HIT Toward Public Health “ It Takes a Village ” Public Health Data Standards Consortium 2012 Annual Business Meeting November 8-9 th, 2012

What Is Driving All The Activity Healthcare Reform Meets HIT Access Public Health Personal Health Disasters Quality Efficiency

Telemedicine Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth. American Telemedicine Association

Electronic Health Record The Electronic Health Record (EHR) is a secure, real-time, point-of- care, patient centric information resource for clinicians. The EHR aids clinicians’ decision making by providing access to patient health record information where and when they need it and by incorporating evidence-based decision support. The EHR automates and streamlines the clinician’s workflow, closing loops in communication and response that result in delays or gaps in care. The EHR also supports the collection of data for uses other than direct clinical care, such as billing, quality management, outcomes reporting, resource planning, and public health disease surveillance and reporting. Healthcare Information Management and Systems Society

Choose Appropriate (not Lithic) Technology Chicago Science Fair 1974

Full Body Scans to Double as Annual Checkups: Solution to Airport Security, Health Care Woes WASHINGTON (The Borowitz Report) In what some in the White House are calling a "win/win" solution to the nation's airport security and health care reform problems, starting next month U.S. airports will begin conducting full body scans that will double as annual physical checkups. President Obama announced the breakthrough solution, telling reporters, "With this all-purpose exam, we will be able to find everything from a hidden weapon to a spot on your lung."

Major Policy Issues Reimbursement & Capital Costs -Aligning Financial Incentives – ARRA -Driving Cost-Effectiveness (i.e. Chronic Care & Disease Mgmt) -Start-up Costs; Capital Investment & Sustainability -Federal Investments (DoD; VHA; IHS; DHHS) Standards (Clinical & Communications – Content, Vocab, Transport) -Quality & Safety; IOM and FDA Infrastructure Issues -Network Infrastructure / Broadband Access / Interoperability (FCC; DoC; RUS) Human Dimension Issues - Arrangements to Practice in an e-enabled Environment - Practitioner and Patient Acceptance - Licensure, Accreditation, Certification - Legal (Stark Law, Liability, FDA, HIPAA & Ongoing Security Concerns) - Training an HIT Workforce (NSF; BHP)

Put Positively “There are no problems…...just insurmountable opportunities” –Pogo !

Is Public Health the Low Hanging Fruit ? Our Pluralistic Health System Suggests Limits on The Voluntary Exchange of Health Information The Marketplace and Competition is (apparently) at Work “That’s Money Flowing Thru Dem Der Wires” (Neuberger) So, Public Health Information; Disease Registries; Disaster Monitoring; Epidemiological Information etc – Represent a Common Understanding Individually Identifiable Information; Patient Records – Maybe or Maybe Not.

Challenges For Rural and Disadvantaged Communities Patients may be isolated, must travel long distances or are homebound; Access is a major problem Rural residents and minorities may be older, and often with certain chronic conditions Cultural and Language Barriers Low patient volume Longer wait times for Care Disjointed care; Lower quality of care Lower income, and less private insurance Many are Less Likely to Own or Use Computers Limited (but growing) Use of Internet

Challenges For Rural and Disadvantaged Communities Underserved Healthcare Providers may have no IT support let alone an IT Department; HIT Worker Shortages Hard to find M.D. or Admin. leaders / Change agents Other business priorities i.e. “surviving” No business case for connectivity / linkages to other institutions (stand-alone EHRs ?) No aggregate buying power (hence pooled vendor selection processes & need for Networking) Need to address critical referral pattern issues, disruptions, patient flows etc.

