Yesterday, Today, and Tomorrow Judy Murphy, RN, FACMI, FHIMSS, FAAN Deputy National Coordinator for Programs & Policy Office of the National Coordinator for Health IT Department of Health & Human Services Washington DC

A look at . . . Yesterday - what we’ve gotten done The status of the HITECH Programs Today - what are our key priorities Health information exchange Patient engagement Tomorrow – what are the biggest challenges in our future Meaningful use of meaningful use Health reform

We’ve come a long way …

On the eve of the Presidential Election A Bit of History … On the eve of the Presidential Election President Bush’s goal in January 2004 “… an Electronic Health Record for every American by the year 2012. By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” - State of the Union address, January 20, 2004 Executive order established the Office of the National Coordinator for Health IT (ONCHIT) as part of the Dept of Health & Human Services Dr. David Brailer appointed the first National Coordinator for Health IT Followed by Dr. Rob Kolodner President Barack Obama’s goal in January 2009 “To lower health care cost, cut medical errors, and improve care, we’ll computerize the nation’s health records in five years, saving billions of dollars in health care costs and countless lives.” - Speech at George Mason University, January 12, 2009 The last two Administrations wanted every American to benefit from health IT and especially from access to EHRs President Bush: Executive order established the Office of the National Coordinator for Health Information Technology (ONC) as part of the Dept of Health & Human Services (HHS) Dr. David Brailer appointed the first National Coordinator President Obama: February 17, 2009 – the American Reinvestment and Recovery Act (ARRA – Stimulus Bill) is signed into law HITECH component of ARRA provides an incentive program to stimulate the adoption and use of HIT, especially EHR’s Dr. David Blumenthal appointed the new National Coordinator Congress authorized HHS to establish programs to improve health care quality, safety, and efficiency through the promotion of health IT and private and secure electronic health information exchange. February 17, 2009 – HITECH Act (part of ARRA) is signed into law Dr. David Bluementhal appointed National Coordinator Health IT Policy and Standards Committees are formed ONC grows from around 30 to over 150 employees Dr. Farzad Mostashari becomes the current National Coordinator

A Remarkable Journey Meaningful Use 4

Progress of Eligible Providers toward EHR Incentive Payments as of 8-31-12 NAMCS Survey: The percentage of primary care providers who have adopted EHRs in their practice has doubled from 20 % to 40 % between 2009 to 2011 Note: The 2012 data will be available in 2013 Source: CMS EHR Incentive Program Data

EHR Adoption of Eligible Providers by state as of 8-31-12 http://dashboard.healthit.gov/HITadoption/

Regional Extension Centers are working with 148,448 Primary Care Providers Includes 70% of all primary care providers in the rural areas and 1,185 Rural or Critical Access Hospitals 2012 GAO Report: Providers 2.3 times more likely to achieve MU if working with an REC http://dashboard.healthit.gov/rec/

Progress of Eligible Hospitals toward EHR Incentive Payments as of 8-31-12 AHA Survey – in one year, from 2010 to 2011: Hospitals increased their use of Basic EHRs from 19% to 35% (84%) Hospitals doubled their use of Comprehensive EHRs from 4% to 9% (125%) Note: The 2012 data will be available in early 2013 Note: Totals reflect the number of unique hospitals that have received payments from Medicare or Medicaid. Source: CMS EHR Incentive Program Data

EHR Adoption of Eligible Hospitals by state as of 8-31-12 http://dashboard.healthit.gov/HITadoption/

Meaningful Use – All Payments as of 8-31-12 ($ in Millions) Source: CMS EHR Incentive Program Data

HITECH Framework for MU of EHRs Taken from: Blumenthal, D. “Launching HITECH,” posted by the NEJM on 12-30-2009.

National Learning Consortium Health IT Resource Center THEN: Work within REC community to share knowledge NOW: Work with all external communities to share knowledge HITRC Community Tools Resources Communities of Practice (CoPs) National Learning Consortium HealthIT.gov

Workforce Training – Community College Program Enrollment & Graduation Students Enrolled or Completed: 21,321

Workforce Training - University-Based Program Enrollment & Graduation As of September 14, 2012 Students Enrolled or Graduated: 1,627 (Target: 1,685)

Health Information Exchange - Directed Exchange Implementation as of 6-30-12 Summary Stats Number of Grantees States/territories with directed exchange options broadly available 36 States/territories piloting directed exchange solutions 10 States/territories with directed exchange options unavailable

Directed Exchange: Estimated number enabled as of 6-30-12 Summary Stats Number Total number of organizations enabled for directed exchange nationally 8.349 Total number of clinical & administrative staff enabled for directed exchange nationally 48,649

Query-Based Exchange: Estimated number enabled as of 6-30-12 Summary Stats Number Total number of organizations enabled for query-based exchange nationally 3,554 Total number of individuals enabled for query-based exchange nationally 56,496

