1. 1 HIT for LTC 101 A story of growth…

2. 2 Tuesday October 9, 2007 Session T-2 Presented by: Eileen Doll and Nathan Lake HIT for LTC 101

3. 3 Introduction Experiences Needs Ever growing To goals… Seeds of need Roots Trunk-IT components and knowledge EHR AND INFORMATION EXCHANGE Growth and expansion…and seeds IT tree HIT tree HIT trunk

4. 4 Seeds of need National Presidential Healthcare IT Goal “Within ten years, every American must have a personal electronic medical record” George W. Bush, “President Unveils Tech Initiatives for Energy, Health Care, Internet”, Minneapolis, MN, April 26, 2004 “Executive Order 13335: Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator” (a) The National Coordinator shall, to the extent permitted by law, develop, maintain, and direct the implementation of a strategic plan to guide the nationwide implementation of interoperable health information technology in both the public and private health care sectors that will reduce medical errors, improve quality, and produce greater value for health care expenditures. Executive Order, George W. Bush, April 27, 2004

5. 5 Seeds of need National Presidential Healthcare IT Goal Executive Order 13410--Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs “…in order to promote federally led efforts to implement more transparent and high-quality health care, it is hereby ordered as follows: …Purpose:…to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers. …to make relevant information available to these beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-Federal public sector. Consistent with the purpose of improving the quality and efficiency of health care, the actions and steps taken by Federal Government agencies should not incur additional costs for the Federal Government. George W. Bush August 22, 2006

6. 6 Needs… Timetables/plans for other national goals 2003—HIPAA 2006 and 2007—CCHIT certification for ambulatory EHR March 2008—CDC convene experts to discuss availability of local/regional cancer, immunization, trauma or other public health data base (registry) information June 2008– CDC facilitate development of national administrative or legal approaches to allow the routine and emergency inter-state data exchange of countermeasure and immunization information. October 2008—CDC to communicate the availability of these “registries” to assist local/regional public health agencies in emergency efforts December 2008—laboratories must be able to receive and route (exchange) all lab results March 2009—CDC to provide free software to local/regional public health agencies to manage “outbreaks” 2010—Institute of Medicine--E-prescribing implementation deadline 2014—”EHR for all” implementation

7. 7 Needs…THE GOAL—1 Presidential efforts, beginning in 2004, and Congressional efforts, and Consumer efforts, and Healthcare Professional efforts, and Governmental public health and emergency management efforts, and Private, insurance, and governmental payer efforts to Electronically Produce, store and Confidentially exchange healthcare information

8. 8 Needs…THE GOAL—2  To provide “better” care—to more people, who will live longer, and who will require and REQUEST increasingly more complicated care in multiple and varied care settings.  “Better” care includes a reduction of redundancies, errors, and improper billing— benefits to the patient, provider and payer.  These efficiencies yield financial benefits for all=“better value”  Financial benefits will allow us to CONTINUE to provide “better care”

9. 9 In the next 2 hours we will discuss… IT—(Information Technology)  Beginning seeds of need—how we got started…  Development and growth of roots into the “trunk” or body of IT—a review and definition of technology components— hardware, software, and STANDARDS– necessary to make a computer or system do its intended job.

10. 10 AND… Health Information Technology—a new tree develops…with many external forces  Shoots and branches—Terminology, acronyms, “buzz words”  Roots develop Trunk—HIT STANDARDS—types, purpose, development, approval, certification  Branching into—network information exchange— RHIN  NHIN

11. 11 AND… HOW—to be effectively involved in your facility or on other levels HOW—to decide what HIT solution is best for YOU When you come to the fork in the road…take it…

12. 12 And Be SMART©… TO SUCCEED, the fork must lead to… S TANDARDS based programs (software), and M ULTIPLE ways (hardware) to enter information and to connect; A CCEPTANCE by users; R ELIABLILITY, with T ECHNOLOGY updates or support when needed SMART © EDHC INC

13. 13 Tree—IT “Information technology (IT), as defined by the Information Technology Association of America (ITAA) is: "the study, design, development, implementation, support or management of computer-based information systems, particularly software applications and computer hardware." In short, IT deals with the use of electronic computers and computer software to convert, store, protect, process, transmit and retrieve information.”Information Technology Association of Americacomputers computer softwareconvertstore protectprocesstransmit retrieve Trunk-a body of IT knowledge

14. 14 Seeds… Seeds or weeds??

15. 15 Roots… Punch technology— used since the 1800’s Binary—1 0 Each punch represented DATA, a term first used in 1946

16. 16 Roots … IBM card—pink=1 st card of a set IBM—normal card 8 bits = 1 byte One of the first IT “STANDARD” s

17. 17 Roots… IBM 7030 “Stretch” computer Fastest computing 1961 to 1964 Photo used for educational purposes from IBM photo archives Information  punches  read  data  sort  analyze (computations)  information Scanned from the Annuals of the History of Computing, Vol. 3 #4 October 1981 UNIVAC-- UNIV ersal A utomatic C omputer

18. 18 Roots and growth…… Personal… Space Convenience Life is complicated… Can’t quite stretch for a “Stretch”…

19. 19 Roots  trunk SO… P ersonal C omputing was born… From pchistory.org MITS Altair 8080— the first PC— Personal Computer From www.old-computers.org The Victor 9000 PC