Numerous Players Use All of the Tools – The Aggregators Federal Government –Congress –Agencies (DHHS, DoC, Ag, DoD, CDC, VA, IHS, NASA, FDA, CMS) –Federal Jt. Working Group on Telehealth; DHHS Mobile Health States –Statewide Initiatives (Governors, Legislatures, Regional Networks) –Hundreds of bills specific to HIT –NGA State Alliance; HIMSS State Coordination Private Sector –Coalitions / Consortia / Organizations (APHA, ATA, HIMSS, eHI, AHIMA, AMIA, Health IT Now ! Coalition; Rural HIT Coalition; mHealth Summit) –Capitol Hill Steering Committee on Telehealth and Healthcare Informatics ) –Standards Groups, CCHIT, HITSP, Promina, Continua, EHNAC –Foundations (Markle, RWJ, Commonwealth, eHI Fndt; RCHN)

Economic Stimulus and ARRA $787 Billion Total Up to $50 B for “Cyber Ready” HIT Efforts Jobs Creation Infrastructure Build out Community Economic Development Public-Private Partnerships Quick Spending Toward Long Term Investment Supporting Broader Healthcare Reforms - Access, Efficiency, Quality

American Recovery and Reinvestment Act Health Information Technology Related Provisions HIT Incentives Over 10 Years (Medicare & Medicaid) Budget Authority (Net)$ 36.3 B Projected Savings $ 15.5 B Net Budget Authority$ 20.8 B National Coordinator for HIT$ 2.0 B Includes Grants to States $ 300 M Includes Transfer to NIST$ 20 M

American Recovery and Reinvestment Act Health Information Technology Related Provisions HRSAPrograms and Services$ 2.5 B (Grants to CHCs$.5 B) (CHC Infrastructure & HIT$ 1.5 B) (Hlth Professions Shortages$.5 B) AHRQ Comparative Effect Research$ 1.1 B (Transfer to NIH$ 400 M) (Use by DHHS Secretary$ 400 M) (Use by AHRQ$ 300 M)

American Recovery and Reinvestment Act Health Information Technology Related Provisions Indian Health Service (Telemedicine)$ 85 M Veterans Health Admin. (IT)$ 50 M NTIA / DoC (Broadband TOP)$ 4.7 B RUS / DoA (Medical Links et al)$ 2.5 B ETA / DoL (Worker Training)$ 4.4 B NIST / DoC (Standards)$ 220 M (Plus $20 M from DHHS) Social Security Admin. (IT)$ 500 M

Additional Items - HRSA $500 M in Recovery Act workforce funds, some for HIT Workforce Training ; Also ETA within DoL - Community College Consortia & University-based Training - Study Concerning Open Source Technology - Beacon Community Agreements – 17 Centers; $220 Million; Including 85 FQHCs - About $700 Million for 60+ Regional Extension Centers - $50 M national HIT Research Center to Coordinate Regional Centers “Mother of All Centers” - $12 M supplemental funds for CAHs and other Rural - National Health Information Network (NHIN)

Privacy and Security - Security Breach Notification - New HIPAA Business Associates - Accounting of Disclosures - Sale/Marketing of Protected Health Information - Access - Enforcement

American Recovery and Reinvestment Act Health Information Technology Related Provisions Incentives through Medicare - Eligible professionals (physicians) and hospitals for the “meaningful use” of certified EHR technology. Up to 100,000 through RECs. - Incentives offered for physicians and physicians will see a reduction in their Medicare reimbursements in 2015 if they are not meaningful users of certified EHR technology - Incentives offered FY11-FY15 for hospitals and hospitals will see a reduction in their Medicare reimbursements in FY15 if they are not meaningful users of certified EHR technology Incentives through Medicaid - Eligible providers must demonstrate a “meaningful use” of certified EHR technology -Incentive payments offered

Regional extension centers Workforce training Medicare & Medicaid Incentives and penalties State grants for health Information exchange Standards & certification framework Privacy & Security framework Adoption of EHRs Meaningful Use of EHRs Exchange of health information Improved individual and population health outcomes Increased transparency and efficiency Improved ability to study and improve care delivery Research to enhance HIT HITECH Act Blumenthal D. Launching HITECH. N Engl J Med Jan 4.

