Connie White Delaney is Professor & Dean, School of Nursing, University of Minnesota. She also serves as Director, Biomedical Health Informatics (BMHI), Associate Director of the CTSI-BMI, and Acting Director of the Institute for Health Informatics (IHI) in the Academic Health Center. Delaney is the first Fellow in the College of Medical Informatics to serve as a Dean of Nursing. Delaney is an appointee to the Health Information Technology Policy Committee, an advisory body established by the American Recovery and Reinvestment Act within the U.S. Government Accountability Office (GAO). Delaney serves on numerous boards, including the Board of the American Association of Colleges of Nursing, Board of LifeScience Alley, the American Medical Informatics Association (AMIA), Premiere Quest National Advisory Panel. ! She is an active researcher and writer in the areas of national standards development for essential nursing care and outcomes/safety data. She holds a BSN with majors in nursing and mathematics, MA in Nursing – Adult Health, Ph.D. Educational Administration and Computer Applications, and completed postdoctoral study in nursing & medical informatics at the University of Utah.

1. iHT2 Health IT Summit in Phoenix
Connie White Delaney, PhD, RN, FAAN, FACMI
May 18, 2011

2. welco
me Industry leaders & senior executives,
CIO, CMO, CMIO, Physician, Practice Manager,
VP and Director of IT
1. Discuss HIT challenges and potential
solutions in the months ahead.
2. Discuss leveraging data to drive evidence
based healthcare and improve outcomes
3. Discuss collaboration across care settings and
missions.

3. 4 Principles for Behavioral Change
1. Social norms
2. Foot in the Door
3. Reciprocity
4. “Diderot Effect”

5. Outcomes
Sustainability
transforming care to improve
4 Principles for outcomes
Behavioral Change manage transitions
decrease costs
1. Social norms assure care appropriateness
2. Foot in the Door engage in disease
3. Reciprocity prevention/health promotion
4. “Diderot Effect” people centered

6. 1. Social norms
2. Foot in the Door
3. Reciprocity
4. “Diderot Effect”

7. 1. Social norms
2. Foot in the Door
Robert Tagalicod, Robert Anthony, and Jessica Kahn 3. Reciprocity
HIT Policy Committee, January 10, 2012 4. “Diderot Effect”
Implementation Report (1/12)
States launched as of January 2012: 42
# of States that disbursed incentives: 33
VT ME
WA
MT ND NH
MN
MA Note: ME,
OR NY
ID SD
WI
RI MA, DE, VT
MI
WY PA CT and NY
IA
NE OH NJ have also
IN DE
NV
UT
IL
WV VA MD disbursed
CO
CA
KS MO KY
DC incentives
NC
TN as of 12/31
OK SC
AR
AZ NM
GA
MS AL
TX LA
FL
AK
Planning Territories
SMHPs Submitted AS
HI
SMHPs Final Approval CNMI
IAPDs Pending GU
IAPDs Approval PR
Launched USVI
8
http://www.cms.gov/EHRIncentivePrograms/ Incentives Disbursed

8. 1. Social norms
2. Foot in the Door
Robert Tagalicod, Robert Anthony, and Jessica Kahn 3. Reciprocity
HIT Policy Committee, January 10, 2012 4. “Diderot Effect”
December 2011 December 2011 YTD YTD
Providers Paid Payments Providers Paid Payments
Eligible Professional 4,997 $ 86,946,000 15,255 $ 274,590,000
Medicare Only Hospital 4 $ 5,600,870 38 $ 56,782,557
Medicare & Medicaid Hospital
(Medicare Payment) 189 $ 369,136,265 566 $ 1,052,839,955
TOTAL 5,190 $ 464,683,136 15,859 $ 1,384,212,512
For final CMS reports, please visit:
http://www.cms.gov/EHRIncentivePrograms/56_DataAndReports.asp 8

9. 1. Social norms
2. Foot in the Door
Robert Tagalicod, Robert Anthony, and Jessica Kahn
HIT Policy Committee, January 10, 2012
3. Reciprocity
4. “Diderot Effect”
Providers Paid by Month Providers Paid
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
9

10. 1. Social norms
2. Foot in the Door
Robert Tagalicod, Robert Anthony, and Jessica Kahn 3. Reciprocity
HIT Policy Committee, January 10, 2012 4. “Diderot Effect”
Incentive Payments by Month
$800,000,000 Incentive Payments
$700,000,000
$600,000,000
$500,000,000
$400,000,000
$300,000,000
$200,000,000
$100,000,000
$0
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

