1. Developing National Health Information Infrastructure (NHII) in the U.S. William A. Yasnoff, MD, PhD, FACMI Senior Advisor National Health Information Infrastructure Department of Health and Human Services William A. Yasnoff, MD, PhD, FACMI Senior Advisor National Health Information Infrastructure Department of Health and Human Services MEDINFO 2004 September 8, 2004

2. 2 2 Overview I. Organization of U.S. health care “system” II. History of NHII III. What is NHII? IV. NHII Challenges V. Accelerating NHII VI. Presidential Attention I. Organization of U.S. health care “system” II. History of NHII III. What is NHII? IV. NHII Challenges V. Accelerating NHII VI. Presidential Attention

3. 3 3 I. Organization of U.S. Health Care “System” n Employer-based coverage l Limited consumer choice of plans l Diversity of pricing/covered services n Multiple competing systems l Hospitals l Health plans n Government is major payer (~50%) l Medicare l Medicaid (shared with states) n Minimal centralized control n Employer-based coverage l Limited consumer choice of plans l Diversity of pricing/covered services n Multiple competing systems l Hospitals l Health plans n Government is major payer (~50%) l Medicare l Medicaid (shared with states) n Minimal centralized control

4. 4 4 II. History of NHII: Reports IOM 1991 1997 Computer-Based Patient Record IOM 2000To Err is Human NRC/ CSTB 2001 Networking Health: Prescriptions for the Internet IOM2001 Crossing the Quality Chasm PITAC2001 Transforming Health Care Through Information Technology NCVHS2001 NHII

5. 5 5 III. What is NHII? n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n “Anywhere, anytime health care information and decision support” n NOT a central database of medical records n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n “Anywhere, anytime health care information and decision support” n NOT a central database of medical records

6. 6 6 What is NHII? (continued) n Includes technologies, practices, relationships, laws, standards, and applications, e.g. l Communication networks l Message & content standards l Computer applications l Confidentiality protections n Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII n Includes technologies, practices, relationships, laws, standards, and applications, e.g. l Communication networks l Message & content standards l Computer applications l Confidentiality protections n Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII

7. 7 7 NHII Requirements: Functions n Overall: “Anytime, anywhere health care information and decision support” n Immediate availability of complete medical record (compiled from all sources) to any point-of-care n Enable up-to-date decision support at any point of care n Enable selective reporting (e.g. for public health) n Enable use of tools to facilitate delivery of care (e.g. e-prescribing) n Allow patients to control access to their information n Overall: “Anytime, anywhere health care information and decision support” n Immediate availability of complete medical record (compiled from all sources) to any point-of-care n Enable up-to-date decision support at any point of care n Enable selective reporting (e.g. for public health) n Enable use of tools to facilitate delivery of care (e.g. e-prescribing) n Allow patients to control access to their information

8. 8 8 NHII Requirements: Implementation Strategy n No national database or identifier n Alignment of incentives n Allow each care facility to maintain its own data n Minimize cost & risk n Use proven implementation strategies (where possible), e.g. incremental approach l Each implementation step benefits all participants l Implementation scope coincides with benefits scope n No national database or identifier n Alignment of incentives n Allow each care facility to maintain its own data n Minimize cost & risk n Use proven implementation strategies (where possible), e.g. incremental approach l Each implementation step benefits all participants l Implementation scope coincides with benefits scope

9. 9 9 IV. NHII Challenges n Health care information is very complex  IT systems more expensive and difficult to build n Health care is highly fragmented n Organizational and change management issues from IT systems are difficult to manage in clinical environment l Physicians are independent contractors l Reimbursement does not provide ROI for IT n Difficult to generate capital needed for IT investment l IT is regarded as an add-on cost, not an investment for competitive advantage n Health care information is very complex  IT systems more expensive and difficult to build n Health care is highly fragmented n Organizational and change management issues from IT systems are difficult to manage in clinical environment l Physicians are independent contractors l Reimbursement does not provide ROI for IT n Difficult to generate capital needed for IT investment l IT is regarded as an add-on cost, not an investment for competitive advantage

