Federal Health Information Technology Initiatives May 5, 2006 Jodi G. Daniel, JD, MPH Director, Office of Policy and Research Office of the National Coordinator for Health IT "The health of people is really the foundation upon which all their happiness and all their powers as a state depend.” "The health of people is really the foundation upon which all their happiness and all their powers as a state depend.” Benjamin Disraeli

2 Basis for Priority on Health IT High rate of medical errors and rising health care costs necessitate it. The health care industry and commercial leaders support it. Consumers need and want it. The Federal Government is providing leadership to achieve it.

3 Medical Errors In 2000, the Institute of Medicine estimated that between 44,000 and 98,000 Americans die each year from preventable medical errors 1. Subsequent studies have estimated that the number may be twice as high 2. Medical errors are killing more people per year, in the U.S., than breast cancer, AIDS, or motor vehicle accidents 3. 1 Kohn, L., J. Corrigan, and M. Donaldson. To Err Is Human: Building a Safer Health System. Committee of Health Care in America, Institute of Medicine HealthGrades. In-Hospital Deaths from Medical Errors at 195,000 perYear, HealthGrades Study Finds. July 27, Institute of Medicine and Centers for Disease Control and Prevention. National Center for Health Statistics: Preliminary Data for 1998 and “If we want safer, higher- quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.” IOM, Quality Chasm Report, 2001

4 Medical Errors from Lack of Information The lack of immediate access to patient healthcare information is the source of one-fifth of these errors percent of errors were initiated by miscommunication, including missed communication between physicians, misinformation in medical records, mishandling of patient requests and messages, inaccessible records, mislabeled specimens, misfiled or missing charts, and inadequate reminder systems 2. 1 Health Research Institute & GlobalTechnology Center. Reactive to Adaptive:Transforming Hospitals with DigitalTechnology, PriceWaterhouseCoopers Smith, Peter, et. al. “Missing Clinical Information During Primary Care Visits,” The Journal of the American Medical Association. February “In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison. If they could be obtained, they would enable us to decide many other questions besides the one alluded to. They would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good.” Florence Nightingale, 1873

5 The Rising Costs Source: Ending the Document Game: Connecting and Transforming Your Healthcare Through Information Technology umentGame.gov The U.S. leads the world in healthcare spending per capita, yet our technology lags behind other nations. “ Americans are spending $1.7 trillion on health care every year, accounting for 15.3 percent of our gross domestic product, at an average cost of $5,670 per person. Our lagging health IT infrastructure compounds the problem, contributing to fragmentation, waste, and inefficiency.” Statement by Senate Majority Leader Bill Frist and Senator Hillary Rodham Clinton

6 The Rising Costs Health care costs are rising faster than inflation: An aging population: –2000, 35 million Americans were 65 or older, –2050, that number will likely increase to 82 million. Chronic Care expenditures: –23% of Medicare beneficiaries have 5 or more chronic conditions –68% total Medicare expenditures. –On average: 13 different doctors 50 prescriptions. Savings from health IT and corresponding changes in care: 7.5 percent of health care costs (Johnston et al., 2003; Pan et al, 2004) 30 percent of health care costs (Wennberg et al., 2002; Wennberg et al., 2004; Fisher et al., 2003; Fisher et al., 2003). Source: US Department of Census: Fast Facts; April 29, 2005

7 Industry and Commercial Support Health IT Leadership Panel convened by the Lewin Group –Asked how IT has transformed other industries, Banking, credit, retail, etc. –Concluded that investment in interoperable health IT is urgent and vital to the broader U.S. economy consumer buy-in is key to success stakeholder incentives must be aligned NHIN Request For Information –Over 500 respondents have fed into the process.

8 Consumers Want Health IT Source: Connecting for Health Collaborative. The Personal Health Working Group: Final Report. Markle Foundation. July 1, Percent Say They Would Their Doctor 63 Percent Would Track Immunizations Americans who know about connected, interoperable health care systems recognize their benefits. Roughly 70% report that they would use one or more features of a PHR.Roughly 70% report that they would use one or more features of a PHR. 69 Percent Would Monitor Their Record for Mistakes 65 Percent Would Transfer Information to New Doctors 63 Percent Would Look Up and Track Their Own Test Results

9 Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2004). Percent of patients who said… 69% … coordination among their various health providers is a problem 32% …they had to wait/reschedule their appointment because the provider did not have all their medical information 48% …their health care provider did not have all of their medical information Consumers Need Health IT

