1. Addressing the Healthcare Needs of our Aging Population with Technology 6-4-04 Jennie Harvell Office of the National Coordinator on Health Information Technology Department of Health and Human Services Jennie Harvell Office of the National Coordinator on Health Information Technology Department of Health and Human Services

2. 2 2 Challenges Facing U.S. Healthcare n Health care spending rising faster than inflation. n Despite spending $1.6 trillion on health care: -medical errors abound; and -medical information is not communicated across providers. n Health care spending rising faster than inflation. n Despite spending $1.6 trillion on health care: -medical errors abound; and -medical information is not communicated across providers.

3. 3 3 Challenges (contd) n The population is aging n Population surviving until 65: -1900 - 41% -2004 - over 80% n 2000: 35 million Americans are 65+ n 2050: increases to 82 million n Biggest expected increase: those 85+ n The population is aging n Population surviving until 65: -1900 - 41% -2004 - over 80% n 2000: 35 million Americans are 65+ n 2050: increases to 82 million n Biggest expected increase: those 85+

4. 4 4 Life Expectancy (Older Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging Related Statistics)

5. 5 5 Chronic Illnesses Approximately 40% of Americans have a chronic condition Prevalence of chronic conditions is increasing (RAND): 2000- 125 million 2010 – 141 million Approximately 40% of Americans have a chronic condition Prevalence of chronic conditions is increasing (RAND): 2000- 125 million 2010 – 141 million

6. 6 6 Chronic Conditions (Older Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging Related Statistics)

7. 7 7 Multiple Chronic Illnesses As people age, the number suffering from chronic illnesses increase. Those reporting 2+ chronic conditions: ages 45-64 = 35% ages 65+ = 62% Approximately half of those with a chronic illness have multiple chronic illnesses. Prevalence of multiple chronic conditions is increasing (RAND): 2000- 60 million 2010 –70 million As people age, the number suffering from chronic illnesses increase. Those reporting 2+ chronic conditions: ages 45-64 = 35% ages 65+ = 62% Approximately half of those with a chronic illness have multiple chronic illnesses. Prevalence of multiple chronic conditions is increasing (RAND): 2000- 60 million 2010 –70 million

8. 8 8 LTC Users Today l 12.2% of Americans reported LTC needs in 1995 l 55% over 65 (3% are children) l 25% community based LTC users are severely disabled l Older Americans with severe disabilities will more than double by 2050 l 12.2% of Americans reported LTC needs in 1995 l 55% over 65 (3% are children) l 25% community based LTC users are severely disabled l Older Americans with severe disabilities will more than double by 2050

9. 9 9 Health Care Spending n Health care spending (in 1998) for those without a chronic illness: $680 n Health care spending (in 1998) for those with chronic illness and ADLs. # of chronic conditions and presence of ADL Limitation 1 chronic illness - $1,500 $3,830 2 chronic illnesses - $2,550 $5,650 3 chronic illnesses - $4,060 $7,800 4 chronic illnesses - $5,650 $11,890 5 chronic illnesses - $7,560 $12,420 (Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02) n Health care spending (in 1998) for those without a chronic illness: $680 n Health care spending (in 1998) for those with chronic illness and ADLs. # of chronic conditions and presence of ADL Limitation 1 chronic illness - $1,500 $3,830 2 chronic illnesses - $2,550 $5,650 3 chronic illnesses - $4,060 $7,800 4 chronic illnesses - $5,650 $11,890 5 chronic illnesses - $7,560 $12,420 (Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02)

10. 10 Challenges in the Current Health Care System n Physicians treating patients with chronic conditions report poor outcomes related to: -receipt of contradictory information from multiple physicians -adverse drug interactions -unnecessary hospitalizations (Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02) n Physicians treating patients with chronic conditions report poor outcomes related to: -receipt of contradictory information from multiple physicians -adverse drug interactions -unnecessary hospitalizations (Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02)

11. 11 Summary: n Persons with chronic illnesses and/or disabilities have: -more frequent contacts with health providers; and -higher health care costs. n Persons with chronic illnesses and disabilities are at higher risk of inefficient practice and medical errors. n Persons with chronic illnesses and/or disabilities have: -more frequent contacts with health providers; and -higher health care costs. n Persons with chronic illnesses and disabilities are at higher risk of inefficient practice and medical errors.