20. 20 Trunk… A PC, or any computer, is HARDWARE Something we can see, feel…or pound on if necessary…

21. 21 Trunk… What HARDWARE makes a MODERN PC? A “tower” which encases standardized key components and attaches to other components. A “hard drive”—which stores data and software In fashionable grey or black

22. 22 Trunk…ALL STANDARDIZED http://creativecommons.org/licenses/by-sa/2.5/ The MOTHERBOARD—this runs the show; all connections are routed in/onto/out via “slots” or “ports” to integrate and operate smoothly Photo Courtesy of Creative commons

23. 23 Trunk …standardized A peripheral is a device such as: A monitor (to display information), a Keyboard (or many other types of device such as an ATM with touch screen) to enter or input information; A modem (to transmit and receive external information either over phone line, DSL line, cable or satellite line), An accessory drive, either for CD, DVD, or “floppy”; A “mouse” or other device to make screen selections; A printer or other “output” device, such as speakers…

24. 24 Trunk…all standardized… HARDWARE— Items such as a Blackberry or other P ersonal D igital A ssistant; or the DSL, T1, phone line, or fiberoptic wire to PHYSICALLY “connect” a computer to other computers or to the internet; A transmitter for “wireless” radio communication; Any/all of the PHYSICAL interconnections and devices. Each piece can ONLY DO TASKS FOR WHICH THEY WERE MECHANICALLY DESIGNED IN A STANDARD WAY

25. 25 Trunk…NETWORK Small network—for a small business or small facility— “Thin client” terminal or PC workstations connect via wire or “wirelessly” to Central or “main” computer—stores all information and acts as the “server” Peripherals are shared Number of users limited by number of terminals From expertsolutionsinc.com MDSBusiness office Activities Admin

26. 26 Trunk…NETWORK Large multi-purpose networks… From expertsolutionsinc.com “Communicate” Bi-directional data exchange In a standard way Centralized data storage Data in multiple areas, can be shared—example of RHIO structure Data in ALL areas— can be connected to through a combination of routings—examples are internet, NHIN

27. 27 Trunk… D isc O perating S ystem One disc told the system what to do (SOFTWARE) One disc stored what was done 8 inch=10KB, 100,000 characters—about the size of a 38 page text document 5 ¼ inch— 100KB to 1.2 MB 3 ½-- 1.4 MB Evolution  growth  SMALLER=MORE STORAGE “Floppy” disc

28. 28 Trunk Uppercase AND lower case letters!! Software supplied on disk, cassette and cartridge! Memory—25KB, 20 KB ROM, 5 KB RAM Vi deo I nterface C hip Color 1980—cost=$300 =2007 ~ $900

29. 29 Trunk…MEMORY ROM=READ ONLY MEMORY  Used to store data which is infrequently changed, like how the system should “boot up” or start—this data REMAINS on the computer hard drive RAM= RANDOM ACCESS MEMORY  Used to find, use, and store many pieces of data as a software program “works” or processes data—the data is not saved when the computer is turned off  VIRTUAL MEMORY—if memory needs exceed RAM capabilities, the actual computer hard drive is used for random data storage RAM—more RAM=faster processing within the limits of the central processing unit—or “chip”

30. 30 Trunk--SOFTWARE SOFTWARE—a “language” which tells the hardware HOW TO RUN, WHAT TO DO WITH data and HOW TO STORE data  “System” software—the Operating System (OS) —MS DOS, Windows 98, Windows Vista, Mac OS, LINUX, UNIX. The OS also contains software programs or “drivers” which tell peripherals how to do their tasks…telling a printer how to actually print.  “Programming” software—gives the programmer tools to write our  “Application” software—which turns keyboard strokes or items touched on a screen or the button on a TV remote control into formatted bits/bytes of data. The data is stored in a specific way so that INFORMATION can be retrieved or specific actions taken.

31. 31 Trunk Software allows us to make a spreadsheet, connect to the internet, write and save a letter, or play Sims® 2 (or 25…). Software can be “proprietary”, “open source”, or mixed… Software operates using RAM!!! More complicated software=More instructions, more system work and more SPACE to work in… Excel ® AOL ® Lotus notes ® Microsoft Word ® Openoffice.org, UNIX, Firefox Windows Vista®

32. 32 Trunk—needs growing room! 1 bit=1 binary decision1 or 0—yes or no 8 bits=1 byte 10 bytes=one word 1 stored character fun 1024 bytes=1 KiloByte ~ The alphabet, plain text, 35 times 1024 KB=1 MegaByte ~2 minute mp3 music file (like from I-tunes ®); a small novel 1024 MG=1 GigaByte mp3 music~18 hrs, 1000 novels, a regular length movie at TV quality 1024 GB=1 TeraByte 4 TB 70 TB 50,000 trees  paper, and printed; est. amount of EHR data produced by a 250 bed NF in 9 months; Size of largest PC hard drive Library of Congress data content as of 5/2007—”high risk” digital material

33. 33 Trunk—grow faster… NO MORE HOT and BULKY MULTIPLE LARGE TRANSISTORS!! Central processing unit-- CPU One unit—or “chip” which contained multiple small transistors 1971—Intel—first PC “chip”—it could only add and subtract, at 4 bits at a time—but ALL ON ONE CHIP!!! The “microprocessor” erupted—silicon fed the “tree” ADD SPEED

34. 34 Trunk…rapid speedy growth 1965, clarified in 1975—Moore’s law—the rate of the ability to add transistors to chips doubles approx. every 2 years—a prediction 1989—80486—1,200,000 transistors 2004—Pentium 4—125,000,000 transistors This growth continues…and bits handled in larger numbers—from 4 bits, to 8 bits, to 32 bits and now 64 bits. Executing one billion instructions per second…

35. 35 Branches…need more So…in response… Congressman Al Gore invented the internet… Academia, business, and all people wanted to connect with each other and share their information… “…a series of tubes.” (Senator Ted Stevens) NOT!!