10 Health IT Activities Over the Years Selected activities to drive interoperability and standardization of health information technology: –1996 – The Health Insurance Portability and Accountability Act (HIPAA) enacted –1998 – The National Committee on Vital and Health Statistics (NCVHS) espoused a national health information infrastructure to promote American health –2002 – Markle Foundation forms the Connecting For Health initiative that assembled public/private leadership in healthcare to promote common electronic standards –2003 – The Federal Health Architecture (FHA) is established in the HHS Office of the Chief Information Officer and is tasked with defining a framework and methodology for establishing the target architecture and standards for interoperability and communication throughout the federal health community –2003 – President Bush signs the Medicare Prescription Drug Improvement and Modernization Act (MMA) allowing CMS to establish key infrastructure for health information technology such as e-prescribing

11 Federal Government’s Leadership Office of the National Coordinator for Health IT Established by Executive Order (April 27, 2004) Responsible for realizing the President’s vision of Health IT: –Widespread adoption of interoperable EHR within 10 years –Medical information follows the consumer –Clinicians have complete, computerized patient information –Quality initiatives measure performance and drive quality-based competition –Public health and bioterrorism surveillance are seamlessly integrated into care

12 Office of the National Coordinator Structure Immediate Office of the National Coordinator David Brailer Immediate Office of the National Coordinator David Brailer Office of Health Information Technology Adoption Office of Health Information Technology Adoption Office of Programs and Coordination Office of Programs and Coordination Office of Interoperability and Standards Office of Interoperability and Standards Office of Policy and Research Office of Policy and Research Operations

13 Publication of a Strategic Framework: July 2004 G oal 1: Inform Clinical Practice Incentivize EHR Adoption Reduce Risk of EHR Investment Promote EHR Diffusion in Rural and Underserved Areas StrategicFramework Goal 2: Interconnect Clinicians Foster Regional Collaboration Develop a Nationwide Health Information Network (NHIN) Coordinate Federal Health Information Systems Goal 3: Personalize Care Use of Personal Health Records,Enhancement of Informed Consumer Choice, and Promotion of Telehealth Systems Goal 4: Improve Population Health Unify PH surveillance architectures, streamline quality and health status monitoring, and accelerate research and dissemination of evidence into practice

14 The Administration: Leadership for Health IT Adoption Lead by example: –Leverage the buying power of the many federal health care programs to jump start health IT adoption Serve as Convener: –Help the health care industry build sustainable public/private collaborations by bringing together: Providers Payers Consumers Employers Health IT vendors Standards Development Organizations (SDOs) Regional Health Information Organizations (RHIOs) State/Territory governments Federal government Etc.

15 ONC Major Initiatives  American Health Information Community  Standards Harmonization Process  Compliance Certification Process  Privacy and Security Solutions  Nationwide Health Information Network  Health IT and Health Care Anti-Fraud  Health IT Adoption  Proposed Changes to Self-Referral and Anti-Kickback Rules  Digital Health Recovery for the Gulf Coast In 2004, President Bush called for the widespread use of electronic health records (EHRs) within 10 years. Despite the demonstrated benefits to care delivery, studies have found use of EHRs remains low among physicians, hospitals and other health care providers. The Office of the National Coordinator for Health Information Technology (ONC) has set the foundation for adoption of interoperable EHRs through the following major initiatives:

16 The American Health Information Community Federal Advisory Committee appointed and chaired by Secretary Leavitt Nine public sector and eight private sector appointees Initial recommendations: –Prioritize Health IT initiatives –Identify breakthrough opportunities including: Biosurveillance Consumer empowerment Electronic health records Chronic care monitoring –Ensure privacy and security protections –Harmonize industry-wide health IT standards –Create an internet-based nationwide health IT architecture

17 Standards Harmonization Process HHS awarded a contract to the American National Standards Institute, a non-profit organization that administers and coordinates the U.S. voluntary standardization activities, to convene the Health Information Technology Standards Panel (HITSP). The HITSP will develop, prototype, and evaluate a harmonization process for achieving a widely accepted and useful set of health IT standards that will support interoperability among health care software applications, particularly EHRs.

18 Compliance Certification Process HHS awarded a contract to the Certification Commission for Health Information Technology (CCHIT) to develop criteria and evaluation processes for certifying EHRs and the infrastructure or network components through which they interoperate. First set of certification criteria have been proposed. Standards Functionality Security Certification will begin summer 2006.

