1. National Health Information Infrastructure: Challenges for Communities William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors Get Connected Knowledge Forum Grapevine, TX June 28, 2005 © 2005 NH i i ADVISORS

2. 2 2 © 2005 NH i i ADVISORS Outline I. Background and History II. What is the NHII? III. How can IT help address current health care problems? IV. How does a community health information exchange (HIE) system work? V. Key Issues in NHII / LHII progress I. Background and History II. What is the NHII? III. How can IT help address current health care problems? IV. How does a community health information exchange (HIE) system work? V. Key Issues in NHII / LHII progress

3. 3 3 © 2005 NH i i ADVISORS I. Background & History

4. 4 4 © 2005 NH i i ADVISORS “Current practice depends upon the clinical decision making capacity and reliability of autonomous individual practitioners, for classes of problems that routinely exceed the bounds of unaided human cognition” -- Dan Masys, MD IOM Annual Meeting (2001)

5. 5 5 © 2005 NH i i ADVISORS INPUT $$ OUTPUT Managing a Factory … … without internal details … … is like health care!

6. 6 6 © 2005 NH i i ADVISORS Health Care System Challenges n Error rates are too high n Quality is inconsistent n Research results are not rapidly used n Costs are escalating n New technologies continue to drive up costs n Demographics of baby boomers will greatly increase demand n Capacity for early detection of bioterrorism is minimal n Error rates are too high n Quality is inconsistent n Research results are not rapidly used n Costs are escalating n New technologies continue to drive up costs n Demographics of baby boomers will greatly increase demand n Capacity for early detection of bioterrorism is minimal

7. 7 7 © 2005 NH i i ADVISORS National Expert Panel Reports IOM 1991 1997 Computer-Based Patient Record IOM2000To Err is Human NRC/ CSTB 2001Networking Health: Prescriptions for the Internet IOM2001Crossing the Quality Chasm PITAC2001Transforming Health Care Through Information Technology NCVHS2001 NHII IOM2002The Future of the Public’s Health in the 21 st Century IOM2002Fostering Rapid Advances in Health Care: Learning from System Demos

8. 8 8 © 2005 NH i i ADVISORS “The committee believes that establishing this information technology infrastructure [NHII] should be the highest priority for all health care stakeholders.” -- Committee on Data Standards for Patient Safety: “Patient Safety: Achieving a New Standard for Care” Institute of Medicine, November, 2003 (Executive Summary)

9. 9 9 © 2005 NH i i ADVISORS Recent NHII Developments n 2003 l SNOMED licensed for all in U.S. l Federal government announces CHI standards for its own use (HL7, SNOMED, LOINC, DICOM, IEEE 1073, NCPDP SCRIPT) l Consensus National Agenda developed (at NHII 2003 meeting) n 2004 l President establishes NHII as goal for U.S. l Health Information Technology coordination office created (in HHS) l Dozens of communities exploring LHII implementation n 2003 l SNOMED licensed for all in U.S. l Federal government announces CHI standards for its own use (HL7, SNOMED, LOINC, DICOM, IEEE 1073, NCPDP SCRIPT) l Consensus National Agenda developed (at NHII 2003 meeting) n 2004 l President establishes NHII as goal for U.S. l Health Information Technology coordination office created (in HHS) l Dozens of communities exploring LHII implementation

10. 10 © 2005 NH i i ADVISORS II. What is the National Health Information Infrastructure (NHII)?

11. 11 © 2005 NH i i ADVISORS II. What is the NHII? A. Vision B. Elements C. Requirements A. Vision B. Elements C. Requirements

12. 12 © 2005 NH i i ADVISORS A. NHII Vision n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n “Anywhere, anytime health care information and decision support” n NOT a national database of medical records n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n “Anywhere, anytime health care information and decision support” n NOT a national database of medical records

13. 13 © 2005 NH i i ADVISORS A. NHII Vision (continued) n Includes organizing principles, systems, standards, procedures, and policies, e.g. l Communication networks l Message & content standards l Computer applications l Confidentiality protections n Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII n Includes organizing principles, systems, standards, procedures, and policies, e.g. l Communication networks l Message & content standards l Computer applications l Confidentiality protections n Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII

14. 14 © 2005 NH i i ADVISORS Four Domains for NHII Personal/ Consumer Public Health/ Community NHII Research/ Policy Clinical/ Provider

15. 15 © 2005 NH i i ADVISORS B. Elements of NHII (1 of 3) n Standards: Messaging & Content l Foundation for remainder of NHII n Electronic Health Record (EHR) Systems l Hospital l Outpatient n Consumer Health Information Systems l Personal health record l Electronic patient-provider communication l Support groups l Authoritative information n Standards: Messaging & Content l Foundation for remainder of NHII n Electronic Health Record (EHR) Systems l Hospital l Outpatient n Consumer Health Information Systems l Personal health record l Electronic patient-provider communication l Support groups l Authoritative information

16. 16 © 2005 NH i i ADVISORS Messaging Standards n What information is requested n Where is the information in the message n Example: “phone number” message l Pick up phone l Listen for dial tone l Dial number – If first digit is 1, then long distance, otherwise local n What information is requested n Where is the information in the message n Example: “phone number” message l Pick up phone l Listen for dial tone l Dial number – If first digit is 1, then long distance, otherwise local

17. 17 © 2005 NH i i ADVISORS Content Standards n A common, agreed-upon, detailed vocabulary for all medical terminology n Without a standard: l “high blood pressure” l “elevated blood pressure” l “hypertension” n With a standard l C487231, hypertension l Unambiguous meaning for both sender and receiver n A common, agreed-upon, detailed vocabulary for all medical terminology n Without a standard: l “high blood pressure” l “elevated blood pressure” l “hypertension” n With a standard l C487231, hypertension l Unambiguous meaning for both sender and receiver

18. 18 © 2005 NH i i ADVISORS B. Elements of NHII (2 of 3) n Ancillary health care systems l Pharmacy l Laboratory l Physical therapy l Post-acute care l Public health reporting n Communication/networking systems l Information moves with patient l Integrated information from all types of providers l Electronic consultation (telemedicine) n Ancillary health care systems l Pharmacy l Laboratory l Physical therapy l Post-acute care l Public health reporting n Communication/networking systems l Information moves with patient l Integrated information from all types of providers l Electronic consultation (telemedicine)

19. 19 © 2005 NH i i ADVISORS B. Elements of NHII (3 of 3) n Decision Support & Education l Professional l Consumer n Confidentiality protections l Information available on need-to-know basis l Authentication of all users l Encryption of data in transit l Audit trails of all usage l Penalties for violations n Decision Support & Education l Professional l Consumer n Confidentiality protections l Information available on need-to-know basis l Authentication of all users l Encryption of data in transit l Audit trails of all usage l Penalties for violations

20. 20 © 2005 NH i i ADVISORS C. NHII Requirements: Functions n Overall: “Anytime, anywhere health care information and decision support” n Immediate availability of complete medical record (compiled from all sources) to any point-of-care n Enable up-to-date decision support at any point of care n Enable selective reporting (e.g. for public health) n Enable use of tools to facilitate delivery of care (e.g. e-prescribing) n Allow patients to control access to their information n Overall: “Anytime, anywhere health care information and decision support” n Immediate availability of complete medical record (compiled from all sources) to any point-of-care n Enable up-to-date decision support at any point of care n Enable selective reporting (e.g. for public health) n Enable use of tools to facilitate delivery of care (e.g. e-prescribing) n Allow patients to control access to their information

21. 21 © 2005 NH i i ADVISORS C. NHII Requirements: Implementation Strategy n No national database or identifier n Alignment of incentives n Allow each care facility to maintain its own data n Minimize cost & risk n Use proven implementation strategies (where possible), e.g. incremental approach l Each implementation step benefits all participants l Implementation scope coincides with benefits scope n No national database or identifier n Alignment of incentives n Allow each care facility to maintain its own data n Minimize cost & risk n Use proven implementation strategies (where possible), e.g. incremental approach l Each implementation step benefits all participants l Implementation scope coincides with benefits scope

22. 22 © 2005 NH i i ADVISORS III. How Can IT Help Address Current Health Care Problems?