Exchange is increasing across the nation 18 states had more than 10% of their hospitals actively engaged in sharing health information electronically as of 6-30-12 State % of Acute Care Hospitals Actively* Participating in Directed Exchange that is supported or enabled by State HIE grantees** Delaware 100% Vermont 79% Michigan 48% Arkansas 45% New York 42% Minnesota 34% North Dakota Colorado 26% California 20% Alaska 18% Utah 14% State % of Acute Care Hospitals Actively* Participating in Query-Based Exchange that is supported or enabled by State HIE grantees** Delaware 67% New York 65% Maryland 54% New Jersey 32% Arizona 27% Colorado 26% Nebraska 20% Idaho 17% Kentucky 16% Michigan 15% Tennessee 12% * Active = at least one directed message sent between production end points or at least one patient record query during previous calendar quarter ** Data self-reported by HIE grantees, Denominators calculated with 2011 Medicare Inpatient Hospital Data

The Beacon Community Program: Where HITECH Comes to Life 17 diverse communities, each funded over 3 yrs to: Build and strengthen health IT infrastructure and exchange capabilities - positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years. Improve cost, quality, and population health - translating investments in health IT in the short run to measureable improvements in the 3-part aim. Test innovative approaches to performance measurement, technology integration, and care delivery - accelerating evidence generation for new approaches.

“Beacons for Public Health” Western New York Beacon Community Buffalo, NY Funded by the CDC and launched in collaboration with the ONC in 2011 Primary goal: Gain an understanding of the range of activities currently conducted in population and public health within the Beacon Communities, to accelerate the work of other organizations across the country Case studies available today! Southeastern Minnesota Beacon Community Rochester, MN Rhode Island Beacon Community Providence, RI Southeast Michigan Beacon Community Detroit, MI Greater Cincinnati Beacon Community Cincinnati, OH Funded by the CDC, the Beacons for Public Health project is going to allow us to explore how technology is helping to support achievement of our population health goals. Several Beacon Communities are actively engaged in technology-enabled public health efforts. The successes and lessons learned from these initiatives—which the Beacon Communities for Public Health Project is documenting—will be useful for other public health departments as they support health information exchange and EHR infrastructure for providers and public health facilities in their communities. SE Minnesota, for example is partnering with public health departments in 11 counties as they consider their exchange strategy for the community. San Diego is working on a more advanced immunization registry initiative and electronic exchange with EMS in their community NOTE: RTI/CDC are here today and have copies of these case studies! Southern Piedmont Beacon Community Concord, NC San Diego Beacon Community San Diego, CA Crescent City Beacon Community New Orleans, LA

IT-Care Management Partnership: Beacons and AF4Q Bangor Beacon Community Brewer, ME Maine Alliance Southeastern Minnesota Beacon Community Rochester, MN Wisconsin Alliance Western NY Alliance Partnership to align “regional health care improvement” programs between ONC (Beacons) and RWJ (Aligning Forces for Quality or AF4Q) On October 24th, pioneering organizations from both programs came together to understand opportunities and gaps related to IT and care management Lessons will be shared through case studies and videos Future topics: Behavioral health and IT, and data use agreements across communities Humboldt County Alliance Keystone Beacon Community Danville, PA Cleveland Alliance Southern Piedmont Beacon Community Concord, NC 21

Connecting Health IT to Payment Bangor Beacon Community Brewer, ME Bangor Beacon HIT infrastructure serves as the foundation for the Bangor Pioneer ACO 3 Beacon Communities (CO, Tulsa and Cincinnati) are working on how Beacon HIT infrastructure can be used to support provider practices participating in CMMI’s comprehensive primary care initiative (CPC) Greater Cincinnati Beacon Community Cincinnati, OH Colorado Beacon Community Grand Junction, CO Great Tulsa Health Access Network Beacon Community Tulsa, OK 22

EHR Certification Program: Certified Health IT Product List (CHPL) 1,642 “Unique” Certified EHR Products as of 11/01/12 2,744 Certified EHR Products when all product versions are counted 896 EHR Vendors/Developers On October 4th, ONC’s Permanent Certification Program was launched; the Temporary Certification Program which was operating for 2 years was sunset Ambulatory Inpatient Total Complete EHR 694 96 790 Modular EHR 436 416 852 1130 512 1642 This table shows a unique count of products. Any additional versions of the same products are not included.

