Quantifying the value of RHIOs

for Nursing

Patricia Flatley BrennanWith collaboration from Stephen Robinson,

Michael Ferris, Stephen Wright, & Jenna Marquard

LM 8949

University of Wisconsin-Madison

School of NursingUniversity of Wisconsin-Madison

By computerizing health records, we can

avoid dangerous medical mistakes, reduce costs, and

improve care.”--President George W. Bush, State of the Union Address, January 20,

2004

President Bush has outlined a plan to ensure that most Americans have electronic health records within the

next 10 years. …

10 years - it’s not so much time…

and what once was new is now familiar

• Jan Zeller contributed new insights about psychoneuroimmuniology

• Cheryl Beck brought together the research on post-partum depression

• Susan Bennett, Sandy Dunbar and Jerilyn Allen gave us ways to measure significant cardiac experiences

• Barbara Daly, Sara Douglas and Ellen Rudy introduced the concept of chronically critically ill

Just how much can happen in a decade?

Or look at health care…– HPV vaccine

– P4P

– NHII, NHIN, RHIO, SNO

– CMS

– Vioxx, then no Vioxx

– Stem cells

• Just ask a kid…– Wireless everywhere– Harry Potter– iPods & Palm Pilots– Purple M&Ms– Spinning– No air travel without

shoe removal– MMORPG– Faceplace, myspace &

iTunes

Progress towards the 10 year vision?

• July 2004– NIHN

• August 2005– CMS/OIG announce relaxation of the Stark

• 2006– Federal Employees Electronic Personal

Health Records Act

• Creating a sustainable, credible financial model remains a significant barrier

Health Information Exchange

relationships(formerly known as RHIOs )

form the core building blocks of the information flows necessary to support high-quality, safe, evidence-based care

RHIO, SNO,

what-evah!

Alliances of hospitals, clinics, Alliances of hospitals, clinics, nursing homes,nursing homes,

public health authorities public health authorities (and suppliers and payers and schools and ..)(and suppliers and payers and schools and ..)

(and maybe patients(and maybe patients))

Many Configurations

The evolution of RHIOs

Behavior of groupsNorming, storming, forming

Governance/Policy * Rates * Incentives * PenaltiesJoining Patterns

Should more players join a RHIO?

It depends on

* present and future state of RHIO* policy considerations* regulatory requirements* business case

First, let’s look at some general economic considerations

of RHIOs

Financial considerations

• Provider-level costs and benefits– Information management at the point of care– The cost of information– The expected value of perfect information

• Institution-level– Preparing and sustaining information exchange

• Alliance perspective– Establishment & maintenance costs– Generating revenue: fees, subscriptions & services

Participation in a RHIO depends in part on a positive financial

appraisalbut…

this requires anticipating the behavior of RHIO &

its participants over time -- which most cost models can’t

handle

What can be learned from current approaches to financing HIT?

• Net Present Value models – Focus on single institution

– Presume perfect knowledge• Risk is known, fixed, and unaffected by the behavior of other

institutions

• Network models – Experts’ estimates of societal benefits & institutional

investment (Warner, 2005; Kaushal et al 2005)

– Static, unchanging participation (Chismar & Thomas, 2004)

– Optimization of network performance in a stable HIE environment (Berman & colleagues, 2001)

To make the RHIO participation decision, the institution must…

• Value participation using key parameters:– Startup costs, including institutional readiness– Network maintenance– Incentives or penalties for delay

• Value participation at many points in time– Sensitive to network configuration, behavior of other

participants, and benefit to institution

• Therefore, – business planning models for RHIO participation must

incorporate network performance, risk, and change over time

What does a hospital need to know ?

• The present & future state of the RHIO• Entry cost• Maintenance costs• Number & size of participants• Policies:

• Incentives, penalties & caps• Institution:

• Cost-to-participate (Institutional IS, cost to convert)

• Anticipated benefit• Base benefit• Incremental benefit

Using Operations Research models to make the business case

• On the value of models– Make explicit representations of complex

situations– Capitalize on computational strength– Explore consequences

• Model approach:– mixed-integer linear programs within the GAMS modeling

system, CPLEX solver

Model parameters

• Model Inputs:– Hospital size

• Tiny, small, medium, large

– Entry Costs– Maintenance costs– Base and Incremental benefits– Exploration: Capacity limits and Penalties

• Results:– RHIO size and composition

Findings: Institutions join RHIO when net benefit over time is positive both for the RHIO and the institution

