1. National Health Information Infrastructure (NHII) William A. Yasnoff, MD, PhD, FACMI Senior Advisor National Health Information Infrastructure Department of Health and Human Services William A. Yasnoff, MD, PhD, FACMI Senior Advisor National Health Information Infrastructure Department of Health and Human Services

2. 2 2 Overview I. What is NHII? II. Why hasn’t it already been done? III. Current Status of NHII IV. What can be done to accelerate NHII progress? V. NHII activities in HHS I. What is NHII? II. Why hasn’t it already been done? III. Current Status of NHII IV. What can be done to accelerate NHII progress? V. NHII activities in HHS

3. 3 3 I. What is NHII? n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n NOT a central 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 NOT a central database of medical records

4. 4 4 What is NHII? (continued) n Includes technologies, practices, relationships, laws, standards, and applications, e.g. l Communication networks l Message & content standards l Computer applications l Confidentiality protections n Individual provider Electronic Medical Record (EMR) systems are only the building blocks, not NHII n Includes technologies, practices, relationships, laws, standards, and applications, e.g. l Communication networks l Message & content standards l Computer applications l Confidentiality protections n Individual provider Electronic Medical Record (EMR) systems are only the building blocks, not NHII

5. 5 5 What will NHII enable? 1.Test results and x-rays always available  eliminate repeat studies 2.Complete medical record always available 3.Decision support always available: guidelines & research results 4.Real-time aggregation to detect patterns (e.g. bioterrorism detection) 5.Quality & payment information derived from record of care – not separate reporting systems 6.Consumers have access to their own records 1.Test results and x-rays always available  eliminate repeat studies 2.Complete medical record always available 3.Decision support always available: guidelines & research results 4.Real-time aggregation to detect patterns (e.g. bioterrorism detection) 5.Quality & payment information derived from record of care – not separate reporting systems 6.Consumers have access to their own records

6. 6 6 Three Domains of NHII Personal/ Consumer Clinical Community/ Public Health NHII

7. 7 7 Characteristics of NHII n Immediate availability of information for patient care l All patient records (NOT a database) l All relevant decision support n Availability of aggregate information l Real-time health monitoring l Developing decision support n Protecting privacy l Secure, confidential information n Government role: facilitate (not direct) l Voluntary standards (not regulatory like HIPAA) l Promote public-private collaboration n Immediate availability of information for patient care l All patient records (NOT a database) l All relevant decision support n Availability of aggregate information l Real-time health monitoring l Developing decision support n Protecting privacy l Secure, confidential information n Government role: facilitate (not direct) l Voluntary standards (not regulatory like HIPAA) l Promote public-private collaboration

8. 8 8 Elements of NHII (1 of 3) n Standards: Messaging & Content l Foundation for remainder of NHII n Electronic Medical Record (EMR) 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 Medical Record (EMR) 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

9. 9 9 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

10. 10 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

11. 11 Elements of NHII (2 of 3) n Ancillary health care systems l Pharmacy l Laboratory l Physical therapy l Home health 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 Home health 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)

12. 12 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

13. 13 Benefits of NHII n Monitor and Protect Public Health (e.g. rapid disease detection) n Improve Patient Safety l IOM: 44,000-98,000 preventable deaths/year (more than motor vehicle accidents, breast cancer, or AIDS) l Estimated cost of medication errors alone is over $76 billion/year n Improve Quality of Care n Effectively Share Decision Support n Understand Health Care Costs n Better-informed Health Care Consumers n Monitor and Protect Public Health (e.g. rapid disease detection) n Improve Patient Safety l IOM: 44,000-98,000 preventable deaths/year (more than motor vehicle accidents, breast cancer, or AIDS) l Estimated cost of medication errors alone is over $76 billion/year n Improve Quality of Care n Effectively Share Decision Support n Understand Health Care Costs n Better-informed Health Care Consumers

14. 14 Overwhelming Support for NHII 1. IOM: Computer-Based Patient Record (1991, updated 1997) 2. IOM: “To Err is Human” (2000) 3. National Research Council/Computer Science & Telecommunications Board: “Networking Health: Prescriptions for the Internet” (2000) 4. IOM: “Crossing the Quality Chasm” (2001) 1. IOM: Computer-Based Patient Record (1991, updated 1997) 2. IOM: “To Err is Human” (2000) 3. National Research Council/Computer Science & Telecommunications Board: “Networking Health: Prescriptions for the Internet” (2000) 4. IOM: “Crossing the Quality Chasm” (2001)

