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  

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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  information.  

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How I learned to practice medicine:

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How my children will practice medicine:

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More practically:

 HIE:      Exchanging  health  information  

 EHR:        Electronically  capturing  and  processing  information  about  patients  

 CDS:    Improved  care  decisions    

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Health Information Exchange (HIE)

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EXCHANGING PATIENT DATA

Vocabulary  Standards   Delivery  Protocols  

Security  and  Trust  relationships  

Document/Message  Standards  

Directories  and  Certificates  

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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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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.  

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  

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

NEJM  Volume  361:841-­‐843  

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Outpatient CT examination volumes

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

#  ordered  via  CPOE  

#  outpatient  CT  exams  

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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)     15  

Search  yields  baseline  of  4,193  ar;cles  printed  in  English  

2,692  excluded  by  .tle  

1,264  excluded  by  .tle  plus  the  abstract  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  and  Benefit  Ar;cles  

154  Ar;cles  on  Costs  

and  Benefits  

101  in  USA  

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

Systematic Review Process

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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).  

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“Mixed”  findings  were  positive  overall,  but  at  least  one  specific  outcome  was  negative  

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   20  

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  

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.  

•  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).  

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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.

Privacy  &  Security  

Health  IT  Outcomes  

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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  &  Family  

Engagement  

Coordinated  Care  

Quality,  Safety  &  Efficiency  

Privacy  &  Security  

Improved  Public  &  

PopulaYon  Health  

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

Conceptual Approach to Meaningful Use

Capture  /  share  data  

Advanced  care  processes  with  decision  support  

Improved  Outcomes  

2011  

2013  

2015  

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Eligible Professionals

(EPs)

Eligible Hospitals

(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

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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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