12. 12 Health Information Technology n By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care. --President George W. Bush, State of the Union Address, January 20, 2004 n All these problems – high costs, uncertain value, medical errors, variable quality, administrative inefficiencies, and poor coordination – are closely connected to our failure to use health information technology as an integral part of medical care. n --President George W. Bush, April 27, 2004 n By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care. --President George W. Bush, State of the Union Address, January 20, 2004 n All these problems – high costs, uncertain value, medical errors, variable quality, administrative inefficiencies, and poor coordination – are closely connected to our failure to use health information technology as an integral part of medical care. n --President George W. Bush, April 27, 2004

13. 13 Policy Goals: n Assure that most Americans have electronic health records within the next 10 years by: n coordinating public and private sector efforts that will accelerate adoption of HIT; n doubling funding (to $100 Million) for demonstration projects on HIT; n using the Government to foster the adoption of HIT (creating incentives); and n creating a new, sub-cabinet level position of National Coordinator of Health Information Technology in HHS. n Assure that most Americans have electronic health records within the next 10 years by: n coordinating public and private sector efforts that will accelerate adoption of HIT; n doubling funding (to $100 Million) for demonstration projects on HIT; n using the Government to foster the adoption of HIT (creating incentives); and n creating a new, sub-cabinet level position of National Coordinator of Health Information Technology in HHS.

14. 14 Executive Order 4/27/04 1. Establish the position of National Coordinator of Health Information Technology (NCHIT). 2. The NCHIT shall work to: - ensure that appropriate information is available to guide medical decisions; - improve quality,reduce errors, advance evidence- based care; - reduce costs, errors, inappropriate care, incomplete information, and increase efficiency; and - increase effective market place, competition, and available accurate information on costs, quality, and outcomes. 1. Establish the position of National Coordinator of Health Information Technology (NCHIT). 2. The NCHIT shall work to: - ensure that appropriate information is available to guide medical decisions; - improve quality,reduce errors, advance evidence- based care; - reduce costs, errors, inappropriate care, incomplete information, and increase efficiency; and - increase effective market place, competition, and available accurate information on costs, quality, and outcomes.

15. 15 Executive Order (contd) Responsibilities - NCHIT shall develop, maintain, and direct a strategic plan to guide national implementation of interoperable HIT which shall: -advance implementation of IT standards; -ensure technical, scientific, and other issues are addressed; -address privacy and security issue of interoperable HIT; and -include measurable outcomes. Responsibilities - NCHIT shall develop, maintain, and direct a strategic plan to guide national implementation of interoperable HIT which shall: -advance implementation of IT standards; -ensure technical, scientific, and other issues are addressed; -address privacy and security issue of interoperable HIT; and -include measurable outcomes.

16. 16 Executive Order (contd) n Reports: - incentives report to promote interoperable HIT; - OPM report on FEHB on incentives to promote interoperable HIT; and - VA/DoD report on working with the private sector to extend the HIT in rural and underserved areas. n Reports: - incentives report to promote interoperable HIT; - OPM report on FEHB on incentives to promote interoperable HIT; and - VA/DoD report on working with the private sector to extend the HIT in rural and underserved areas.