MU Attestations by Vendor (7/28/12) http://www.modernhealthcare.com/article/20120728/MAGAZINE/307289983

TODAY - Key Priorities: Keeping the Patient at the center of all we do Patient-Centric health care and health record by Laying the groundwork for interoperability with standards, testing & certification Facilitating broad implementation of health information exchange Patient Engagement by enabling patient Access Action Attitude

Focus on INTEROPERABILITY in the Stage 2 Meaningful Use Criteria E-prescribing (ambulatory and inpatient discharge) Transition of Care summary exchange: Create & transmit from EHR Receive & incorporate into EHR Lab tests & results from inpatient to ambulatory Public health reporting – transmission to: Immunization Registries Public Health Agencies for syndromic surveillance Public health Agencies for reportable lab results Cancer Registries Patient ability to View, Download and Transmit their health data to a 3rd Party Create an export summary of patient data, in order to enable data portability

Focus on PATIENT ENGAGEMENT in the Stage 2 Meaningful Use Criteria Reminders for preventive/follow-up care provided Educational resources identified and provided Online access to personal health information (portal, PHR) Visit Summaries provided Patients can send secure messages to their provider Patients can View, Download and Transmit to 3rd Party

Back in the Day… - AMA’s Code of Medical Ethics (1847) “The obedience of a patient to the prescriptions of his physician should be prompt and implicit. [The patient] should never permit his own crude opinions as to their fitness to influence his attention to them.” - AMA’s Code of Medical Ethics (1847) The role of the patient – and the provider – have changed considerably in the last 150 years, as demonstrated by this statement from the AMA. _________________________________ Notes: The image is from http://catalogue.wellcome.ac.uk/record=b1178275~S8 A bedridden sick young woman being examined by a doctor, accompanied by her anxious parents. Engraving by F. Engleheart, 1838, after Sir D. Wilkie. Available through Creative Commons license.

And Now… “Patients share the responsibility for their own health care….” - AMA’s Code of Medical Ethics (current) “Patients can help. We can be a second set of eyes on our medical records. I corrected the mistakes in my health record, but many patients don't understand how important it will be to have correct medical information, until the crisis hits. Better to clean it up now, not when there’s time pressure.” – Dave deBronkart (ePatient Dave) This updated statement by the AMA – and the quotes from actual patients -- represent a shift toward patient engagement in healthcare and health. This change is due to multiple factors, including changes in attitude about the capabilities of patients, as well as other trends from outside of healthcare, such as the wide adoption of information technology, that are changing our society in numerous ways: Assumptions about consumer engagement in health: - Actionable information (right info, right place, right time) contributes to individuals’ ability to effectively engage in their health - Actionable information for individuals can contribute to the following health outcomes: - Increased ability to coordinate care among multiple providers - Stronger partnerships with providers in patient-centered care - Better self management - The goal is effective engagement… not necessarily more engagement; effective health engagement by individuals should be guided by scientific evidence - Provider and patient attitudes—not just technical and financial considerations—impact individuals’ ability to use information to engage effectively in their health Powerful “megatrends” support consumer engagement in health: - Communication technology is getting cheaper and more ubiquitous (cell phones, smart phones, tablets, etc) - Online communities are growing and proliferating (Facebook, Twitter, etc) - Technology for information collection and analysis is getting cheaper and ubiquitous (sensors, more powerful computers, etc.) - Trends are toward opportunities for greater consumer engagement in most (other!) aspects of our lives - Meaningful Use and other factors are bringing health information held by providers online - Market forces (including health reform) are requiring consumers to take greater responsibility for their health and health care _________________________________ Notes: This version of the AMA code was written in 1993 and remains current. The patients and quotes pictured are from actual people interviewed by ONC. Go to http://www.healthit.gov/patients-families/health-it-stories for more.

ONC’s Consumer Engagement Strategy: The Three A’s Access Access Give consumers electronic access to their health information. Attitudes Action Action All are interdependent Tell you what we are doing in each…. Support a shift in attitudes and expectations regarding consumer (and provider) roles. Catalyze development of tools and services that help consumers (and providers) take action using their health information. DRAFT: Not for distribution

ACCESS: Consumer eHealth Pledge Program Over 400 organizations have Pledged to provide access to personal health information for 1/3 of Americans… 31

Taking the Blue Button nation-wide www.healthit.gov/pledge Get more organizations to offer Blue Button Make “Blue Button” a household name = “electronic access to my health data” Advance technical capabilities = “set it and forget it” One of 5 game-changing projects involving the 2012 Presidential Innovation Fellows

ACTION: Making it easier for Patients to use Health IT Surgeon General’s Healthy Apps Challenge More at: http://sghealthyapps.challenge.gov PHR Model Privacy Notice More at: http://bit.ly/qfjP1a 52 % of Americans would use a smart phone or PDF to monitor their health if they were able to access their medical records and download info about their medical condition or treatments… Together with the Department of Veterans Affairs, ONC issued a challenge for developers that builds on the current Blue Button feature that allows patients to download their health information and share it with health care providers, caregivers and others they trust The challenge requires the development of a tool that will help individuals to use their health information, combined with other types of information, such as cost data or comparative health data, to help the patient better understand their own health status and make more informed decisions regarding their health care.