36. 36 Trunk Over telephone and later other “lines”… One large network—with many small networks and individuals— communicating via data exchange… MAGIC???

37. 37 Trunk—exchange data TCP/IP—the first, most important data exchange standard T ransmission C ontrol P rotocol and I nternet P rotocol… Developed and tested from 1973 Adopted by military in 1982 Adopted in January 1, 1983 as the standard for the internet Commercial use began in 1985 (Compuserve, later AOL in 1991) Without this standard, we would not be here…

38. 38 Trunk—network and internet communication standard—TCP/IP Connect—via some type of device—modem (telephone) or ethernet (cable, DSL)—each connection location has an Internet Protocol address—in a standardized format and standardized “language” based on type of connection Connection is routed to another IP address—standardized format A data request from one IP address to another is transmitted via a transmission control protocol (type of data guides which protocol)— each protocol has standard function and process The process or application puts data into standardized “packets” based on the type of data to be transported This standard will be changing!!! More users=more addresses needed Different devices

39. 39 TRUNK—Standards In the US—standards are developed by organizations in a field, trade, or industry—a part of our democratic history Each organization is comprised of individuals (“experts in the field”) who know what SHOULD BE (“best practice” for safety or efficiency) and the WORST of what actually is. Standard—represents the expected physical characteristic or performance—and can change

40. 40 Trunk—standards Standards CHANGE By “vintage” standards, Marilyn Monroe wore a size 12 dress--- In “modern” standards, she would wear a size 6 or 8… WHY??

41. 41 Trunk—Standards an agreed upon “norm”— “…an approved model…a rule or principle that is used as a basis for judgment…weight, measure, value, or comparison…authorized or approved…” (from Dictionary.com Unabridged (v 1.1). Random House, Inc.) STANDARDS for functional or operational parameters exist for just about everything A STANDARD IS TESTED and CERTIFIED by other organizations/agencies

42. 42 Trunk…Standards…USA NIST—“promote U.S. innovation and industrial competitiveness by advancing measurement science, standards, and technology in ways that enhance economic security and improve our quality of life.” From—www.nist.gov

43. 43 Trunk…Standards…USA ANSI—American National Standards Institute promotes and facilitates voluntary consensus standards and ensures their integrity. provides all interested U.S. parties with a neutral venue to come together and work towards common agreements Standards approved by other organizations may be submitted to ANSI for “final” approval and acceptance From—www.ansi.org ANSI cooperates internationally

44. 44 Trunk—Standards…international ISO—International Organization for Standardization “…world's largest developer and publisher of International Standards. …a network of the national standards institutes of 155 countries, one member per country, with a Central Secretariat in Geneva, Switzerland, that coordinates the system. …a non-governmental organization that forms a bridge between the public and private sectors. On the one hand, many of its member institutes are part of the governmental structure of their countries, or are mandated by their government. On the other hand, other members have their roots uniquely in the private sector, having been set up by national partnerships of industry associations. …enables a consensus to be reached on solutions that meet both the requirements of business and the broader needs of society. ISO forms a bridge between the public and private sectors.” From—www.iso.org

45. 45 Trunk—IT standards Mother and babies.jpg—info Info in STANDARD DATA SYMBOL STANDARD DATA ORDER Info out ‹#÷äQE1…Q@Q@Q@Q@Q@Q@Q @Q@Q@Q@Q@Q@Q@Q@Q@Q@Q @Q@Q@Q@Q@Q@Q@Q@Q@Q@Q @Q@Q@Q@Q@Q@Q@Q@Q@R1À 4?›Ç¡¦ù˃֩ê:¤]Œ×W2Ç1©%å p‹ŸLšùïÆ¿´>¨yö:5¤v’ckÍâVqþÏ2’ ‰QŒ¤{OŒ¾$h>´/¨^§œ~å¬8’ i \×¾gñßÄÿ?ˆ7#í±[$¹0x$ŽM§ ³æWR݃¢h³ø‡X1@²K<Ì<Éãˆ6 Iî@¾ðÀí3I+{{,·wG‘¹J*ý?5“– ¥I$yƒþk/¸F“[Xdn— ǶQ¹ÿ?€â½º„PŦÙØ}®ûʍÖG 6"à©È÷?Ä~"½ÞÔ[ÆŠ¤£$’JS=þ µ©˜Ø"1Fƒ$àÏÒ¸ŸŒvO{à½E#Ÿ! Æç}½«º? DATA