17. 17 EHRs: A Key to Improving Quality and Improving Efficiency Standardized Electronic Health Records (EHRs) are one of the essential building blocks for the evolution of a national health information infrastructure (NHII). The NCVHS stated that implementation of the NHII will have a dramatic impact on the effectiveness, efficiency and overall quality of health and health care in the United States. NCVHS, 2001: pg 2 Standardized Electronic Health Records (EHRs) are one of the essential building blocks for the evolution of a national health information infrastructure (NHII). The NCVHS stated that implementation of the NHII will have a dramatic impact on the effectiveness, efficiency and overall quality of health and health care in the United States. NCVHS, 2001: pg 2

18. 18 Why are standards needed for EHRs? n The promise of an NHII is based in part on the ability of EHRs to exchange and reuse health information. n Interoperable health information requires: - clear, unambiguous data - data that can be encoded - ability of computers to send and receive electronic information (i.e., messaging) n The promise of an NHII is based in part on the ability of EHRs to exchange and reuse health information. n Interoperable health information requires: - clear, unambiguous data - data that can be encoded - ability of computers to send and receive electronic information (i.e., messaging)

19. 19 What standards are needed? For interoperable exchange of information across clinicians, institutions, payers, and vendor products standards are needed for: - terminology (content) - messaging standardized formats for the exchange of specific findings and electronic documents - definition of EHR functions For interoperable exchange of information across clinicians, institutions, payers, and vendor products standards are needed for: - terminology (content) - messaging standardized formats for the exchange of specific findings and electronic documents - definition of EHR functions

20. 20 What does this mean for Post- Acute and Long-Term Care? n In 2001, Congress was concerned about the noncomparable data in Medicare, particularly in post-acute care. n Required HHS to submit a report 1/05 on the development of standard instruments for the assessment of health and functional status of patients for whom an array of Medicare services are provided (BIPA Section 545). n In 2001, Congress was concerned about the noncomparable data in Medicare, particularly in post-acute care. n Required HHS to submit a report 1/05 on the development of standard instruments for the assessment of health and functional status of patients for whom an array of Medicare services are provided (BIPA Section 545).

21. 21 BIPA Section 545 Requires that the Secretary design standard health and functional assessment instruments so that: 1. elements that are common may be readily comparable and statistically compatible; and 2. only elements necessary to meet program objectives are collected. Requires that the Secretary design standard health and functional assessment instruments so that: 1. elements that are common may be readily comparable and statistically compatible; and 2. only elements necessary to meet program objectives are collected.

22. 22 Framing the BIPA Mandate ASPE sponsored and partnered with CMS to develop a framework for this mandate. Issues that emerged included: - a common data dictionary for functional status measurement is needed; - federally required assessments should be more clinically useful while balancing provider burden; - real-time exchange of comparable data across settings would promote continuity and coordination of care; and - HIT is needed to promote comparability of data across the continuum. ASPE sponsored and partnered with CMS to develop a framework for this mandate. Issues that emerged included: - a common data dictionary for functional status measurement is needed; - federally required assessments should be more clinically useful while balancing provider burden; - real-time exchange of comparable data across settings would promote continuity and coordination of care; and - HIT is needed to promote comparability of data across the continuum.

23. 23 Federal Efforts to Encourage EHRs, Particularly in Post-Acute and Long- Term Care (PAC/LTC) - Mayo Study - SNOMED-CT license - Consolidated Health Informatics (CHI) Initiative - Council for the Application of Health Information Technology (CAHIT) - HL7 EHR Functional Model and Standard -Study on the status of EHR implementation in PAC/LTC -Apelon Study -Modify patient assessment content and conform with CHI standards -upcoming NHII conference - Mayo Study - SNOMED-CT license - Consolidated Health Informatics (CHI) Initiative - Council for the Application of Health Information Technology (CAHIT) - HL7 EHR Functional Model and Standard -Study on the status of EHR implementation in PAC/LTC -Apelon Study -Modify patient assessment content and conform with CHI standards -upcoming NHII conference

24. 24 Mayo Study ASPE funded Mayo Clinic to examine: 1. Whether leading terminology and classification systems provide content coverage to support clinical decision-making and quality oversight in nursing homes in three domains (pressure ulcers, chronic pain, and urinary incontinence). 2.Whether MDS v.2 content provides the information needed to understand quality. 3. Whether MDS v.2 content is captured by selected terminology/ classification systems (SNOMED- CT, ICF, and ICNP). ASPE funded Mayo Clinic to examine: 1. Whether leading terminology and classification systems provide content coverage to support clinical decision-making and quality oversight in nursing homes in three domains (pressure ulcers, chronic pain, and urinary incontinence). 2.Whether MDS v.2 content provides the information needed to understand quality. 3. Whether MDS v.2 content is captured by selected terminology/ classification systems (SNOMED- CT, ICF, and ICNP).

