0. 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

1. 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

2. We’ve come a long way …

3. 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 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

4. A Remarkable Journey
Meaningful Use 4

5. 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 to 2011
Note: The 2012 data will be available in 2013
Source: CMS EHR Incentive Program Data

6. EHR Adoption of Eligible Providers by state as of 8-31-12

7. 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

8. 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

9. EHR Adoption of Eligible Hospitals by state as of 8-31-12

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

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

12. 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

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

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

15. 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

16. 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

17. 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

18. Exchange is increasing across the nation
18 states had more than 10% of their hospitals actively engaged in sharing health information electronically as of
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

19. 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.

20. “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

21. 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

22. 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

23. 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.

24. MU Attestations by Vendor (7/28/12)

25. 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

26. 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

27. 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

28. 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
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.

29. 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 for more.

30. 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

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

32. Taking the Blue Button nation-wide
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

33. ACTION: Making it easier for Patients to use Health IT
Surgeon General’s Healthy Apps Challenge
More at:
PHR Model Privacy
Notice
More at:
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.

34. 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:
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.

35. ATTITUDE: Health IT Animation
1 and 3 minute versions of the animation are available to use for patient teaching

36. Beat Down Blood Pressure
Consumer Video Challenge

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

38. What’s in Your Health Record
Consumer Video Challenge

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

40. 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

41. 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

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

43. 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

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

45. 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

46. 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

47. 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 .

49. THE FUTURE IS NOW.
THIS IS OUR TIME.
Thanks!