19 Nationwide Health Information Network (NHIN) Contracts have been awarded by HHS to four consortia of health care and health information technology organizations to develop prototypes for the Nationwide Health Information Network (NHIN) architecture. –Accenture –Computer Sciences Corporation –IBM –Northrop Grumman

20 Privacy and Security Solutions HHS awarded a contract to RTI International to lead the Health Information Security and Privacy Collaboration (HISPC) –HISPC - A collaboration that includes the National Governors Association (NGA), up to 40 state and territorial governments, and a multi-disciplinary team of experts. 18-month period RTI will subcontract with up to 40 states to: –Identify within the state business practices and state laws that affect electronic health information exchange –Propose solutions and implementation plans –Collaborate on regional and national meetings to develop solutions with broader application Provide final report on overall project outcomes and recommendations

21 Health Information Technology and Health Care Anti-Fraud Examine how automated coding software and a nationwide interoperable health information technology infrastructure can address healthcare fraud. The project was conducted through a contract with the Foundation of Research and Education (FORE) of the American Health Information Management Association (AHIMA).

22 Proposed Changes to Self-Referral and Anti-Kickback Rules HHS announced proposed rules that would ease self-referral and anti-kickback restrictions. The proposed rules would provide a Stark exception and an Anti-kickback safe harbor to allow hospitals and other entities to provide physicians with e-prescribing and electronic health record software and related training. Proposals published in the Fed. Reg. 10/5/2005.

23 Consumer Value Standards Harmonization Compliance Certification NHIN Privacy / Security Health IT Adoption Infrastructure Industry Transformation Technology Industry BiosurveillanceConsumer Empowerment Chronic CareElectronic Health Records Breakthroughs Health Care Industry Coordination of Policies, Resources, and Priorities Office of the National Coordinator -Health IT Policy Council -Federal Health Arch. The Community -Workgroups Health Information Technology Deployment Coordination

24 Other HHS Health IT Initiatives Agency for Healthcare Research and Quality (AHRQ) –Health IT Grants and Contracts 2005: 16 grantees were awarded a total of $22.3 million to continue projects to improve the quality and safety of health care through IT 2004: $139 million in contracts & grants to promote use of health IT –State and Regional Demonstrations in Health IT (5 awardees) –Transforming Health Care Quality Through Health IT (100+ grants awarded in 38 states)

25 Other HHS Health IT Initiatives Centers for Medicare and Medicaid Services (CMS) –Doctor's Office Quality - Information Technology (DOQ- IT) Promotes adoption of EHR systems and IT in small- to-medium sized physician offices

26 Other HHS Health IT Initiatives Health Resources and Services Administration (HRSA) –Healthy Communities Access Program (HCAP) Develop/strengthen health care safety net delivery systems through providing an infrastructure to coordinate health care for uninsured. Development of information systems to support coordination of efforts that increase access to care. –Office for the Advancement of Telehealth grants (OAT) Support community-based activities in informatics, electronic medical records, and telemedicine.

27 Regional Health Information Organizations (RHIOs) What is a RHIO? –Non-governmental, multi-stakeholder organizations –Provide oversight, coordination, and operational management for health information exchange. –Guide day-to-day operations on data access and data protection rules, support EHR implementation, clinical improvement programs, and sustainable financing for health information sharing. –Covers a defined and contiguous geographic area Why RHIOs? –Clinical care is largely shaped by local referral patterns, and public health is organized locally within states, including corresponding surveillance and reporting activities. –Reimbursement structures, both through private insurers and Medicaid, reinforce the state and regional context of health delivery.

28 State level Regional Health Information Organizations (RHIOs) States have a unique opportunity to either coordinate ongoing regional activities or create the public-private governance and policy and technical framework needed for successful health information exchange. States can address the policy/legal barriers, consider funding mechanisms, ensure coordination with State level programs i.e., public health/biosurveillance and Medicaid. Governors and organizations representing states (NGA, NCSL, etc) can lead change at a state level.

29 What can you do? Connect with federal efforts… –American Health Information Community –Grant/contract opportunities –Standards/certification processes Participate in State/Local Efforts –RHIO/e-health efforts –Policy efforts to reduce barriers to health IT

30 Our Challenge is not new… “That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.” The London Times, 1834 By way of Dr. Jeremy Nobel Harvard School of Public Health

31 For More Information Visit… “Health IT can enable transformation of healthcare by allowing a better way to care — consumer by consumer, physician by physician, disease by disease, and region by region.” David Brailer, M.D., Ph.D., National Coordinator for Health Information Technology