25. 25 Mayo Study Findings – Coverage Provided by Terminologies and Classifications n SNOMED CT provides relatively complete coverage of terms suggested by the experts and the literature as needed to understand quality in the domains of pressure ulcers, pain, and incontinence (77% - 95% match rates). n ICF and ICNP provided less than 20% complete match rates of the terms suggested by experts n SNOMED CT provides relatively complete coverage of terms suggested by the experts and the literature as needed to understand quality in the domains of pressure ulcers, pain, and incontinence (77% - 95% match rates). n ICF and ICNP provided less than 20% complete match rates of the terms suggested by experts

26. 26 MDS Findings n MDS provides limited coverage of terms needed to understand nursing home quality in the domains of incontinence and pain; better coverage for the domain of pressure ulcers. n Most MDS data is not captured by SNOMED CT, ICF, or ICNP: - SNOMED CT provided a complete match for 46% of the MDS terms; and - ICF and ICNP were found to provide a complete match for terms in the MDS 2% and 12% of the time, respectively. n MDS provides limited coverage of terms needed to understand nursing home quality in the domains of incontinence and pain; better coverage for the domain of pressure ulcers. n Most MDS data is not captured by SNOMED CT, ICF, or ICNP: - SNOMED CT provided a complete match for 46% of the MDS terms; and - ICF and ICNP were found to provide a complete match for terms in the MDS 2% and 12% of the time, respectively.

27. 27 SNOMED-CT n HHS acquired a licensed with the College of American Pathologists (CAP) to make SNOMED- CT freely available to U.S. health care entities. n SNOMED-CT is recognized as the worlds most comprehensive clinical terminology database (350,000+ terms). n SNOMED-CT is available via the Unified Medical Language System (UMLS) at the NLM/HHS. n HHS acquired a licensed with the College of American Pathologists (CAP) to make SNOMED- CT freely available to U.S. health care entities. n SNOMED-CT is recognized as the worlds most comprehensive clinical terminology database (350,000+ terms). n SNOMED-CT is available via the Unified Medical Language System (UMLS) at the NLM/HHS.

28. 28 Consolidated Health Informatics Initiative Presidents e-Gov initiative includes the CHI Initiative. n Goal: Working in sync with the health industry, adopt standards that enable inter-operability in federal health care enterprise. n Involved agencies include: HHS, VA, DoD n Process: For specified domains, workgroups identified and made recommendations for standards that meet federal health information needs. Presidents e-Gov initiative includes the CHI Initiative. n Goal: Working in sync with the health industry, adopt standards that enable inter-operability in federal health care enterprise. n Involved agencies include: HHS, VA, DoD n Process: For specified domains, workgroups identified and made recommendations for standards that meet federal health information needs.

29. 29 CHI Standards Adopted Adopted March 2003 1. Laboratory Results Names: LOINC ® adopted 2. Messaging Standards: Includes scheduling, medical record/image management, patient administration, observation reporting, financial management, patient care: HL7 ® adopted 3. Messaging Standards: Includes retail pharmacy transactions NCPDP SCRIPT ® adopted 4. Messaging Standards: Connectivity: IEEE 1073 adopted 5. Messaging Standards: Includes Image Information to Workstations: DICOM ® adopted Adopted March 2003 1. Laboratory Results Names: LOINC ® adopted 2. Messaging Standards: Includes scheduling, medical record/image management, patient administration, observation reporting, financial management, patient care: HL7 ® adopted 3. Messaging Standards: Includes retail pharmacy transactions NCPDP SCRIPT ® adopted 4. Messaging Standards: Connectivity: IEEE 1073 adopted 5. Messaging Standards: Includes Image Information to Workstations: DICOM ® adopted