46. 46 Trunk—IT Standards… STANDARDS tell a software program how to convert entered information  data  PRODUCE  STORE/“SAVE” A FILE ON THE DISK The STANDARD file “type” is indicated at the end of the file—the file EXTENSION STANDARDS tell a software program how to “open” a data file  convert  display information SAME AS original, based on the file type Data in a file with the “.jpeg” or “.jpg” extension (a STANDARD developed by the 'Joint Photographic Experts Group’ a member of ISO) IS ALWAYS STORED USING THE SAME STANDARD SYMBOL/S AND ALWAYS IN THE SAME STANDARD ORDER INTEROPERABILITY INTEGRATED 

47. 47 Trunk—IT Interoperability INTEROPERABLE programs or systems “talk” to each other—they “communicate” following exact STANDARDS Information IN, Information OUT INTEROPERABLE = COMPATIBLE INTEGRATED = Built in—act as one SOFTWARE—“bells and whistles”, “look”, “feel”=“USER FRIENDLY” If a SOFTWARE program doesn’t produce the expected STANDARD result, no matter how “user- friendly”, it cannot be used !! ???????????????????????????????????????????????????????????

48. 48 Trunk…HIT H ealth I nformation T echnology “The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making.” (D. Brailer, ONCHIT, HHS, 2004)

49. 49 One goal… From--http://www.flickr.com/photos/juhansonin/393271975/in/set-72057594067707294—a public file

50. 50 Trunk…EHR An EHR … (1) longitudinal collection of Electronic Health information for and about persons, where health information is defined as information pertaining to the health of an individual or health care provided to an individual; … And…(4) support of efficient processes for health care delivery. Critical building blocks of an EHR system are the electronic health Records (EHR) maintained by providers (e.g., hospitals, nursing homes, ambulatory settings) and by individuals (also called personal health records).” PHR IOM report to Agency for Healthcare Research and Quality (AHRQ), July, 2003

51. 51 Trunk…EHR “…a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting.” Healthcare Information and Management Systems Society

52. 52 Broken branch??… EMR=Electronic medical record—refers to an institution’s or provider’s own record of medical care for a patient May or may NOT meet the standards for EHR…

53. 53 Trunk…Standards for WHAT??? Content—What information should be included, eg., lab results, x-ray results, narrative notes, history, physical findings, care plan interventions, diagnosis, eye color, name and nickname, Braden scale?, what pain scale, dog’s name?? Storage—How the content will be stored as DATA—nomenclature, ICD9 code, ICD10 code, standard name, alpha or numeric, mm-dd-yyyy versus dd-mm-yyyy Functions—What the system can do—how it will work—how information can be entered, stored as data and for how long, retrieved and presented as information, and communicated securely when needed

54. 54 Trunk—FUNCTIONALITY Standards IOM report to Agency for Healthcare Research and Quality (AHRQ), July, 2003 What an EHR should DO--FUNCTIONALITY

55. 55 Trunk—developing HIT standards Standard: ”Documented agreements containing technical specifications or other precise criteria to be used consistently as rules, guidelines, or definitions of characteristics to ensure that materials, products, processes, and services are fit for their purpose. A standard specifies a well defined approach that supports a business process and: Has been agreed upon by a group of experts Has been publicly vetted Provides rules, guidelines, or characteristics Helps to ensure that materials, products, processes and services are fit for their intended purpose Available in an accessible format Subject to ongoing review and revision process” (from ehealth initiative at http://toolkit.ehealthinitiative.org/glossary)

56. 56 Standards—the “Bottom line”… We need standards to allow Information exchange at 3 “interoperability” levels (From Clinical Loinc tutorial, pg 9, 050321)  Basic—allows messages to be exchanged between computer systems—word processing, spreadsheets, etc.  Functional—describes the standard syntax (format) of the message—document templates, forms, data structures, message standards  Semantic—requires use of standard vocabularies within a message

57. 57 Trunk—HIT exchange standards-1 We must be able to exchange different types of data at different times and in different ways… 1.Clinical messaging--delivers electronic clinical results (such as laboratory, test results, radiology reports, or transcribed reports) from the source system (lab, radiology center, etc.) to the intended recipients (ordering physician, primary care physician, hospital, SNF, etc.) 2.Sharing of clinical data at point of care— gathers and provides electronic clinical information (history, diagnoses, etc.)

58. 58 Trunk—HIT exchange standards-2 3.Medication history—electronically shares medication history obtained from multiple sources (pharmacy, hospital, SNF, MD office) with the clinician or facility currently treating the patient 4.E-prescribing and/or CPOE (computerized physician order entry)—automates the process for clinicians to prescribe medications for patients. “Ideal” systems would automatically check for drug/drug interaction, prescription drug plan status, dosage (and other factors) and provide feedback to clinician

59. 59 Trunk—HIT exchange standards-3 4.Quality metrics—shares healthcare information among multiple data sources for the purpose of quality measurement that can support provider quality initiatives and also serve as the basis for determining incentives (such as P4P.) “Metrics”—parameters you or others use to measure or track periodic assessments of performance AND the methods to carry out and interpret the information. A “benchmark” or “best practice” metric may be company, industry, or patient specific. Return hospitalizations, fall rate, medication errors, persons over 60 who received influenza shot, in-house DU formation, etc. are all possible “metrics”.

