AMERICAN HOSPITAL ASSOCIATION ANNUAL SURVEY IT SUPPLEMENT BRIEF #4 JULY 2018 Advanced Use of Health Information Technology to Support New Models of Care A growing number of hospitals and functions built into their health IT at least one of the following: an ACO, a health systems are implementing systems, such as computerized provider medical home program, or participation new models of care delivery and order entry (CPOE) and the integration in a bundled payment program. In payment that focus on enhanced of clinical guidelines for decision the 2016/2017 survey, 41 percent of care coordination and value, such as support. responding hospitals reported that they accountable care organizations (ACOs), participated in new models of care, patient-centered medical homes, and This brief is the fourth in a series of up from 19 percent of respondents in bundled payment programs. These issue briefs highlighting data from the 2012. models emphasize quality and patient 2016 AHA Annual Survey Information safety as essential components of Technology Supplement for community value and depend on hospitals’ and hospitals collected November 2016 – Accessing and interacting with health systems’ ability to collect and April 2017.1 This fourth brief compares health data use electronic data through health the use of health IT by hospitals and information technology (IT) to health systems that are participating in The vast majority of hospitals and coordinate care and evaluate progress new models of care with those that are health systems give patients the ability toward achieving expected quality not.2 Hospitals and health systems are to view and download their health improvements and cost savings. considered to be participating in new data through the hospital’s electronic models of care if they reported having health record (EHR), as discussed in Over the last five years, hospitals and health systems across the board have made significant investments Patients of new model participants are more likely to be able to view in health IT. These investments have and download their health information. greatly expanded the availability of Chart 1: Patients' Ability to View and Download Data, 2012 and 2016/2017 electronic patient data to patients and 98% to partnering care providers, as well as 89% 90% 80% allowed for the integration of electronic health tools to improve care outcomes. 49% Many new models of care require this 28% 21% 13% enhanced functionality in order to coordinate care across settings of care. 2012 2016/2017 2012 2016/2017 As such, hospitals and health systems View health Download information from participating in these models are information online health record somewhat more likely to have advanced ■ Non-participants ■ Participants 1 clinical or summary of care records5 Nearly all hospitals now support electronic clinical documentation of with hospitals and ambulatory care physician notes and discharge summaries. providers both inside and outside Chart 2: Hospitals with Computerized Systems Allowing for Electronic Clinical of their own system. Notably, new Documentation Implemented Fully or in At Least One Unit, 2012 and model participants were much more 2016/2017 94% 96% 96% 98% likely to have the ability to share with 91% 79% hospitals outside their system in 2012 72% 56% and have maintained that capability (Chart 3). Furthermore, patients in hospitals participating in new care 2012 2016/2017 2012 2016/2017 models are more likely to be able to Physician notes Discharge summaries electronically transmit summaries of care to third-party providers than ■ Non-participants ■ Participants patients in hospitals not participating in new models (Chart 4). This may be the the first brief in this series from March compared to 94 percent of those not result of heightened attention to care 2018.3 This enables patients to play participating in new models. coordination and physician relationships a more informed, active role in their in new models of care. health and health care. Since 2012, the overall number of hospitals and Sharing data with other health systems providing this capability providers for patient care Ensuring high-quality care has increased dramatically across the board, but patients receiving care from New payment and delivery models Many quality improvement efforts a hospital or health system participating incentivize care coordination as a key leverage health IT to improve in new models of care are more likely component of higher quality, more communication and reduce the to be able to access their information efficient care. The summary of care likelihood of errors, such as by electronically (Chart 1). Ninety-eight record is a critical piece of data. As including the physician order process percent of hospitals and health systems discussed in the second brief in this in the health IT system. Hospitals participating in at least one new model series,4 sharing of information with and health systems have significantly of care offer patients the ability to view hospitals and ambulatory care providers increased their use of health IT for their information electronically and outside of the system has increased quality improvement and patient safety 90 percent offer them the ability to dramatically over the past several years, as system capabilities have expanded, download their health information, with most hospitals and health systems as discussed in the third brief in this compared to 89 percent and 80 percent reporting they now electronically share (respectively) in hospitals and health systems that are not participating in a The percentage of hospitals and health systems sharing records outside new care model. of a hospital