30. 30 CHI Standards Adopted May 2004 Demographics (HL7 ® ) Lab Result Contents (SNOMED CT ® ) Units (HL7 ® ) Immunizations (HL7 ® ) Medications (Federal Drug Terminologies, FDA Standards, RxNorm, VAs National Drug File Reference Terminology) Interventions/Procedures: Lab Test Order Names (LOINC ® ) Interventions/Procedures: Non-Lab (SNOMED-CT ® ) Demographics (HL7 ® ) Lab Result Contents (SNOMED CT ® ) Units (HL7 ® ) Immunizations (HL7 ® ) Medications (Federal Drug Terminologies, FDA Standards, RxNorm, VAs National Drug File Reference Terminology) Interventions/Procedures: Lab Test Order Names (LOINC ® ) Interventions/Procedures: Non-Lab (SNOMED-CT ® )

31. 31 CHI Standards Adopted May 2004 Anatomy (SNOMED CT ® and NCI Thesaurus) Diagnosis/Problem Lists (SNOMED CT ® ) Nursing (SNOMED CT ® ) Financial/Payment (HIPAA Transactions and Code Sets) Genes and Proteins (Human Genome Nomenclature – HUGN) Clinical Encounters (HL7 ® ) Text-Based Reports (HL7 ® – Clinical Document Architecture) Chemicals (EPAs Substance Registry System) Anatomy (SNOMED CT ® and NCI Thesaurus) Diagnosis/Problem Lists (SNOMED CT ® ) Nursing (SNOMED CT ® ) Financial/Payment (HIPAA Transactions and Code Sets) Genes and Proteins (Human Genome Nomenclature – HUGN) Clinical Encounters (HL7 ® ) Text-Based Reports (HL7 ® – Clinical Document Architecture) Chemicals (EPAs Substance Registry System)

32. 32 CHI Domains with No Standard Physiology Medical Devices and Supplies History and Physical Disability Multimedia Population Health Physiology Medical Devices and Supplies History and Physical Disability Multimedia Population Health

33. 33 CHI - Disability Domain Workgroup lead by ASPE and comprised of representatives from: CMS, NCHS, VA, SSA n Extended content coverage analyses of SNOMED-CT, ICF, and other sources in the UMLS Metathesaurus for terms sampled from: - NH MDS - HH OASIS - FIM (used by the VA and included in the Medicare Rehab Hospital patient assessment instrument) - Social Security Administration - National Center for Health Statistics Workgroup lead by ASPE and comprised of representatives from: CMS, NCHS, VA, SSA n Extended content coverage analyses of SNOMED-CT, ICF, and other sources in the UMLS Metathesaurus for terms sampled from: - NH MDS - HH OASIS - FIM (used by the VA and included in the Medicare Rehab Hospital patient assessment instrument) - Social Security Administration - National Center for Health Statistics

34. 34 Disability Workgroup (contd) Findings: n neither SNOMED CT nor ICF adequately address the disability data or scaling needs of involved federal agencies. n The CHI Council recommended that: - work proceed to refine an existing granular terminology; -consider whether and how incorporation into LOINC of disability questions could contribute to future standardization of disability questions; and -enhance LOINC coverage of disability questions used by the Federal government. Findings: n neither SNOMED CT nor ICF adequately address the disability data or scaling needs of involved federal agencies. n The CHI Council recommended that: - work proceed to refine an existing granular terminology; -consider whether and how incorporation into LOINC of disability questions could contribute to future standardization of disability questions; and -enhance LOINC coverage of disability questions used by the Federal government.