60. 60 Trunk—HIT exchange standards-4 5.Administrative data sharing—for emergency and community/public health purposes—transfer/discharge from one health setting to another CCD HL7 approved standard-- C ontinuity of C are D ocument — standardized content, layout, terminology Begin testing 2008

61. 61 Trunk—setting standards Who sets HIT standards, and who makes sure that the standards produce interoperable data exchange?  SDO—Standards Setting Organization/s and the individuals in these organizations… Within an interwoven structure… With oversight to be sure standards and products “harmonize”…(are interoperable— work together ) And “certification” (tested and meeting or exceeding applicable standards) for products which do… With efforts/plan which are “transparent” (visible and open to discussion and review) to any/all interested parties.

62. 62 Trunk…The plan for growth… ONCHIT—(AKA ONC)—Office of the National Coordinator for Health Information Technology —Robert M. Kolodner, MD—tasks—  1.consult with HHS Secretary Michael Leavitt– to implement interoperable EHR by 2014 and  2.provides management and support for the… AHIC—American Health Information Community

63. 63 A public-private “Community” was established to serve as the focal point for America’s health information concerns and drive opportunities for increasing interoperability—4 contracts given to carry out specific functions Healthcare Information Technology Standards Panel (HITSP) Nationwide Health Information Network Architecture Projects (NHIN) The Health Information Security and Privacy Collaboration (HISPC) The Certification Commission for Healthcare Information Technology (CCHIT) American Health Information Community The Community is a federally- chartered commission and will provide input and recommendations to HHS on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected, in a smooth, market-led way. HITSP includes 348 different member organizations and is administered by a Board of Directors 24 SDOs (7%) 247 Non-SDOs (71%) 30 Govt. bodies (9%) 12 Consumer groups (3%) 36 Project Team and Undeclared (10%) HITSP includes 348 different member organizations and is administered by a Board of Directors 24 SDOs (7%) 247 Non-SDOs (71%) 30 Govt. bodies (9%) 12 Consumer groups (3%) 36 Project Team and Undeclared (10%) Evaluation of Standards Harmonization Process for HIT

64. 64 Trunk branches and grows… HHS will spend $13M to create AHIC 2.0 WASHINGTON …Office of the National Coordinator (ONC) for Health IT recently discussed details of its $13 million, 2-year contract proposal to design a successor for the federal healthcare IT advisory panel. Robert Kolodner, MD, the National Coordinator for Health Information Technology …transitioned to a private-sector successor by spring of next year. …part of HHS’s suggested model is for AHIC to derive some of its own revenue source through charging for access to the Nationwide Health Information Network. NHIN …the standards process currently underway will not be jeopardized, as the Health Information Technology Standards Panel (HITSP) and the Certification Commission for Healthcare Information Technology (CCHIT) will become part of the planning process, Kolodner said. Reported in Healthcare IT News By Diana Manos, Senior Editor on 09/05/07Diana Manos, Senior Editor

65. 65 Trunk—SDO HITSP Dr. John Halamka, Chair Member populated Technical Committees “ H ealth I nformation T echnology S tandards P anel” The HITSP team–“…a cooperative partnership between the public and private sectors…Comprised of a wide range of stakeholders… sponsored by the American National Standards Institute (ANSI) in cooperation with strategic partners such as the Healthcare Information and Management Systems Society (HIMSS), the Advanced Technology Institute (ATI) and Booz Allen Hamilton…”—is charged with completing eleven different tasks, with current efforts focused on the harmonization process.

66. 66 Trunk—SDO The Community HHS Secretary Mike Leavitt, Chair Project Management Team Executive in Charge, F. Schrotter, ANSI Program Manager, L. Jones GSI Deputy PM, J Corley, ATI Project Manager, Julie Pooley, BoozAllen Project Management Team Executive in Charge, F. Schrotter, ANSI Program Manager, L. Jones GSI Deputy PM, J Corley, ATI Project Manager, Julie Pooley, BoozAllen Harmonization Process Delivery Technical Manager Joyce Sensmeier, HIMSS Harmonization Process Delivery Technical Manager Joyce Sensmeier, HIMSS Harmonization Process Definition Technical Manager Michelle Deane, ANSI Harmonization Process Definition Technical Manager Michelle Deane, ANSI HHS ONCHIT1 PO, Dr. John Loonsk HHS ONCHIT1 PO, Dr. John Loonsk HITSP Dr. John Halamka, Chair Member populated Technical Committees Eleven Tasks are included in this contract: 1. Comprehensive Work Plan 2. Conduct a Project Start Up Meeting 3. Deliver Recommended Use-Cases 4. Participate in related meetings and activities, including the AHIC Meetings 5. Develop a Gap Analysis 6. Standards Selection, Evaluations and Testing 7. Define a Harmonization Approach 8. Develop Interoperability Specifications 9. Develop and Evaluate a Business Plan for the self-sustaining processes 10. Submit Monthly Reports – ongoing efforts 11. Assist with communications – ongoing efforts Evaluation of Standards Harmonization Process for HIT

67. 67 “…engages multiple stakeholders to ensure an objective, open, and consensus-driven process and credible result. Stakeholders will include: Clinicians and provider organizations who purchase health IT products; Safety net providers who purchase or receive health IT products; Vendors who develop, market, install and support health IT products; Payers or purchasers who are prepared to offer incentives for health IT adoption; Health care consumers; Quality organizations; Public health agencies; Clinical and health-services researchers; Standards development organizations; Federal agencies and coordinating bodies representing various Federal agencies as identified by the National Coordinator.” From—www.cchit.org Trunk—product certification Certification Commission for Healthcare Information Technology Will assure that EHR products ARE COMPLIANT with standards as developed…it…