23. 23 © 2005 NH i i ADVISORS III. How can IT help address current health care problems? A. Improving Healthcare Delivery at Point of Care (Improving Quality) l Complete patient information l Decision support B. Reducing Costs & Achieving Efficiencies l Eliminate duplicate tests & imaging l Eliminate duplicate communication channels (labs, x-rays, etc.) C. Support Public Health Initiatives & Biosurveillance l Automated disease reporting l Automated syndrome reporting A. Improving Healthcare Delivery at Point of Care (Improving Quality) l Complete patient information l Decision support B. Reducing Costs & Achieving Efficiencies l Eliminate duplicate tests & imaging l Eliminate duplicate communication channels (labs, x-rays, etc.) C. Support Public Health Initiatives & Biosurveillance l Automated disease reporting l Automated syndrome reporting

24. 24 © 2005 NH i i ADVISORS A.1. Complete Patient Information n Patients treated by multiple providers n Records often unavailable (even within single care organization) n When available, information in paper records not easily organized for use n Result: Information for care largely dependent on patient memory n Outcome: errors, overuse, underuse n Patients treated by multiple providers n Records often unavailable (even within single care organization) n When available, information in paper records not easily organized for use n Result: Information for care largely dependent on patient memory n Outcome: errors, overuse, underuse

25. 25 © 2005 NH i i ADVISORS A.2. Decision Support n RAND: only 55% of recommended care delivered n Widespread application of new medical research results takes average of 17 years n Clinicians know what needs to be done, but 100% accurate application of knowledge is cognitive impossibility n When reminded, clinicians demonstrate greatly improved compliance n RAND: only 55% of recommended care delivered n Widespread application of new medical research results takes average of 17 years n Clinicians know what needs to be done, but 100% accurate application of knowledge is cognitive impossibility n When reminded, clinicians demonstrate greatly improved compliance

26. 26 © 2005 NH i i ADVISORS B. Reducing Costs Net National Savings Community Health Information Exchange Outpatient EHR Inpt EHR Source: Center for Information Technology Leadership, Partners Health Care, Harvard (2004) TOTAL $121.04 ~10 ~44 ~77 TOTAL $131+

27. 27 © 2005 NH i i ADVISORS C. Impact of Surveillance on BT Mortality Time Number Dead Animal or Human Indicators 10 5 (Linear) Victims Directly Exposed = 0 Fatalities With Early Warning and an Informed Public Health Response Fatalities With Traditional Public Health Response Effective Treatment Period Surveillance Traditional Disease Detection Phase II Acute Illness Phase I Initial Symptoms t Modified from chart developed by Hopkins Bioterrorism Preparedness Center

28. 28 © 2005 NH i i ADVISORS IV. How Does a Community Health Information Exchange System Work?

29. 29 © 2005 NH i i ADVISORS Clinical Encounter Index of where patients have records Temporary Aggregate Patient History Patient Authorized Inquiry Hospital Record Laboratory Results Specialist Record Patient data delivered to Physician LHII System Records Returned Requests for Records Community Clinician EHR System Encounter Data Stored in EHR Pointer to Encounter Data Added to Index

30. 30 © 2005 NH i i ADVISORS Index of where patients have records Temporary Aggregate Patient History Authorized Inquiry from LHII Hospital Record Laboratory Results Specialist Record Patient data delivered to other LHII LHII System Records Returned Requests for Records U.S. another LHII

31. 31 © 2005 NH i i ADVISORS Advantages of LHII Approach n Existing HII systems are local n Health care is local  benefits are local n Facilitates high level of trust needed n Easier to align local incentives n Local scope increases probability of success n Specific local needs can be addressed n Can develop a repeatable implementation process n Parallel implementation  more rapid progress n Use of standards allows connectivity between LHIIs  NHII n Existing HII systems are local n Health care is local  benefits are local n Facilitates high level of trust needed n Easier to align local incentives n Local scope increases probability of success n Specific local needs can be addressed n Can develop a repeatable implementation process n Parallel implementation  more rapid progress n Use of standards allows connectivity between LHIIs  NHII

32. 32 © 2005 NH i i ADVISORS V. Key Issues in NHII / LHII Progress

33. 33 © 2005 NH i i ADVISORS VI. Key Issues in NHII/LHII Progress A. Key enablers for effective health IT B. Key issues in developing a Health Information Exchange (HIE) C. Strategic principles to guide HIE development A. Key enablers for effective health IT B. Key issues in developing a Health Information Exchange (HIE) C. Strategic principles to guide HIE development