11. Providers Included in MU Analysis
Robert Tagalicod, Robert Anthony, and Jessica Kahn
HIT Policy Committee, January 10, 2012
At the time of the analysis:
• 33,595 Medicare EPs had attested
• 33,240 Successfully
• 355 Unsuccessfully (89 previously unsuccessful resubmitted)
• 842 Acute Care and Critical Access Hospitals had attested
• All successfully
• Official data should be sourced and cited from the CMS website,
updated monthly
(http://www.cms.gov/EHRIncentivePrograms/56_DataAndReports.asp)
11

12. Updated Work Plan for
Developing Recommendations for Stage 3 (Tang et al, 2012 )
• Nov 9: Reported on Oct 5 Hearing; input from HITPC
• Nov 30: Sec announced intent to delay stage 2 to 2014
– => IF we were to assume stage 3 begins 2 years after stage 2
(await NPRM and Final Rule), HITPC MU recommendations
would be needed by mid-2013
• Need lead time for HITSC work if relevant standards
need to be adopted or developed
– 4Q12 for HITSC-sensitive MU recommendations
– 2Q13 for policy-only MU recommendations
• January 2012 @ HITPC: Initial HITSC
recommendations for HITPC review related to quality
measure development
– Planned joint workshop with HITSC/ONC/CMS on Quality
Measures

13. Initial Recommendations for
HITSC
Group 1 for Immediate Action – Could Impact
Stage 2

14. Recommendations for HITSC
Rec 1: Certification of CQM Reports (Tang et al, 2012)
• Problem:
1. Many healthcare organizations use reporting systems (vs. EHRs) to
generate quality reports for public reporting and quality improvement
2. MU certification rules state that the healthcare organizations must
use the certified EHR to report the CQM measures to CMS
3. EHR vendors hardwire CQM calculations without knowing local
clinical workflows, causing workflow work arounds
4. Not all CQMs are relevant to all certified HIT systems
• Proposed Solution:
– HIT vendor products should be certified for all CQMs relevant to the
scope of the product
– Providers should be permitted to use non-certified systems to
generate CQM reports, as long as all the data used in the calculation
of the measure are derived from certified HIT systems
– All submitted CQMs are subject to audit
– CQM reporting systems should be tested (subject to audit) based on
a standardized test data set

15. Initial Recommendations for
HITSC
Group 2 – Longer Lead Time Required

16. Initial Recommendations for HITSC
Recommendation 2: “CQM Platform” (Tang et al, 2012)
• Problem:
1. Clinical Quality Measures (CQMs) are being “hard wired” into EHRs,
which require upgrades in order to implement or revise
2. EHR vendors are pre-defining data elements used in calculating
CQMs, which impact clinical workflows of clinicians
3. Healthcare organizations do not have an easy way to report on
quality-improvement measures (vs. just CQMs)
• Proposed Solution:
– By stage 3, EHR vendors should develop a “CQM platform" onto
which new and evolving CQMs can be added to an EHR without
requiring an upgrade to the EHR system.
– Longer term, such platforms should be capable of incorporating CQM
"plug-ins" that can be shared, and that allow organizations to localize
data fields that fit local work flow.
– We recommend that HITSC develop certification criteria to
encourage/require this CQM platform as part of MU

17. Initial Recommendations for HITSC
Rec 3: Patient-Reported Data and CQMs (Tang, 2012)
• Problem:
1. Most CQMs are written for clinicians, pertinent to diseases
2. Most CQMs do not incorporate information meaningful for consumers
• Proposed Solution:
– Some CQMs should incorporate patient-reported data and outcomes
– HIT vendors should develop secure, patient-friendly systems that
allow direct entry of patient-reported data that can be incorporated
into CQM reports
– Patients should be able to access CQM reports

18. Initial Recommendations for HITSC
Rec 4: Delta Measures (Tang et al, 2012)
• Problem:
1. Most CQMs report risk-adjusted population means
2. Patients seek measures that would apply to “people like me”
• Proposed Solution:
– Some CQMs should report on percent of patients improving (“delta
measures”) vs. only reporting risk-adjusted population means
– EHR vendors should be able to calculate delta measures

19. Follow-Up Actions on
New CQM Recommendations (Tang et al, 2012)
• Form joint HITPC/HITSC work group, including CMS,
ONC, CQM stakeholders
• Conduct hearing on longer term CQM actions (CQM
platform, new CQM concepts)
– QM supply chain
– QM consumer issues (informed by NCVHS February hearing
on Measures that Matter to Consumers)
– HIT vendor considerations
• All-day working session following hearing