68. 68 Standards—CCHIT & MITRE “Software to Evaluate Compatibility of Systems Will Be Free and Publically (SIC) Available September 10, 2007…Certification Commission for Healthcare Information Technology (CCHITSM) and the MITRE Corporation…collaborative relationship… to…evaluate compliance of electronic health records (EHR) and networks with certification criteria for interoperability... testing software will be developed under an open source license so that it is free and publically (SIC) available, and the Certification Commission will use the software running on a secure platform during its inspection of a product's compliance…Mark Leavitt, M.D., Ph.D., Commission chair. "It will be a big job, so we hope many others will collaborate: health IT companies, government entities and others -- that's why CCHIT and MITRE chose the open source project model. It's in sync with the Commission's transparent, volunteer-based processes as well.“ The first focus …tool to verify standards compliance of a Continuity of Care Document (CCD) sent or received by EHRs. … project schedule that will have the CCD verification tool ready in time for CCHIT's 2008 pilot testing and certification launch.” From—www.cchit.org NO MORE SILOS!!

69. 69 WHAT?? SILO? TRANSPARENT?? If each organization maintains its data in a non-standard way, it is in a “silo”— What is a silo??  a Central Park penguin?  a storage facility for grain? No—”Silo”ed means that a system “stands alone” and is incapable of reciprocal operation with other related management systems… Data exchange requires interoperable systems… And how we accomplish this must be transparent—open to, visible to, and understandable by all stakeholders Silo—the NY Central Park penguin who raised a chick with another male penguin. With transparency, all becomes clear

70. 70 Hold on…2008??? I like my silo!! Paper keeps me warm!! Where’s my SPACE!!! I need TIME!!! This is CRAZY!!! WHHOOAAAAA!! Prep, plan, change…

71. 71 Trunk—SDO—HIPAA H ealth I nsurance P ortability and A ccountability A ct Personal Health Information Privacy Security of Electronic Records

72. 72 Trunk—SDO NIST—special division to test conformance to IT standards Gathers and displays current HIT standards at http://hcsl.sdct.nist.gov:8080/hcsl/index.html May become a bigger “player” in HIT standards development…

73. 73 Trunk—SDO—CHI Under FHA (Federal Health Architecture) Program under ONC (Office of the National Coordinator) “CHI is a collaborative effort to adopt health information interoperability standards, particularly health vocabulary and messaging standards, for implementation in federal government systems. About 20 department/agencies including the Department of Health and Human Services, the Department of Defense and the Department of Veteran's Affairs are active in the CHI governance process.” Established 27 health domains Now working on “Implementation of adopted standards, Maintenance of adopted standards, and Identification and adoption of new standards.” From:www.hhs.gov/healthit/chi.html C onsolidated H ealth I nformatics (initiative)

74. 74 Trunk—SDO—function HL7—Health Language 7— An ANSI approved American National Standard for electronic data exchange in health care. It enables disparate computer applications to exchange key sets of clinical and administrative information. (from ehealth initiative) EHR-S (System) Functional Model—the EHR-S Functional model standardizes what functions our LTC EHR must possess—in areas of Direct Care, Information Infrastructure, and Supportive Services The standard indicates the functions which may, should, or SHALL be included, structured, or “work” in an EHR system

75. 75 Trunk—SDO—function In February 2007, at this year’s LTC HIT summit, the Chicago attendees received, and responded to, a challenge—  Develop the HL7 LTC EHR-S profile— participate and reach consensus with your expert colleagues 4 PERSONS LED AND STILL LEAD THE CHALLENGE… 136 LTC colleagues “answered” the challenge… care providers, vendors, IT specialists, pharmacy consultants, nurses, government liaisons, and many others… But not all “met” the challenge”—for 1 ½, 3, or 5 or more hours each week—thinking and communicating, to develop and approve each profile section…

