ONC Presentation

1. Health Information Technology
Bringing Health Information to Life
DAVID
BLUMENTHAL,
MD,
MPP
National
Coordinator
of
Health
Information
Technology
US
Department
of
Health
&
Human
Services
09.22.10

2. Today’s Agenda
• The
Problem.
• The
Solution.
• The
Role
of
HIT.
• The
Barriers.
• HITECH
Act.
• Professionalism
2

3. A Familiar Story: A Broken System
COST
• $Billions
in
unnecessary
and
wasteful
spending.
• Overuse
puts
patients
at
risk,
drains
resources,
and
makes
healthcare
less
accessible
and
less
effective.
QUALITY
• Despite
rapid
advances,
thousands
of
patients
die
each
year
from
medical
error
COVERAGE
• 46.8
million
uninsured;
many
more
underinsured
3
Office of the National Coordinator for Health Information Technology

4. The Role of Health
Information Technology
4

5. HIT: The circulatory system of medicine.
 Information:
lifeblood
of
medicine.
 We
manage
information
as
Hippocrates
did
in
400
B.C.
 HIT:
the
most
effective
technologies
for
recording,
transmitting
and
processing
5
information.

6. How I learned to practice medicine:
6

7. How my children will practice medicine:
7

8. More practically:
EHR:
HIE:
CDS:
Electronically
capturing
Exchanging
Improved
care
and
processing
health
decisions
information
about
information
patients
8

9. Health Information Exchange
(HIE)
9

10. EXCHANGING PATIENT DATA
Document/Message
Security
and
Trust
Directories
and
Certificates
Standards
relationships
Vocabulary
Standards
Delivery
Protocols
10

11. Information Exchange is a Team
Sport
• The
health
care
community
needs
to
work
together
socially,
economically
and
politically
to
create
HIE
• The
problem
is
not
software,
but
humanware:
competition,
mistrust,
and
the
lack
of
a
business
case
for
HIE
11

12. Clinical Decision Support (CDS)
• Uses
algorithms,
order
sets,
guidelines,
and
institutional
policy
to
encourage
evidence-­‐based
practices
• Helps
providers
improve
documentation,
clinical
decision
making,
and
guideline
compliance,
while
reducing
utilization
of
care.
• Allows
CPOE
to
change
practice:
– Validates
order
appropriateness
– Verifies
similar
order
has
not
been
placed
– Able
to
stratify
based
on
patient
characteristics
Wilson
GA,
McDonald
CJ,
McCabe
GP=
Jr.
The
effect
of
immediate
access
to
a
computerized
medical
record
on
physician
test
ordering:
a
controlled
clinical
trial
in
the
emergency
room.
Am
J
Public
Health
1982;72(7):698-­‐702.
12

13. Growth in Use of Advanced Imaging under
Medicare, 1995–2005
NEJM
Volume
361:841-­‐843
13
Office of the National Coordinator for Health Information Technology

14. Outpatient CT examination volumes
#
outpatient
CT
exams
#
ordered
via
CPOE
SOURCE:
Sistrom
C
L
et
al.
Radiology
2009;251:147-­‐155
14

15. ONC Review of Recent Literature
• Updates
and
expands
Goldzweig
et
al.
(2009)
review
of
health
IT
studies
published
2004
-­‐2007
• Focuses
on
peer-­‐reviewed
articles
dealing
with
the
costs
and
benefits
of
health
IT
since
early
2007
• Focuses
on
individual
outcomes
within
articles
and
articles’
overall
conclusions.
Outcomes
include:
– Quality
of
care
– Efficiency/costs
of
care
– Provider
and/or
patient
satisfaction.
• Results
are
still
preliminary
Buntin,
Hoaglin,
Burke,
Blumenthal
(in
process
–
do
not
cite
without
permission)
15

16. Systematic Review Process
Search
yields
baseline
of
4,193
2,692
excluded
by
.tle
ar;cles
printed
in
English
1,264
excluded
by
.tle
64
focused
269
focused
plus
the
abstract
on
privacy
on
adop.on
or
security
231
arYcles
flagged
for
inclusion
43
Excluded
34
Reviews
174
Cost
154
Ar;cles
101
in
USA
a>er
further
excluded
and
Benefit
on
Costs
review1
from
and
Benefits
Ar;cles
analyses
16
1
=
E.g.
reviewers
determined
arYcle
did
not
address
a
relevant
aspect
of
health
IT
or
it
lacked
outcomes

17. Preliminary Findings
• Vast
majority
(142/154
non-­‐review
articles,
92
percent)
positive
or
mixed
finding*
• More
comprehensive
studies
that
evaluated
both
efficiency
and
effectiveness
of
care
are
overwhelmingly
more
positive
(p
=
.0001)
than
those
that
did
not.
• Studies
evaluating
EHRs
are
also
more
positive
than
those
that
did
not
(e.g.
an
ERx
stand-­‐alone)
(p
=
.03).
“Mixed”
findings
were
positive
overall,
but
at
least
one
specific
outcome
was
negative
17