Data capture and sharing Advanced clinical processes Improved outcomes Bending the Curve Towards Transformed Health Achieving Meaningful Use of Health Data “Phased-in series of improved clinical data capture supporting more rigorous and robust quality measurement and improvement.” “These goals can be achieved only through the effective use of information to support better decision-making and more effective care processes that improve health outcomes and reduce cost growth” Connecting for Health, Markle Foundation “Achieving the Health IT Objectives of the American Recovery and Reinvestment Act” April 2009

Use information to transform care Stage 2 MU ACOs Stage 3 MU PCMHs 3-Part Aim Registries to manage patient populations Team based care, case management Enhanced access and continuity Privacy & security protections Care coordination Privacy & security protections Patient centered care coordination Improved population health Registries for disease management Evidenced based medicine Patient self management Privacy & security protections Care coordination Structured data utilized Data utilized to improve delivery and outcomes Patient informed Patient engaged, community resources Stage 1 MU Privacy & security protections Basic EHR functionality, structured data Utilize technology to gather information Improve access to information Meaningful Use: A Building Block

Meaningful Use: Public Health Requirements Stage 1 Ensuring readiness for immunization information reporting systems; testing public health receive and send capabilities; expansions to current case reporting systems; increased capacity for data management and analysis Stage 2 Capability to submit immunization data in corp set for EPs; reporting lab results and syndromic surveillance in all corps sets for EHs; Two new PH objectives: 1) Cancer cases to cancer registries; and 2) Specific cases to specialized registries.

Meaningful Use: How are we doing? Physicians –Physician adoption of any EHR system has more than tripled since 2002, going from 17 percent to 57 percent in 2011 (NCHS Data Brief). –The adoption of basic EHRs has doubled since 2008, going from 17% to 34% in 2011 (NCHS Data Brief). –Adoption has grown significantly among important subgroups of physicians including small practices and rural providers. Hospitals –Hospital adoption has more than doubled since 2009, increasing from 16% to 35% Over 2,800 hospitals and more than 90,000 doctors have received $5 billion in incentive payments for ensuring meaningful use of health IT since the program inception

PPACA Health Reform IT Provisions 1)Independence at Home Pilots - up to 10,000 people – using electronic health information system, remote monitoring, mobile diagnostic technology 2)Accountable Care Organizations – using telehealth, remote monitoring and other technologies. FQHCs ???. Final Rule last week 3)Patient-Centered Medical Home models – using health information systems 4)Medicare Advantage Provisions 5)Medication Management Using Telehealth 6)Independent Payment Advisory Board – controversial, may impact HIT 7)Medicaid Health Homes – using information technologies; wireless 8)CMS Innovation Center - $10 billion for pilots – 18 models to address broad payment and practice reforms, promote coordinated care for high-risk & chronic patients

Unfinished Legislative Business Looking Ahead Toward 113 th Congress HITECH Inclusion of Missing Providers and Services -Behavioral / Mental Health -- Sen. Whitehouse (D-RI) S Physicians Assistants -- Reps Bass (D-CA); Terry (R-NE) HR Home Care – Sens Thune (R-SD); Klobuchar (D-MN) S.501 -Long Term Care Providers -EMS Providers -Telehealth

Unfinished Legislative Business Looking Ahead Toward 113 th Congress - Streamlining Licensure and Credentialing Act. Sen. Udall (D-NM ) -Stripping the E-Prescribing Mandates fr. Meaningful Use. Rep Ellmers (R-N.C.) HR Multi-campus Hospital Act. Rep. Zach Space (D-OH) HR Improving Patient Safety Through Technology, Legal Safe Harbors, Reporting Errors Rep. Marino (R-PA) -House Small Business Cmte Hearing on Small Practice Adoption Barriers - Rep. Ellmers

Neal Neuberger, Executive Director Arnol Simmons, Manager Public Policy Initiatives Institute for e-Health Policy 4300 Wilson Boulevard, Suite 250 Arlington, VA