system has improved significantly since 2012. Clinical documentation tools in health Chart 3: Hospitals' Ability to Share and Exchange Clinical/Summary Care IT are widely prevalent in hospitals Records with Other Hospitals, 2012 and 2016/2017 and health systems (Chart 2). Ninety- 84% 86% 80% eight percent of hospitals and health 66% 70% 69% systems participating in new models 44% have implemented electronic clinical 26% documentation of discharge summaries, compared to 96 percent of those not 2012 2016/2017 2012 2016/2017 participating in new models. Ninety-six With hospitals inside With hospitals outside percent have implemented electronic of your system of your system documentation of physician notes, ■ Non-participants ■ Participants 2 three-fourths of hospitals and Patients of new models of care participants are more likely to be able to electronically transmit summaries to third parties, though this capacity health systems report that they have has expanded across the board since 2013. implemented or are beginning to implement telemedicine in at least one Chart 4: Ability for Patients to Electronically Transmit Care/Referral unit (Chart 7).7 Those participating Summaries to a Third Party, 2013 and 2016/2017 in new models are more likely to offer 78% telemedicine in at least one unit than 70% those not participating in new models. Other health care service functions, such as requesting prescription refills, 17% 11% involve a service for an existing patient that may not require a full office visit. 2013 2016/2017 New model hospitals and health systems ■ Non-participants ■ Participants are much more likely to have health IT systems that allow patients to request series.6 Hospitals and health systems to use health IT to assess adherence to prescription refills online, compared to participating in new models of care are clinical practice guidelines (Chart 6). hospitals and health systems that are not somewhat more likely to use health IT participating in new models. for quality improvement activities, both in the delivery of patient care and in Delivery of health care services monitoring for overall trends (Chart 5). through health IT Looking Ahead For example, 95 percent of new model hospitals have health IT systems that There is growing interest in using health Hospitals and health systems that are allow physicians to prescribe discharge IT systems to facilitate the delivery of participating in new models of care, medication orders electronically − care, particularly by those hospitals and such as ACOs, patient-centered medical compared to 85 percent of hospitals that health systems participating in new homes, and bundled payment programs, are not participating in new models. models of care. Some functions, such deploy more advanced uses of health IT CPOE of medications has been nearly as telehealth, may take the place of an to support success in the new models. universally adopted − 99 percent of office visit, allow access to specialists This finding supports a policy approach new model hospitals have CPOE of for emergency departments, or provide that emphasizes value-based models over medications, compared to 96 percent around the clock intensivist support to prescriptive requirements to use health of hospitals that are not participating in an intensive care unit. Almost IT in specific ways. new models. High-quality care must be safe and New model participants are more likely to have health IT systems that effective. Clinical practice guidelines support electronic prescribing of discharge medication orders, while are recommended courses of action nearly all hospitals now support CPOE of medications. for providers to deliver safe and Chart 5: Hospitals' Computerized Systems Allowing for Medication effective care based on evidence from Management, 2012 and 2016/2017 research. When correctly developed and 95% 96% 99% deployed, these guidelines can support 85% 83% the delivery of high-quality care by 66% 69% 49% assisting provider decision-making and helping organizations assess the care being provided. Hospitals and health systems participating in new models of 2012 2016/2017 2012 2016/2017 care are more likely to have integrated Prescribe discharge medication CPOE of medications (implemented clinical guidelines for physician decision orders electronically fully or in at least one unit) support into their health IT system and ■ Non-participants ■ Participants 3 improvements and savings over Health IT systems for new model of care participants are more likely to traditional methods of health care have integrated clinical guidelines for decision support and monitoring. services delivery. Chart 6: Integration of Clinical Guidelines for Quality Improvement and Monitoring, 2012, 2014 and 2016/2017 Adequacy and interoperability of health 96% IT is a major concern for new models 89% 78% 75% of care. A 2017 survey of ACOs found 68% 61% 58% that ACOs needed more than an EHR 49% to achieve their goals and, therefore, purchased additional technologies to plug into their existing systems, such 2012 2016/2017 2014 2016/2017 as patient portals and decision-support Clinical guidelines (implemented Assess adherence to clinical tools.8 ACOs struggle to integrate data fully or in at least one unit) practice guidelines from multiple providers, although ■ Non-participants ■ Participants such integration is a core feature of the model.9 These efforts are not without growing other providers in that model, in pains. Hospitals and health systems both hospital and ambulatory care Looking ahead, hospitals and health participating in new models are more settings. Alternatively, it may be that systems that participate in new models likely to