stakeholders Providers Purchasers Payors Vendors Software Hardware Malpractice insurers Patients
55	Key Alliances and Resources Governor Romney/administration Mass ACP Massachusetts Medical Society Department of Health and Human Services Massachusetts legislature/Harriet Chandler Mass Health Data Consortium/MassShare Massachusetts Coalition for Prevention of Medical Error Major insurers Malpractice carriers (ProMutual, CRICO) Large purchasers—GE, IBM/Leapfrog National Alliance for Primary Care Informatics Masspro
56	Components of Initial Proposal Build consensus among key stakeholders Identify vendors of computer hardware and EHR software interested in collaborating with Massachusetts Ideally 2-4 Identify purchasers or business groups willing to pay a premium to providers who are willing to make or have already made the transition to electronic records Identify incentive package that will make it attractive for providers to adopt
57	Use of Funds Central coordinating group Identification of vendors Development of specifications Educational outreach Focus groups Extraction of quality data—Masspro Addressing key data exchange needs—Mass Health Data Consortium Drugs, labs, radiology Modeling of benefit—Center for IT Leadership
58	Current Status Have broad consensus about moving ahead Have $50 million in support from Blue Cross Soliciting additional support Received grant from AHRQ to evaluate this effort Exact shape taking place now
59	Short-term NAPCI Plans Follow-up of state meeting Primary care and NHII white paper Tool for individual provider to calculate ROI for their practice Practice type, practice size Survey other available tools/touch base with societies Trying in general to represent primary care in numerous on-going discussions
60	Conclusions Extremely exciting time Hard to keep up Widespread recognition that increasing the use of EHRs in outpatient setting is essential Financial incentive are essential—UK one model Primary care needs to have a seat at table We need to make sure our needs are met—and need to be more explicit about what they are We will need PC informatics and informaticians Should be highly specific about our requests