1. The Future of Health Data Standards and the Business Perspective: The National Health Information Infrastructure (NHII) Helga E. Rippen, MD, PhD, MPH Deputy Senior Advisor National Health Information Infrastructure Department of Health and Human Services Helga E. Rippen, MD, PhD, MPH Deputy Senior Advisor National Health Information Infrastructure Department of Health and Human Services Fifth Annual Public Health Data Standards Consortium Steering Committee Meeting Bethesda, Maryland; March 17, 2004

2. 2 2 “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)

3. 3 3 Overview I. Why does health care need NHII? II. What is NHII? III. How will the NHII Influence Standards? IV. Moving the NHII Forward with Standardization I. Why does health care need NHII? II. What is NHII? III. How will the NHII Influence Standards? IV. Moving the NHII Forward with Standardization

4. 4 4 I. 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

5. 5 5 Solution: Information Technology (IT) for Health Care n 20% of labs and x-rays done because prior results unavailable n 1 in 7 hospitalizations occur because information about patient not available n “NHII is required to make patient safety a standard of care” – IOM, 2003 n Ambulatory CPOE could save $44 B/yr n Potential net efficiency gain from use of information technology in health care: > $87 Billion/yr n 20% of labs and x-rays done because prior results unavailable n 1 in 7 hospitalizations occur because information about patient not available n “NHII is required to make patient safety a standard of care” – IOM, 2003 n Ambulatory CPOE could save $44 B/yr n Potential net efficiency gain from use of information technology in health care: > $87 Billion/yr

6. 6 6 II. What is NHII? n “Anywhere, anytime health care information and decision support” l Comprehensive knowledge-based network of interoperable systems l Capable of providing information for sound decisions about health when and where needed n NOT a central database of medical records n “Anywhere, anytime health care information and decision support” l Comprehensive knowledge-based network of interoperable systems l Capable of providing information for sound decisions about health when and where needed n NOT a central database of medical records

7. 7 7 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 Health Record (EHR) 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 Health Record (EHR) systems are only the building blocks, not NHII

8. 8 8 Four Domains of NHII Personal/ Consumer Public Health/ Community NHII Research/ Policy Clinical

9. 9 9 NHII Requirements: Functions 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 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

10. 10 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

11. 11 NHII 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 ~6 ~25 ~55 TOTAL $87

12. 12 Inpatient EHR Community Health Information Exchange Outpatient EHR Inpt EHR Benefits go to hospital Larger hospitals are investing Capital is obstacle for small & rural institutions ~6 ~25 ~55

13. 13 Outpatient EHR Community Health Information Exchange Outpatient EHR Inpt EHR Benefits go to payer No business case for physicians (especially small practices) Payer incentives needed (e.g. Maine) ~6 ~25 ~55

14. 14 Community Health Information Exchange Community Health Information Exchange Outpatient EHR Inpt EHR Substantial benefits to all First mover disadvantage Seed funding needed Focus of current Federal initiatives ~6 ~25 ~55

15. 15 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

16. 16 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

17. 17 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

18. 18 What will NHII Enable? 1.Linkage between medical care & public health (e.g. for bioterrorism detection) 2.Test results and x-rays always available  eliminate repeat studies 3.Complete medical record always available 4.Decision support always available: guidelines & research results 5.Quality & payment information derived from record of care – not separate reporting systems 6.Consumers have access to their own records 1.Linkage between medical care & public health (e.g. for bioterrorism detection) 2.Test results and x-rays always available  eliminate repeat studies 3.Complete medical record always available 4.Decision support always available: guidelines & research results 5.Quality & payment information derived from record of care – not separate reporting systems 6.Consumers have access to their own records

19. 19 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 l Post acute and long-term care 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 l Post acute and long-term care n Consumer Health Information Systems l Personal health record l Electronic patient-provider communication l Support groups l Authoritative information

20. 20 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)

21. 21 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

22. 22 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) 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) n Improve Quality of Care n Effectively Share Decision Support n Understand Health Care Costs n Better-informed Health Care Consumers

23. 23 III. How will the NHII Influence Standards? Personal/ Consumer Public Health/ Community NHII Research/ Policy Clinical Wide reach requires standards that are complementary and integrated

24. 24 Health Information is Complex Death Family Health Birth Clinical encounters Health events Environmental events Lifestyle Etc.... Public Health Research Individual health record

25. 25 Health Information is Complex Public Health Research Individual health record ConsumerHealthcare Decision Support

26. 26 Some Standard Requirements n Common vocabulary n Messaging standard n Security and authentification standards n Coding standards for decision support n Standards for health record portability n Common vocabulary n Messaging standard n Security and authentification standards n Coding standards for decision support n Standards for health record portability

27. 27 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

28. 28 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

29. 29 IV: Moving the NHII Forward with Standardization n Adoption of standards across government agencies (PHIN/CHI/FHA) l HL7, DICOM, IEEE 1073, NCPDP SCRIPT l SNOMED, LOINC n Facilitating standards development by HL7 l EHR functions l EHR interchange standard n Adoption of standards across government agencies (PHIN/CHI/FHA) l HL7, DICOM, IEEE 1073, NCPDP SCRIPT l SNOMED, LOINC n Facilitating standards development by HL7 l EHR functions l EHR interchange standard

30. 30 Questions? Helga E. Rippen, MD, PhD, MPH Helga.rippen@hhs.gov 202/205-8678 For more information about NHII http://aspe.hhs.gov/sp/nhii