15. 15 Overwhelming Support for NHII (continued) 5. President’s Information Technology Advisory Committee: “Transforming Health Care Through Information Technology” (2001) 6. NCVHS report on NHII (2001): “The Committee believes that implementation of the NHII will have a dramatic impact on the effectiveness, efficiency, and overall quality of health and health care in the U.S.” [p. 2] 5. President’s Information Technology Advisory Committee: “Transforming Health Care Through Information Technology” (2001) 6. NCVHS report on NHII (2001): “The Committee believes that implementation of the NHII will have a dramatic impact on the effectiveness, efficiency, and overall quality of health and health care in the U.S.” [p. 2]

16. 16 II. Why hasn’t NHII already been done? n Health care is the largest sector of the economy that has not fully embraced information technology n Analogies to NHII in other sectors l Airline reservation systems l Banking information infrastructure – Access to funds via ATMs – Personal financial management l Auto industry: supply chain management l Retail industry: supply chain management, inventory control n Health care is the largest sector of the economy that has not fully embraced information technology n Analogies to NHII in other sectors l Airline reservation systems l Banking information infrastructure – Access to funds via ATMs – Personal financial management l Auto industry: supply chain management l Retail industry: supply chain management, inventory control

17. 17 Why hasn’t NHII already been done? (continued) n Health care information is very complex  IT systems more expensive and difficult to build n Health care is highly fragmented n Organizational and change management issues from IT systems are difficult to manage in clinical environment l Physicians are independent contractors l Lack of incentives for information sharing n Difficult to generate capital needed for IT investment l IT is regarded as an add-on cost, not an investment for competitive advantage n Health care information is very complex  IT systems more expensive and difficult to build n Health care is highly fragmented n Organizational and change management issues from IT systems are difficult to manage in clinical environment l Physicians are independent contractors l Lack of incentives for information sharing n Difficult to generate capital needed for IT investment l IT is regarded as an add-on cost, not an investment for competitive advantage

18. 18 III. Current Status of NHII n Islands of Information n Fragmentary & isolated elements of NHII exist l Uneven distribution l Lack of coordination l Minimal interoperability l Many “one-of-a-kind” systems n Much duplicative work l Limited dissemination of – Systems – Lessons learned n Islands of Information n Fragmentary & isolated elements of NHII exist l Uneven distribution l Lack of coordination l Minimal interoperability l Many “one-of-a-kind” systems n Much duplicative work l Limited dissemination of – Systems – Lessons learned

19. 19 Current Status of NHII (continued) n NHII requires: l Information capture: all medical information must be in machine readable form l Connectivity: electronic connections must exist among all providers and institutions l Communication standards: everyone must agree on how messages will be sent & received l Content standards: everyone must agree on the terms to be used and their meanings n NHII requires: l Information capture: all medical information must be in machine readable form l Connectivity: electronic connections must exist among all providers and institutions l Communication standards: everyone must agree on how messages will be sent & received l Content standards: everyone must agree on the terms to be used and their meanings

20. 20 IV. Accelerating NHII progress n Standards – Messaging and Content l Interoperability l Comparable Information n Coordination and Collaboration l Collecting and disseminating information l Facilitating cooperation n Encourage Capital Investment l Promote market-based solutions n Research l What are the problems of NHII? l Learn from prototype systems n Standards – Messaging and Content l Interoperability l Comparable Information n Coordination and Collaboration l Collecting and disseminating information l Facilitating cooperation n Encourage Capital Investment l Promote market-based solutions n Research l What are the problems of NHII? l Learn from prototype systems

21. 21 V. NHII activities in HHS n HIPAA l Transaction standards l Message format standards l Privacy & security rules n NCVHS activities l NHII blueprint and continued hearings l Continuing development of standards recommendations n Consolidated Health Informatics project n IOM report on actions to facilitate NHII deployment n HIPAA l Transaction standards l Message format standards l Privacy & security rules n NCVHS activities l NHII blueprint and continued hearings l Continuing development of standards recommendations n Consolidated Health Informatics project n IOM report on actions to facilitate NHII deployment

22. 22 NHII activities in HHS (continued) n Senior Advisor, NHII (in ASPE) l Inform – Disseminate NHII vision – Catalog NHII activities – Disseminate “lessons learned” l Collaborate with Stakeholders l Convene – National meetings on NHII – Start in 2003 l Voluntary process – no new regulations n Senior Advisor, NHII (in ASPE) l Inform – Disseminate NHII vision – Catalog NHII activities – Disseminate “lessons learned” l Collaborate with Stakeholders l Convene – National meetings on NHII – Start in 2003 l Voluntary process – no new regulations

23. 23 Questions? William A. Yasnoff, MD, PhD william.yasnoff@hhs.gov 202/690-7862