20. Summary (Tang et al, 2012)
• Re: Certification Policies: We recommend that clinical
quality measures should be based on clinical data
from certified EHRs, and reported using standard
definitions, subject to audit. CQMs can be reported to
CMS from non-certified systems as long as the above
is true.
• Re: CQM Reporting: Vendor-neutral CQM platforms
that accept “CQM plug-ins” should be developed to
support evolving quality measurement
• Re: Patient-centered CQMs: New CQMs that are
meaningful to patients should be developed, and
patient-reported data should be captured and
reported using HIT

21. microscopic macroscopic
Clinical Consumer
Research Health
Informatics Informatics
Human Health
& Disease
[translational
bioinformatics]
molecular and tissues & individual populations
cellular processes organs patients

22. What is the CTSI?
CTSI is part of is part of a national Clinical and Translational
Science Award (CTSA) consortium created to accelerate
laboratory discoveries into treatments for patients. The CTSA
program is led by the National Institutes of Health's National
Center for Research Resources.

23. Health Knowledge Discovery & Dissemination
Community
Bench Practice
Bedside

24. CTSA Institutions, 2006 - 2011
NCRR Fact Sheet: Clinical and Translational Science Awards, Summer 2011, www.ncrr.nih.gov

25. CTSA UMN: What We Do
• Biomedical Informatics – Provides infrastructure, expertise, and training in
Biomedical Informatics.
• Clinical Translational Research Services – Provides research services,
support, and collaboration, including project management, research
coordination, clinical procedures, and biostatistics.
• Education, Training, and Research Career Development – Provides trainees
with opportunities to enhance quality and productivity.
• Office of Community Engagement for Health – Helps researchers link to
community interests and researcher partners.
• Office of Discovery and Translation - Develops novel research methods,
tools, and technologies.

27. U of Minnesota AHC Information Exchange (AHC IE)

28. Complete the Informatics Infrastructure
• Network All Care Sites
– Tie all Providers into the Health Information
Infrastructure
• Information Exchange
• Standards
• Link Care Teams
– All Health Workers plus Citizens/Patients as real
Partners on the Care Team

29. How do we achieve interoperable
healthcare information systems?
(Fridsma/ Humphreys, 2012)
Enable Curate a
stakeholders to portfolio of
come up with standards,
simple, shared services, and
solutions to policies that
common accelerate
information Team information
Accuracy &
exchange Compliance convened to exchange
challenges solve problem
Solutions
& Usability
Enforce compliance with
validated information exchange
standards, services and policies
to assure interoperability
between validated systems

30. How do we achieve interoperable
healthcare information systems?
(Fridsma/ Humphreys, 2012)
•Enable stakeholders to come up with simple, shared
solutions to common information exchange challenges
•Curate a portfolio of standards, services, and policies
that accelerate information exchange
•Enforce Compliance with validated information exchange
standards, services and policies to assure interoperability
between validated systems
Office of the National Coordinator for
30
Health Information Technology

31. Defining the Nationwide Health
Information Network
(Fridsma/ Humphreys, 2012)
A set of services, standards and
policies that enable secure health
information exchange over the Internet.
Office of the National Coordinator for
31
Health Information Technology

32. Diagram of NwHIN Portfolio 1.0
(Fridsma/ Humphreys, 2012)
INTEROPERABILITY
STACK
NwHIN Building Blocks
Vocabulary &
SNOMED-CT LOINC ICD-10 RxNorm
Code Sets
Consolidated Lab Results IG HL7 v.2.5.1
Content
CDA Quality Reporting Public Health
Structure Lab Results Reporting
Care Summaries
Transport SMTP-Direct SOAP-Secure
Based Exchange Web Services
Security X.509 - Digital
SAML
Certificates
DNS, LDAP- UDDI-Certificate
Certificate Provider
Services Certificate & Service
Authority Directories
Discovery Discovery
Office of the National Coordinator for
32
Health Information Technology

33. NLM Vocabulary Portfolio
(Fridsma/ Humphreys, 2012)
• Support maintenance, dissemination, free US use
– SNOMED CT
– LOINC
• Develop, maintain, disseminate, use in services research
– RxNorm (in cooperation with FDA, VA, drug information providers)
– MeSH, NCBI Taxonomy
– UMLS Metathesaurus (includes all above, HIPAA codes, many more)
• Create associated products, tools for users, e.g.,
– Vocabulary subsets, mappings, extensions
– Lexical & mapping tools, browsers, download sites, APIs
• Provide customer service
– Documentation, training materials, query response, licensing
• Contribute to US HIT standards coordination, policy development