report barriers to the use of hospitals in new models have had to of care will continue to help move the health IT for patient care, possibly focus on interoperability in order to field toward higher value health care. because they are more likely to be using meet reporting requirements that are Those that already participate in such health IT and, therefore, more likely directly linked to reimbursement for models have more advanced health IT to encounter a barrier. One interesting these models. New models also may systems in place to support their efforts. exception is that those participating drive expanded use of health IT for As more hospitals and health systems in new models are less likely to report telehealth. For example, a hospital implement these new models, it will be workflow (i.e., typical process) to be participating in an ACO may find important to understand what health a barrier. It may be that hospitals and that remote monitoring or counseling IT functions best support high-quality health systems participating in new using telecommunications can be coordinated care and how they may be models more rapidly develop internal incorporated into the process of care integrated into hospital practices in the processes that support these advanced through health IT and yield quality most efficient and effective way. capabilities as part of daily practice. Hospitals and health systems Health IT systems at hospitals and health systems participating in new participating in new models also are models of care are more likely to facilitate the delivery of patient care less likely to report that they experience through functions like telehealth and prescription refills. challenges exchanging information across different vendor platforms Chart 7: Access to Health Care Services Through Health IT, 2012 and (data not shown). Interoperability is 2016/2017 a core concern for many new models 74% 69% 57% 58% of care that rely heavily on the ability 43% to exchange data among internal 39% 37% and external providers to support 16% enhanced care coordination. It may be that hospitals and health systems 2012 2016/2017 2012 2016/2017 participating in a particular new Telehealth (implemented fully Request prescription model are required to use a particular or in at least one unit) refills online health IT system to coordinate with ■ Non-participants ■ Participants 4 POLICY QUESTIONS 1. What features of new models of care drive greater adoption of advanced health IT functions? 2. How effective are health IT systems in supporting higher quality care and/or reducing costs within new models of care? 3. Do new models of care sufficiently reward the investment in health IT that may be necessary to participate in the model? 4. What are best practices for integration of health IT into hospital and health system operations to best support new models of care? 5. How can hospitals and health systems optimize both care delivery and their health IT systems to succeed in new models of care? Sources 1. Data from the American Hospital Association Annual Survey Information Technology Supplement conducted November 2016 – April 2017. Reported results are unweighted. 2. In the 2016/2017 survey, 1261 hospitals/health systems responding to the survey were participating in new models and 1807 were not. 3. American Hospital Association. Expanding Electronic Patient Engagement. https://www.aha.org/system/files/2018-03/expanding- electronic-engagement.pdf. March 2018. Accessed May 2018. 4. American Hospital Association. Sharing Health Information for Treatment. https://www.aha.org/system/files/2018-03/sharing- health-information.pdf. March 2018. Accessed May 2018. 5. For purposes of Meaningful Use, a clinical summary is an “after-visit summary that provides a patient with relevant and actionable information and instructions” that includes specific data elements. Centers for Medicare and Medicaid Services. Stage 2 Eligible Professional Meaningful Use Core Measures, Measure 8 of 17. November 2014. https://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_8_ClinicalSummaries.pdf. Accessed Feb 8, 2018. 6. A summary of care record is a similar document required of a provider that transfers or refers their patient to another setting of care or provider. Centers for Medicare and Medicaid Services. Stage 2 Eligible Professional Meaningful Use Core Measures, Measure 15 of 17. August 2015. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_ EPCore_15_SummaryCare.pdf. Accessed February 6, 2018 7. American Hospital Association. Fact Sheet: Telehealth. April 2018. https://www.aha.org/factsheet/2018-04-12-fact-sheet-telehealth. Accessed May 2018. 8. De Lisle K, et al. The 2017 ACO Survey: What Do Current Trends Tell Us About The Future Of Accountable Care? Health Affairs Blog, October 2017. https://www.healthaffairs.org/do/10.1377/hblog20171021.165999/full/. Accessed March 2018. 9. Davis J. Survey: Accountable Care Organizations Struggling with Out-of-Network Integration, Interoperability. Healthcare IT News. January 21, 2016. http://www.healthcareitnews.com/news/survey-accountable-care-organizations-struggling-out-network- integration-interoperability. Accessed May 2018. TrendWatch, produced by the American Hospital Association, highlights important trends in the hospital and health care field. The Department of Health Policy and Management in the Milken Institute School of Public Health at the George Washington University supplied research and analytic support for this issue brief. ©2018 American Hospital Association | All rights reserved. Washington, D.C. Office | 800 10th Street, NW | Two CityCenter, Suite 400 | Washington, DC 20001 | (202) 638-1100 | www.aha.org 5