Net Benefit

-10

-5

0

5

10

15

20

25

30

t1 t2 t3 t4 t5 t6 t7 t8 t9 t10 t11 t12 t13 t14 t15 t16

1

2

3

5

6

7

8

12

13

14

15

Benefits over time: four hospitals

• Basic assumption: perfect knowledge of deterministic benefit over time

• Sample joining pattern• Three hospitals join; one never

does

Hospital 1

-5

0

5

10

15

20

25

30

t1 t2 t3 t4 t5

Hospital 5

-5

0

5

10

15

20

25

30

t1 t2 t3 t4 t5

Hospital 9

-5

0

5

10

15

20

25

30

t1 t2 t3 t4 t5

Hospital 12

-5

0

5

10

15

20

25

30

t1 t2 t3 t4 t5

Capacity limits effect RHIO size and composition

Effect of capacity limit on RHIO size/composition

0

500

1000

1500

2000

2500

3000

t1 t2 t3 t4 t16 t1 t2 t3 t4 t16

1.2 1.2 1.2 1.2 1.2 2.8 2.8 2.8 2.8 2.8

large

med

small

tiny

Penalties influence growth and participation

Effect of penalty on RHIO size/composition

0

500

1000

1500

2000

2500

3000

3500

t1 t2 t3 t4 t16 t1 t2 t3 t4 t16

0.01 0.01 0.01 0.01 0.01 0.1 0.1 0.1 0.1 0.1

large

med

small

tiny

Major discussion points

• Conversion costs do not exert a strong effect on participation

• Participation is highly sensitive to incremental benefit caps

• Changing the price-to-enter has a slight effect on participation

• Participation is highly sensitive to benefit reduction and penalties due to RHIO size

Modeling Strategies and Directions

• Models provide a way to examine structure and policies of innovation

• Realistic application to healthcare and to RHIOs in particular requires– Careful work with industry partners

• Data collection, adaptation to the business

– Close interaction to ensure models’ output is relevant and useful for healthcare decisions

• Application of more sophisticated and robust models awaits exploration and validation of preliminary work and the input of care providers, including most essentially, nurses!

So what does all this matter to

Nursing?

Why should nurses be concerned about the economic value of

RHIOs?• Assuring the

information needed for patient care

• Insuring a positive information benefit/burdens balance

• Envisioning both data coordination and clinical practice benefits

… the dinner plate that knows what is on it

Imagine that the dinner plate that knows what is on it can…

… weigh the food

… do a chemical analysis

… use an embedded chip to

… obtain nutritional information from an USDA database

… query your health goals & recent intake

… flash green if you’re OK or red if you must skip dessert!

What if there was a information pathway from the point of care,

anywhere!• What if --

– All hospitals had such a plate and a

patient’s nutritional status could be

tracked exactly?

– A kid with peanut allergy had a lunch

box with a sensor to alert her whenever

a peanut-containing substance was

entered?

– A band aid could alert you if an

infection was starting?

Technology-enhanced Practice

Activated, engaged patients & their

care teamsTechnology in the service of nursing

Nurses

What makes up the economic value of RHIOs to nursing?

Value of information

Expected value of perfect information

Cost of acquiring information

How do RHIOs benefit Nursing?

• Access to pertinent (!) health information– Clinical care providers’ records– Personal health histories– Family health history– Resources

• Information• Authentication and authorization• Public health monitoring• Evidence in the context of care

• Extends nursing’s patient care opportunities– Promoting self-monitoring– Creating the personal health record

Nursing’s role in insuring Health Information Exchange:

Framework for action

Point-of-Care

Process of Care Delivery

Point of Care Issues

• Safeguarding the clinical care process

• Insuring knowledge for action

• Creating tools for effective information integration

• Assessing the economics of data collection & management

Process of Care Delivery

• Articulate the many points of care

• Expand the vision from cost/charge/drug to information for action

• Advocate for fair sharing of benefits & burden

Capitalizing on RHIOs: Informing the Debates

• Creating a full-view of the patient

• When does information matter?

• When does evidence matter?

Quantifying the costs and benefits to nursing

• Practice benefits

• Practice costs

• Workload benefits

• Workload costs

• Advancing the care of vulnerable populations

• Creating the nursing response set

Will automation change nurses,

nursing or

both?H. Peplau, 1962

Quo Vadis, Nursing, and how will you pay for it?

Thanks for your interest!pbrennan@engr.wisc.edu

healthsystems.engr.wisc.edu

healthsystems.engr.wisc.edu