ACTION Blue Button Mash-Up Challenge – develop an app that mashes up PHR data with other health-related data sets Leon Rodriguez, Director-Office of Civil Rights: clarification of the patient’s right to access their own health information under HIPAA (videos, pamphlets, answers to questions, and other guidance) More at: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/righttoaccessmemo.pdf 52 % of Americans would use a smart phone or PDF to monitor their health if they were able to access their medical records and download info about their medical condition or treatments… Together with the Department of Veterans Affairs, ONC issued a challenge for developers that builds on the current Blue Button feature that allows patients to download their health information and share it with health care providers, caregivers and others they trust The challenge requires the development of a tool that will help individuals to use their health information, combined with other types of information, such as cost data or comparative health data, to help the patient better understand their own health status and make more informed decisions regarding their health care.

ATTITUDE: Health IT Animation http://www.healthit.gov/patients-families/video/preview-health-it-you-giving-you-access-your-medical-records 1 and 3 minute versions of the animation are available to use for patient teaching https://dl.dropbox.com/u/110138592/HHS_Final_HD_WithSound_5.21.2012-APPROVED-FINAL-2500.wmv

Beat Down Blood Pressure Consumer Video Challenge

Beat Down Blood Pressure Winner A Regular Guy Beats Down Blood Pressure: http://vimeo.com/42121895 Based on self-reported 3 quarters of data – will be collecting more to understand trends across communities 37

What’s in Your Health Record Consumer Video Challenge

What’s in Your Health Record Winner Wright and Luft: http://vimeo.com/46790323 Based on self-reported 3 quarters of data – will be collecting more to understand trends across communities 39

Stages of Meaningful Use TOMORROW – The biggest challenges in our future Data capturing and sharing Advanced clinical processes Improved outcomes Stage 3 Stage 2 Stages of Meaningful Use Stage 1

HIT as the means, not the end Dr. David Blumenthal, previous National Coordinator of HIT, emphasizes “HIT is the means, but not the end. Getting an EHR up and running in health care is not the main objective behind the incentives provided by the federal government under ARRA. Improving health is. Promoting health care reform is.” At the National HIPAA Summit in Washington, D.C. on September 16, 2009

Best Care at Lower Cost The Path to Continuously Learning Health Care in America September 2012 iom.edu/bestcare

10 Recommendations Supportive policy environment Foundational elements 1. The digital infrastructure – Improve the capacity to capture clinical, delivery process, and financial data for better care, system improvement, and creating new knowledge. 2. The data utility – Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge. Care improvement targets Clinical decision support Patient-centered care Community links Care continuity 7. Optimized operations Supportive policy environment 8. Financial incentives. 9. Performance transparency 10. Broad leadership

Our National Quality Strategy Better Health for the Population Lower Cost Through Improvement Better Care for Individuals

Health Information Technology Health IT: Helping to Drive the 3-Part Aim Improving patients’ experience of care within the Institute of Medicine’s 6 domains of quality: Safety, Effectiveness, Patient- Centeredness, Timeliness, Efficiency, and Equity. Better healthcare Keeping patients well so they can do what they want to do. Increasing the overall health of populations: address behavioral risk factors; focus on preventive care. Better health Lowering the total cost of care while improving quality, resulting in reduced monthly expenditures for Medicare, Medicaid, and CHIP beneficiaries. Reduced costs $ With the foundation we have built in Stage 1 Increasingly rigorous health information exchange requirements in Stage 2 Standards adoption to reduce cost and Payment reform providing the business case We expect exchange to take off in 2012 Health Information Technology

Meaningful Use as a Building Block Utilize technology Access to information Transform health care Improved population health Enhanced access and continuity Data utilized to improve delivery and outcomes Data utilized to improve delivery and outcomes Patient self management Patient engaged, community resources Care coordination Care coordination Patient centered care coordination As the ability to integrate and manage grows, so does the data reporting requirements and expanded use of the data. Patient informed Evidenced based medicine Team based care, case management Basic EHR functionality, structured data Structured data utilized Registries for disease management Registries to manage patient populations Privacy & security protections Privacy & security protections Privacy & security protections Privacy & security protections PCMH 3-Part Aim ACO’s “Stage 3 MU” Stage 1 MU Stage 2 MU

Meaningful Use Is Just the Beginning: Other Three Part Aim Programs A recent analysis identified that the national network of RECs are currently working on over 190 different programs to help providers meet the Three Part Aim * Based on information from 53 of 62 RECs. Some are working on several different Three-Part Aim Programs .

THE FUTURE IS NOW. THIS IS OUR TIME. Thanks! judy.murphy@hhs.gov