76. 76 Trunk—SDO—function adediger@medicalodges.comadediger@medicalodges.com; aprybyl@momentumhealthware.com; allan.neoh@achievehealthcare.com; akillian@phoebe.org; annessa@nasl.org; bmanard@aahsa.org; beth.delahunt@achievehealthcare.com; bpilous@ohqio.sdps.org; bill.russell@erickson.com; brenda_k_parks@keane.com; brian.young@accu- med.com; bryceb6@sunshineterrace.com; cmcspadden@ascp.com; cthomas@accu-med.com; christa.hojlo@va.gov; cbaker@accu-med.com; dan.cobb@healthmedx.com; daniel.stein@dbmi.columbia.edu; daniel.wilt@erickson.com; darin@american-data.com; daveo17@bellsouth.net; dave@ianet.org; debra_sperry@hotmail.com; denise.trcka@achievehealthcare.com; doc@mditech.com; dbrickey@healthtech.net; dgutkind@lintechsoftware.com; edoll@hfam.org, frank.leonard@AFRH.gov; frank.mckinney@achievehealthca re.com; geoffb@vigilan.com; gillian.gray@fundltc.com; gsloan@accu- med.com; gbean@txqio.sdps.org; hboddy@goldcrest.net; hk489@nyu.edu; irenewright@ahconline.com; jalbert@masonicare.org; jke6@pitt.edu; jhusher@good-sam.com; janet.barber2@va.gov; Jeanette.Kranacs@cms.hhs.gov; jwoodside@consulatehc.com; jennie.harvell@hhs.gov; jesse.wrenn@dbmi.columbia.edu; jdalton@parkriverestates.com; jim_hancock@qs1.com; joann.ross@genesishcc.com; john@mail.american-data.com; jobrooks@hcr-manorcare.com; joy.thompson@cms.hhs.gov; jdpurcell@savasc.com; jennik02@odjfs.state.oh.us; julie.thompson@beaconpartners.com; kingra@citizensmemorial.com; kdownie@aahsa.org; karthik.natarajan@dbmi.columbia.edu; kmhurst@savasc.com; kspeights@healthtech.net; kbrouse@chs- ga.org; keith.weaver@odh.ohio.gov; kevin_a_mccormack@keane.com; kevin@lakepointnc.com; kwarren@txqio.sdps.org; kcerchiara@hipconsulting.net; lhillock@chs-ga.org; lkunz@dartchart.com; llucas@fulhealth.org; llucas@bright.net; lorraine.toderash@momentumhealthware.com; lhyman@ehealthsolutions.com; derosiam@ahconline.com; mjwhite@columbus.rr.com; marellano@aanac.org; mmoen@healthware-consulting.com; martin.rice@cms.hhs.gov; mary.guthrie2@va.gov; mary.pratt@cms.hhs.gov; matthew.mullins@momentumhealth ware.com; melanie.brodnik@osumc.edu; carterm@ahconline.com; michelle.dougherty@ahima.org; mike.crowder@goldenven.com; measley@hqmmail.com; mmercier@hcr-manorcare.com; nrobinson@amda.com; nate@american-data.com; nlake@healthtech.net; nmadison@healthtech.net; ppadula@mslc.com; kress@actslife.org; rhonda@ahis.net; rhonda_g_hamilton@wellpoint.com; richard.giddings@achievehealthcare.com; rsutton@accu-med.com; rabrams@myziva.com; rsmith@co.strafford.nh.us; roiqualls@ehealthdatasolutions.com; rchambers@elizabryant.org; rdepriest@hcr-manorcare.com; septembers@nehca.org; sheila.lambowitz@cms.hhs.gov; shellyspiro@yahoo.com; steven.handler@verizon.net; suelewis@accu-med.com; sue.mitchell@omnicare.com; serucinski@savasc.com; spweaver@co.bucks.pa.us; tomwelsh@esgi.com; tim.smith@goldenven.com; tsmith@ahca.org; tydette.tisdell@va.gov; yael.harris@hhs.gov; zbolton@gmail.com;aprybyl@momentumhealthware.comallan.neoh@achievehealthcare.com akillian@phoebe.organnessa@nasl.orgbmanard@aahsa.orgbeth.delahunt@achievehealthcare.com bpilous@ohqio.sdps.orgbill.russell@erickson.combrenda_k_parks@keane.combrian.young@accu- med.combryceb6@sunshineterrace.comcmcspadden@ascp.comcthomas@accu-med.com christa.hojlo@va.govcbaker@accu-med.comdan.cobb@healthmedx.com daniel.stein@dbmi.columbia.edudaniel.wilt@erickson.comdarin@american-data.com daveo17@bellsouth.netdave@ianet.orgdebra_sperry@hotmail.com denise.trcka@achievehealthcare.comdoc@mditech.comdbrickey@healthtech.net dgutkind@lintechsoftware.comfrank.leonard@AFRH.gov frank.mckinney@achievehealthca re.comgeoffb@vigilan.comgillian.gray@fundltc.comgsloan@accu- med.comgbean@txqio.sdps.orghboddy@goldcrest.nethk489@nyu.eduirenewright@ahconline.com jalbert@masonicare.orgjke6@pitt.edujhusher@good-sam.comjanet.barber2@va.gov Jeanette.Kranacs@cms.hhs.govjwoodside@consulatehc.comjennie.harvell@hhs.gov jesse.wrenn@dbmi.columbia.edujdalton@parkriverestates.comjim_hancock@qs1.com joann.ross@genesishcc.comjohn@mail.american-data.comjobrooks@hcr-manorcare.com joy.thompson@cms.hhs.govjdpurcell@savasc.comjennik02@odjfs.state.oh.us julie.thompson@beaconpartners.comkingra@citizensmemorial.comkdownie@aahsa.org karthik.natarajan@dbmi.columbia.edukmhurst@savasc.comkspeights@healthtech.netkbrouse@chs- ga.orgkeith.weaver@odh.ohio.govkevin_a_mccormack@keane.comkevin@lakepointnc.com kwarren@txqio.sdps.orgkcerchiara@hipconsulting.netlhillock@chs-ga.orglkunz@dartchart.com llucas@fulhealth.orgllucas@bright.netlorraine.toderash@momentumhealthware.com lhyman@ehealthsolutions.comderosiam@ahconline.commjwhite@columbus.rr.com marellano@aanac.orgmmoen@healthware-consulting.commartin.rice@cms.hhs.gov mary.guthrie2@va.govmary.pratt@cms.hhs.govmatthew.mullins@momentumhealth ware.com melanie.brodnik@osumc.educarterm@ahconline.commichelle.dougherty@ahima.org mike.crowder@goldenven.commeasley@hqmmail.commmercier@hcr-manorcare.com nrobinson@amda.comnate@american-data.comnlake@healthtech.netnmadison@healthtech.net ppadula@mslc.comkress@actslife.orgrhonda@ahis.netrhonda_g_hamilton@wellpoint.com richard.giddings@achievehealthcare.comrsutton@accu-med.comrabrams@myziva.com rsmith@co.strafford.nh.usroiqualls@ehealthdatasolutions.comrchambers@elizabryant.org rdepriest@hcr-manorcare.comseptembers@nehca.orgsheila.lambowitz@cms.hhs.gov shellyspiro@yahoo.comsteven.handler@verizon.netsuelewis@accu-med.com sue.mitchell@omnicare.comserucinski@savasc.comspweaver@co.bucks.pa.ustomwelsh@esgi.com tim.smith@goldenven.comtsmith@ahca.orgtydette.tisdell@va.govyael.harris@hhs.gov zbolton@gmail.com