35. 35 Council for the Application of Health Information Technology The Secretary of HHS created CAHIT in 6/03 to promote a timely exchange of information about and across relevant HHS activities and opportunities. CAHIT establishes the Departments position on health information technology issues after considering opinions and perspectives from HHS agencies and offices. The Secretary of HHS created CAHIT in 6/03 to promote a timely exchange of information about and across relevant HHS activities and opportunities. CAHIT establishes the Departments position on health information technology issues after considering opinions and perspectives from HHS agencies and offices.

36. 36 CAHIT Coordination Role – Example: - Coordinated efforts to modify the MDS to support implementation of EHRs. - CMS is funding work to enhance the clinical content of the MDS. - CMS and ASPE will fund work to embed CHI standards in the MDS to maximally support EHR implementation. - Coordinated efforts to modify the MDS to support implementation of EHRs. - CMS is funding work to enhance the clinical content of the MDS. - CMS and ASPE will fund work to embed CHI standards in the MDS to maximally support EHR implementation.

37. 37 Study on Electronic Health Information in Post-Acute and Long-Term Care n ASPE funded UCHSC to study the current status of implementation of interoperable electronic health information systems (EHIS) in nursing homes, home health agencies, and rehabilitation facilities. n A written report will be available 7/04 summarizing findings and recommendations the public and private sectors could pursue to accelerate the adoption of EHRs in post-acute and long-term care. n ASPE funded UCHSC to study the current status of implementation of interoperable electronic health information systems (EHIS) in nursing homes, home health agencies, and rehabilitation facilities. n A written report will be available 7/04 summarizing findings and recommendations the public and private sectors could pursue to accelerate the adoption of EHRs in post-acute and long-term care.

38. 38 Study on Content and Messaging Standards and the MDS n ASPE is funding Apelon to examine the applicability of terminology and messaging standards for selected MDS items. Specifically, we have asked Apelon to: - Examine, for selected MDS v.2 and v. 3 items, the ability to encode MDS questions and answers in LOINC and standardized terminologies (e.g., SNOMED and CHI-endorsed standards); and - advance options for how an MDS redesign could use terminology and messaging standards. Study to be complete in July 2004. n ASPE is funding Apelon to examine the applicability of terminology and messaging standards for selected MDS items. Specifically, we have asked Apelon to: - Examine, for selected MDS v.2 and v. 3 items, the ability to encode MDS questions and answers in LOINC and standardized terminologies (e.g., SNOMED and CHI-endorsed standards); and - advance options for how an MDS redesign could use terminology and messaging standards. Study to be complete in July 2004.

39. 39 Technology Website n ASPE funded "Technology for Long Term Care" to develop a website to on information on technologies that can help improve quality of life and care for the elderly and the disabled in LTC residential settings. n www.TechForLTC.org provides information for professionals in NHs, ALFs, board and care facilities, ADC facilities, and CCRC. n ASPE funded "Technology for Long Term Care" to develop a website to on information on technologies that can help improve quality of life and care for the elderly and the disabled in LTC residential settings. n www.TechForLTC.org provides information for professionals in NHs, ALFs, board and care facilities, ADC facilities, and CCRC.

40. 40 Upcoming NHII Conference n Participation is important n NHII Website: http://aspe.hhs.gov/sp/nhiihttp://aspe.hhs.gov/sp/nhii n Participation is important n NHII Website: http://aspe.hhs.gov/sp/nhiihttp://aspe.hhs.gov/sp/nhii

41. 41 Jennie Harvell Office of the National Coordinator on Health Information Technology/ HHS Jennie.Harvell@hhs.gov 202/690-6443 n http://aspe.hhs.gov/daltcp/home.shtml http://aspe.hhs.gov/daltcp/home.shtml Jennie Harvell Office of the National Coordinator on Health Information Technology/ HHS Jennie.Harvell@hhs.gov 202/690-6443 n http://aspe.hhs.gov/daltcp/home.shtml http://aspe.hhs.gov/daltcp/home.shtml