34. 34 © 2005 NH i i ADVISORS A. Key enablers for effective health IT 1. Electronic Health Records (EHRs) 2. Community Health Information Exchange 1. Electronic Health Records (EHRs) 2. Community Health Information Exchange >>> Requires Reimbursement Reform

35. 35 © 2005 NH i i ADVISORS A. Key enablers for effective health IT (continued) 3. Interoperability l What exactly is it? l How will we get it? l Many activities in progress – CCHIT - Certification Commission for Health Information Technology (HIMSS, AHIMA, The Alliance) – Standards Organizations (HL7, ASTM, X12, SNOMED [CAP]) – EHRVA - EHR Vendor Association – Systemic Interoperability Commission (part of MMA) 3. Interoperability l What exactly is it? l How will we get it? l Many activities in progress – CCHIT - Certification Commission for Health Information Technology (HIMSS, AHIMA, The Alliance) – Standards Organizations (HL7, ASTM, X12, SNOMED [CAP]) – EHRVA - EHR Vendor Association – Systemic Interoperability Commission (part of MMA)

36. 36 © 2005 NH i i ADVISORS B. Key issues in developing a Health Information Exchange (HIE) 1. Buy- In 2. Governance 3. Ownership of Information 4. Finance 5. Technology 1. Buy- In 2. Governance 3. Ownership of Information 4. Finance 5. Technology

37. 37 © 2005 NH i i ADVISORS B. Key issues in developing a Health Information Exchange (HIE) 1. Buy- In  Include all stakeholders  Understand stated and unstated interests  Positive and negative persuasion o Positive: self-interest, community interest o Negative: public perception of non-cooperation 1. Buy- In  Include all stakeholders  Understand stated and unstated interests  Positive and negative persuasion o Positive: self-interest, community interest o Negative: public perception of non-cooperation

38. 38 © 2005 NH i i ADVISORS B. Key issues in developing a Health Information Exchange (HIE) 2. Governance  New organization often needed  All stakeholders represented  Consensus decision-making  Separate privacy oversight board 2. Governance  New organization often needed  All stakeholders represented  Consensus decision-making  Separate privacy oversight board

39. 39 © 2005 NH i i ADVISORS B. Key issues in developing a Health Information Exchange (HIE) 3. Ownership of Information  Endless battle - no winners  Transform to “access” o Patient information needs to be available for care o Use of available information is well-established principle o Withholding needed patient information untenable 3. Ownership of Information  Endless battle - no winners  Transform to “access” o Patient information needs to be available for care o Use of available information is well-established principle o Withholding needed patient information untenable

40. 40 © 2005 NH i i ADVISORS B. Key issues in developing a Health Information Exchange (HIE) 4. Finance  Grants may impair sustainability  “Stakeholders” must have a real “stake” (by contributing $$)  Payments for operations should come from those who benefit 4. Finance  Grants may impair sustainability  “Stakeholders” must have a real “stake” (by contributing $$)  Payments for operations should come from those who benefit

41. 41 © 2005 NH i i ADVISORS B. Key issues in developing a Health Information Exchange (HIE) 5. Technology  Should not drive initiative  Don’t put technologists in charge  Use proven products and techniques (“Does it work?”)  Test and train  Overcommunicate 5. Technology  Should not drive initiative  Don’t put technologists in charge  Use proven products and techniques (“Does it work?”)  Test and train  Overcommunicate

42. 42 © 2005 NH i i ADVISORS C. Strategic principles to guide HIE development 1. Learn from others 2. Build consensus 3. Implement incrementally 4. Do easy projects first 5. Make each step self-sustaining 6. Gradual implementation of comprehensive system 1. Learn from others 2. Build consensus 3. Implement incrementally 4. Do easy projects first 5. Make each step self-sustaining 6. Gradual implementation of comprehensive system

43. 43 © 2005 NH i i ADVISORS Mission: Stop flying blind by …

44. 44 © 2005 NH i i ADVISORS … adding data-driven guidance

45. 45 © 2005 NH i i ADVISORS Questions? William A. Yasnoff, MD, PhD, FACMI william.yasnoff@nhiiadvisors.com 703/527-5678