10. 10 V. Accelerating NHII progress n Inform l Disseminate NHII vision l Catalog NHII activities l Disseminate “lessons learned” n Collaborate with Stakeholders n Convene l NHII 03: 6/30-7/2/2003 – Develop a consensus agenda l NHII 04: 7/21-23/2004 in D.C. – Release strategic framework – More stakeholder feedback n Inform l Disseminate NHII vision l Catalog NHII activities l Disseminate “lessons learned” n Collaborate with Stakeholders n Convene l NHII 03: 6/30-7/2/2003 – Develop a consensus agenda l NHII 04: 7/21-23/2004 in D.C. – Release strategic framework – More stakeholder feedback

11. 11 NHII 03 Final Recommendations I.Management 1)Governance 2)Education 3)Shared Resources 4)Metrics II.Enablers 1)Financial Incentives* 2)Standards* 3)Legal Issues I.Management 1)Governance 2)Education 3)Shared Resources 4)Metrics II.Enablers 1)Financial Incentives* 2)Standards* 3)Legal Issues III.Implementation Strategy 1)Demonstration Projects 2)Architecture* 3)Identifiers IV.Targeted Domains 1)Consumer Health* 2)Research* *original breakout track Views expressed do not necessarily represent U.S. Government policy

12. 12 V. Accelerating NHII progress (2) n Standardize l HL7, DICOM, IEEE 1073, NCPDP SCRIPT l SNOMED, LOINC l HL7 projects: EHR functions, EHR interchange format n Demonstrate l $50 million in FY 04 budget for NHII demonstration projects (AHRQ) l President has requested additional $50 million for FY 05 n Evaluate l Rigorous assessment of NHII benefits l Policy options for aligning financial incentives n Standardize l HL7, DICOM, IEEE 1073, NCPDP SCRIPT l SNOMED, LOINC l HL7 projects: EHR functions, EHR interchange format n Demonstrate l $50 million in FY 04 budget for NHII demonstration projects (AHRQ) l President has requested additional $50 million for FY 05 n Evaluate l Rigorous assessment of NHII benefits l Policy options for aligning financial incentives

13. 13 Clinical Encounter Index of where patients have records Temporary Aggregate Patient History Patient Authorized Inquiry Hospital Record Laboratory Results Specialist Record Patient data delivered to Physician Info exch system Records Returned Requests for Records community

14. 14 Index of where patients have records Temporary Aggregate Patient History Authorized Inquiry Hospital Record Laboratory Results Specialist Record Patient data delivered Info exch system Records Returned Requests for Records U.S. another Info Exch System

15. 15 Advantages of Local Approach n Existing HII systems are local n Health care is local  benefits are local n Facilitates high level of trust needed n Easier to align local incentives n Local scope increases probability of success n Specific local needs can be addressed n Can develop a repeatable implementation process n Parallel implementation  more rapid progress n Use of standards allows connectivity between local info exchanges  NHII n Existing HII systems are local n Health care is local  benefits are local n Facilitates high level of trust needed n Easier to align local incentives n Local scope increases probability of success n Specific local needs can be addressed n Can develop a repeatable implementation process n Parallel implementation  more rapid progress n Use of standards allows connectivity between local info exchanges  NHII

16. 16 VI. Presidential Attention “ Our 21 st century health care system uses a 19 th century paperwork system” -- President George W. Bush April 27, 2004

17. 17 President’s Executive Order April 27, 2004 n Creates position of National Health IT Coordinator in HHS l David Brailer MD, PhD l Reports to HHS Secretary l New Office in HHS (ONCHIT) n Responsible for l Coordinating all Federal and private sector efforts toward NHII l Developing and monitoring strategic plan n Creates position of National Health IT Coordinator in HHS l David Brailer MD, PhD l Reports to HHS Secretary l New Office in HHS (ONCHIT) n Responsible for l Coordinating all Federal and private sector efforts toward NHII l Developing and monitoring strategic plan

18. 18 Strategic Framework (7/21/2004) n EHR Adoption & Use l Incentives n Interconnecting Clinicians l RHIOs n Personalize Care l Develop personal health records n Improve Population Health l Use electronic health information for public health & research n EHR Adoption & Use l Incentives n Interconnecting Clinicians l RHIOs n Personalize Care l Develop personal health records n Improve Population Health l Use electronic health information for public health & research

19. 19 Questions? William A. Yasnoff, MD, PhD william.yasnoff@hhs.gov 202/690-7862 For more information about NHII http://aspe.hhs.gov/sp/nhii For more information about ONCHIT http://www.hhs.gov/onchit/index.html