34. ONC-NLM Interagency Agreement
(Fridsma/ Humphreys, 2012)
• Sets priorities for NLM vocabulary work in
support of meaningful use, e.g.,
– Additions to SNOMED CT, LOINC,
RxNorm
– High priority subsets and mappings
– Tools for value set development,
maintenance
– Enhanced APIs
• Provides additional funding for some
activities

35. • Health People 2020
• HealthyPeople.gov
• National Quality Strategy (March 21 2011)
• http://www.hhs.gov/news/press/2011pres/03/20110321a.ht
ml
• Improve the overall quality, by making health care more patient-centered,
reliable, accessible, and safe.
• Healthy People/Healthy Communities: Improve the health of the U.S.
population by supporting proven interventions to address behavioral,
social and, environmental determinants of health in addition to delivering
higher-quality care.
• Affordable Care: Reduce the cost of quality health care for individuals,
families, employers, and government.

36. National Quality Strategy

37. • Two goals of Partnership for Patients (HealthCare.gov)
April 12, 2011 are to:
• Keep patients from getting injured or sicker.
• 2013, preventable hospital-acquired conditions
decrease by 40% compared to 2010
• ~1.8 million fewer injuries to patients (> 60,000 lives
saved over three years)
• Help patients heal without complication.
• 2013, preventable complications during a transition
from one care setting to another decreased so that all
hospital readmissions reduced by 20% compared to
2010
• ~1.6 million patients would recover from illness
without suffering a preventable complication requiring
re-hospitalization within 30 days of discharge.

38. 21st Century Healthcare System
• Robust information infrastructure
• Widespread use of evidence-based medicine
• Aligned incentives & regulatory requirements
• Workforce skilled in:
– Evidence-based health
– Information &
communication technologies
– Process improvement
“
”

39. Future: Manage Change
Supported by Information Technology & Informatics
• Build Knowledgeable Teams • Manage the Base of
• Reinvent Workflow Knowledge
• Integrate Innovations • Complete the HIT &
• Remove ‘Outdated’ Practices Informatics Infrastructure
• Reduce Variation • Change Management &
Work Redesign
• Improve Safety/Quality while
Reducing Costs • Enhance Clinical Decision
Support

40. Policy
Federal Advisory Committees
• Health IT Policy Committee
– Makes recommendations to the National
Coordinator for Health IT on a policy framework for
the development and adoption of a nationwide
health information infrastructure, including
standards for the exchange of patient medical
information.
• Health IT Standards Committee
– Focuses on the standards to implement the
policies recommended by the Health IT Policy
Committee
Relationship to CMS

41. Vision [framework]
A system that is designed to generate and apply the best evidence for
the collaborative health care choices of each patient and provider; to
drive the process of new discovery as a natural outgrowth of patient
care; and to ensure innovation, quality, safety, and value in health care.
(Charter of the Institute of Medicine Roundtable on Value & Science-
Driven Health Care)

42. Health IT in the HHS Strategic Plan
HHS’ Strategic Plan
Health IT objective in HHS Plan Goal 1: Transform Health Care
Goal 2: Advance Scientific Knowledge and
Innovation
Goal 3: Advance the Health, Safety, and Well-
Being of the American People
Goal 4: Increase Efficiency, Transparency, and
Accountability of HHS Programs
Goal 5: Strengthen the Nation’s Health and
Human Services Infrastructure and Workforce
42

43. Federal Health IT Strategic Plan: 2011-2015
Federal Health IT Strategic Plan
Pre-decisional Draft – Do Not Disclose
43

44. Evolution of the Strategic Framework
to the Strategic Plan
Context
• The Framework was well underway prior to the release of the Affordable Care Act
Similarities:
• Largely the same priorities and vision
• Focus on Outcomes
Differences:
• Structurally different
• Reflects impact of the Affordable Care Act
• Makes empowering individuals a goal
Strategic Plan
Goal I: Achieve Adoption and Information
Exchange through Meaningful Use of Health IT
Goal II: Improve Care, Improve Population
Health, and Reduce Health Care Costs through
the Use of Health IT
Goal III: Inspire Confidence and Trust in Health
IT
Goal IV: Empower Individuals with Health IT to
Improve their Health and the Health Care System
Goal V: Achieve Rapid Learning and
Technological Advancement
44

45. 4 Principles for Behavioral Change
1. Social norms
2. Foot in the Door
3. Reciprocity
4. “Diderot Effect”