18. US EHR Adoption
18

19. Current Levels of Adoption by
Ambulatory Physicians
No
Functional
EHR
80%
•
37%
intend
to
install
a
new
EHR
system
or
replace
current
system
within
the
next
3
years.
Source:
2009
NaYonal
Ambulatory
Medical
Care
Survey
(NAMCS)
Electronic
Medical
Records
Supplement.
19

20. Hospital adoption.
• Hospitals
(2009):
– 13.5
percent
basic.
– 2.7
percent
comprehensive.
– Large
percentages
with
EHR
components.
Source:
2009
American
Hospital
AssociaYon
(AHA)
IT
Supplement
20

21. Major Barriers to EHR Adoption
Percent
of
physicians
reporYng
a
“major
barrier”
Source:
DesRoches
CM
et
al.
Electronic
health
records
in
ambulatory
care—a
naYonal
survey
of
physicians.
N
Engl
J
Med.
359(1):50-­‐60,
2008
Jul
3.
21

22. The Federal Government’s
Response: HITECH ACT
• Part
of
American
Recovery
and
Reinvestment
Act
of
2009
(ARRA).
• Addresses
major
barriers
to
adoption,
and
much
more.
– Technical
assistance,
support
and
better
information.
– Money/market
reform.
– Health
Information
Exchange
– Privacy
and
security.
22

23. HITECH FRAMEWORK: MEANINGFUL USE
23

24. Financial provisions:
• Medicare/Medicaid
incentives:
$9-­‐27
billion
starting
2011.
– Reward
the
“MEANINGFUL
USE”
OF
EHRs
– Physicians:
$44,000/$63,750
over
5-­‐10
years.
• Penalties
starting
in
2015.
– Hospitals:
$2M
bonus
plus
extra
DRG
payments.
• Support
for
adoption:
– $2
billion
to
Office
of
National
Coordinator
for
Health
Information
Technology
(ONC).
24

25. Technical Assistance with Adoption
• $693
million
– 60
Regional
Extension
Centers.
– Health
Information
Technology
Research
Center.
• $118
million
– Training
over
40,000
new
health
IT
support
personnel
25

26. Technical Assistance with Health
Information Exchange
• $564
million
– Promote
HIE
through
State
leadership
• Other
ONC
Programs
and
Policies
– Regulation
specifying
standards
and
certification
criteria
– Regulation
creating
certification
process
– Development
of
technical
basis
for
a
Nationwide
Health
Information
Network
26

27. Privacy and Security as a
Foundation.
Health
IT
Outcomes
Privacy
&
Security
27

28. FEDERAL GOVERNMENT’S ROLE:
Privacy & Security
• Banned
sale
of
health
information
without
consent.
• Ongoing
audit
trail
requirements
• Federal
activity
in
enforcement
• Expanded
patient
rights
to
access
their
information
• Innovative
encryption
technology
to
prevent
breaches
28

29. Pillars of Meaningful Use
Patient
&
Improved
Coordinated
Quality,
Family
Privacy
&
Public
&
Care
Safety
&
Engagement
Security
PopulaYon
Efficiency
Health
29

30. 30

31. Conceptual Approach to Meaningful Use
2015
2013
Improved
Outcomes
Advanced
2011
care
processes
Capture
/
with
decision
share
data
support
31
Healthit.hhs.gov
31
Office of the National Coordinator for Health Information Technology

32. Eligible Eligible
Professionals Hospitals
(EPs) (EHs)
Objectives and Measures 25 24
Measures requiring “Yes/No” Reporting 7 8
Measures requiring Numerator/Denominator Reporting 18 16
“Core” Set Criteria 15 14
“Menu” Set Criteria (must choose at minimum) 5 out of 10 5 out of 10
Reporting Period Year One of Application 90 days 90 days
Subsequent Reporting Period(s) 1 Year 1 Year
32

33. Remaining challenges
• HITECH
a
great
start,
but
many
challenges
to
implementation.
– Getting
regional
centers
up
and
running.
– Assuring
infrastructure
for
exchange.
– Training
necessary
workforce.
– Sustaining
economic
incentives
for
adoption
and
meaningful
use.
• Role
of
overall
health
reform.
– Defining
future
stages
of
meaningful
use
• Keep
providers
on
the
escalator
to
more
sophisticated
and
beneficial
uses
of
HIT.
33

34. Professionalism and HIT
• Key
components
of
professionalism.
– Unique
competence,
based
in
science
and
demonstrated
capability.
– Self-­‐governance.
– Moral/ethical
commitments.
• Within
10
years,
use
of
EHRs
will
be
a
core
technical
competency.
34

35. Professionalism will drive HIT:
• Primary
care
specialty
societies
have
all
endorsed
use
of
HIT
as
an
element
of
maintenance
of
certification.
• I
predict:
– ACGME.
– Licensing
Boards.
– AMA/AAMC
medical
school
accreditation
will
follow
suit.
35

36. Technology Adoption
WILL
THE
STETHOSCOPE
EVER
COME
INTO
GENERAL
USE
IN
CLINICAL
MEDICINE?
A
STRONGLY
NEGATIVE
VIEW
EXPRESSED
IN
1821
36

37. QUESTION & ANSWER
37