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  

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

Office of the National Coordinator for Health Information Technology

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The Role of Health Information Technology

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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.  

How I learned to practice medicine:

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How my children will practice medicine:

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More practically:

 EHR:  

 HIE:      Electronically  capturing    Exchanging  
and  processing   information  about   patients  

   

 CDS:  

health   information  

 Improved  care   decisions    

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Health Information Exchange (HIE)

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EXCHANGING PATIENT DATA

Document/Message   Standards   Vocabulary  Standards  

Directories  and  Certificates  

Security  and  Trust   relationships  

Delivery  Protocols  
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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  
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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.  

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Growth in Use of Advanced Imaging under Medicare, 1995–2005

NEJM  Volume  361:841-­‐843  
Office of the National Coordinator for Health Information Technology

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Outpatient CT examination volumes
#  outpatient  CT  exams  

#  ordered  via  CPOE  

SOURCE:  Sistrom  C  L  et  al.  Radiology  2009;251:147-­‐155  

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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)    

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Systematic Review Process
Search  yields  baseline  of  4,193   ar;cles  printed  in  English   1,264  excluded  by  .tle   plus  the  abstract   2,692  excluded  by  .tle  

269  focused   on  adop.on  

64  focused   on  privacy   or  security  

231  arYcles  flagged   for  inclusion  

43  Excluded   a>er  further   review1  

34  Reviews   excluded   from   analyses  

174  Cost   154  Ar;cles   and  Benefit   on  Costs   and  Benefits   Ar;cles  

101  in  USA  

1  =  E.g.  reviewers  determined  arYcle  did  not  address  a  relevant  aspect  of  health  IT  or  it  lacked  outcomes  

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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  

US EHR Adoption

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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.    

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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  

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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.    

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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.  
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HITECH FRAMEWORK: MEANINGFUL USE

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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.   – Hospitals:  $2M  bonus  plus  extra  DRG   payments.   •  Support  for  adoption:   – $2  billion  to  Office  of  National  Coordinator  for   Health  Information  Technology  (ONC).  
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•  Penalties  starting  in  2015.  

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  

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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  
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Privacy and Security as a Foundation.
Health  IT  Outcomes  

Privacy  &   Security  

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

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Conceptual Approach to Meaningful Use

2015   2013   2011  

Capture  /   share  data  

Advanced   care   processes   with  decision   support  

Improved   Outcomes  

31   Healthit.hhs.gov  
Office of the National Coordinator for Health Information Technology

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

Eligible Hospitals (EHs) 24 8 16 14 5 out of 10 90 days 1 Year
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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.  
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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.  
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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.  
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Technology Adoption
WILL  THE  STETHOSCOPE  EVER  COME  INTO  GENERAL  USE  IN     CLINICAL  MEDICINE?   A  STRONGLY  NEGATIVE  VIEW  EXPRESSED  IN  1821  

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QUESTION & ANSWER

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