77. 77 Trunk—SDO—function LTC EHR-S Profile Information Infrastructure section—almost completed…14 persons regularly attended—all participated in re-writing and voting on assuring that the profile reflects our industry needs Direct Care section—moving slowly…16 to 20 persons regularly attend and vote—additional time will be spent by workgroup members to carefully review and finish—MEET the challenge! Supportive Services section—review and vote will begin shortly—MEET the challenge!! 14-20 persons directing EHR software functionality for 17,000 SNF’s??? STATUS AS OF 10-7-07

78. 78 Trunk—SDO— pharmaceutical “Mission Statement: NCPDP creates and promotes standards for the transfer of data to and from the pharmacy services sector of the healthcare industry. The organization provides a forum and support wherein our diverse membership can efficiently and effectively develop and maintain these standards through a consensus building process. …a not-for-profit ANSI-accredited Standards Development Organization.” From–www.ncpdp.org Standards for prescription entry, transmission, reconciliation, and fulfillment— an integral part on an EHR.

79. 79 Trunk—SDO—terminology “ S ystemized No menclature of Med icine-- SNOMED … a dynamic, scientifically validated clinical health care terminology and infrastructure that makes health care knowledge more usable and accessible. SNOMED CT— SNOMED Clinical Terms– provides a common language that enables a consistent way of capturing, sharing and aggregating health data across specialties and sites of care.” – concepts, descriptions, relationships… (from www.snomed.org)www.snomed.org Example: For the concept Pneumonia (disorder), the ConceptID is 233604007 IHTSDO®

80. 80 Trunk—SDO—format/terminology Logical Observation Identifier Names and Codes— LOINC “LOINC is a voluntary effort housed in the Regenstrief Institute, an internationally respected non-profit medical research organization associated with Indiana University. LOINC system was initiated in 1994 by the Regenstrief Institute and developed by Regenstrief and the LOINC committee as a response to the demand for electronic movement of clinical data from laboratories that produce the data to hospitals, physician's offices, and payers who use the data for clinical care and management purposes.”Indiana University (from www.regenstrief.org/loinc) LOINC has expanded beyond laboratory; for clinical symptoms and results MDS 2.0 has been LOINC’d or LOINCified…

81. 81 Trunk—EHR hardware… The Motion C5 device helps hospital personnel monitor patient information, allowing them to document vital signs, medications, plan of care and test results. ( Baltimore Sun photo by Chiaki Kawajiri / August 8, 2007) Photo for For non-commercial use only A tablet device— usually wireless. Very portable, but has limited screen size.

82. 82 TRUNK—EHR HARDWARE Stationary devices, such as KIOSKS— can be wall mounted or mounted on rolling table stands. Staff enters information near OR IN patient care =timely and more accurate documentation. Other hardware, wireless/wired—multiple configurations

83. 83 Branches and growth… RHIO—Regional Health Information Organization or RHIN—Regional Health Information Network, and finally a… NHIN—National Health Information Network—CMS has selected vendors which will be allowed to compete for this “prize”—Enterprise System Developlent, 10 years, $4 billion HIE —Health Information Exchange via

84. 84 As the tree grows, where will you be?? Or gathering up the leaves and paper—hoping for a fire???… In a “connected” home environment … with plans for continuing modernization??

85. 85 WE NEED YOU TO ADVANCE HIT!! Visit the “virtual nursing home” and technology Halls. Talk with these vendors and other experts—be sure you have knowledgeable contacts who will REMAIN up to date! SHARE and continuously expand YOUR KNOWLEDGE Start your plan NOW!!

86. 86 WE NEED YOU TO ADVANCE HIT!! And when you get back home… GET YOUR staff and FACILITY READY— cultural change may prove to be more costly than actual system change if not tackled first Don’t do it alone… PARTICIPATE AT THE LOCAL LEVEL PARTICIPATE AT THE NATIONAL LEVEL

87. 87 Thank you for your participation!! Grateful thanks are given to: Health Facilities Association of Maryland and Members of its HIT committee, and, AHCA’s HIT Committee, And others… Who willingly offered their time and expertise to provide ruthless criticism and constructive suggestions…that’s what friends are for… This presentation (containing links to organizations and other resources) will be available on the AHCA Members website shortly after the convention. Eileen Doll, RN, BS, NHA Healthcare Consultant EDHC INC EDHCINC@gmail.com Nathan Lake, RN, BSN, MSHA Director, Clinical Design American HEALTHTECH nlake@healthtech.net

88. 88