Key Initiatives on Health Information Technology

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Key Initiatives on Health Information Technology

• AHIMA Long-Term Care Health IT Summit
• August 22, 2005
• Susan Christensen
• Agency for Healthcare Research and Quality

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Overview

• Current State
• What is HIT Were Talking About?
• Federal Leadership Broadly
• Standards
• Federal Activities More Focused
• Pending Legislation
• Appendix More detail, drilling down into
  standards, implications for LTC

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Current State

• Health care, particularly LTC, is fragmented by
  provider, time and payer, creating opportunities
  for errors, including
• incomplete/contradictory health information over
  time and at points of transition
• medication errors
• delivery of unnecessary services
• This fragmentation is also a barrier to
  coordinated care, chronic care management, and
  outcomes measurement, hindering
  patient-centeredness, efficiency, equity and
  research for quality improvement

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Beyond Ready Essential to Change

• Crossing the Quality Chasm (IOM, 2001) six
  specific aims for improvement health care should
  be safe, effective, patient-centered, timely,
  efficient, and equitable.
• The committee believes IT must play a central
  role in the redesign of the health care system if
  a substantial improvement in quality is to be
  achieved during the coming decade.
• IT has barely touched patient care.

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Where is US Health Care and IT?
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So What Is HIT?

• National health information infrastructure is not
  a centralized government database, but rules for
  the road that offer a way to connect distributed
  health data in the framework of a secure network.
  (IOM, 2001) We need
• National standards to protect privacy
• National consensus on comprehensive standards for
  the definition, collection, coding, and exchange
  of clinical data
• Strong leadership to address legal, societal,
  organizational, and cultural issues
• Public knowledge of IT issues and benefits

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Federal Leadership

• Presidents Executive Order 13335 (April 2004)
  federal leadership for the development of a
  nationwide interoperable electronic health
  information system
• Created Office of the National Health Information
  Technology Coordinator in HHS
• Vision
• Appropriate clinical information available at
  time and place of care
• Increased EBM and patient safety
• Reduction of costs from service duplication
• Improved care coordination across continuum of
  providers
• ONCHIT required to develop a national strategic
  plan to support
• Public-private collaboration to develop, adopt
  and implement standards
• Evaluate benefits of HIT
• Address privacy and security issues
• ONCHIT serves as principal advisor to Secretary
  on national HIT policy, coordinates federal
  activities, and coordinates public-private
  outreach and consultation

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AHIC

• In July, the Secretary announced the creation of
  American Health Information Community (AHIC),
  chaired by the Secretary
• Formed under auspices of FACA, AHIC will provide
  input and recommendations to HHS on how to make
  health records digital and interoperable and
  assure that privacy and security are protected
• Representatives of DoD, VA and other federal
  agencies with large stake in healthcare IT
• 17 Commissioners currently soliciting
  nominations from consumer groups, providers,
  payers, hospitals, vendors, privacy interests,
  and any other member of public
• Dissolution within two to five years with goal of
  creating self-sustaining, private sector
  replacement

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HIT Standards

• The use of HIT standards will enable
• Exchange of information across clinicians,
  institutions, and payers
• Reuse of information
• To realize the Presidents vision and support
  interoperable information exchange and reuse,
  standards are needed
• Terminology
• Messaging
• Definition of EHR functions
• Privacy, security, and reliability

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Importance of Content and Messaging Standards

• Content standards permit a common, agreed-upon,
  detailed vocabulary and code for all medical
  terminology.
• Messaging standards provide a format for the
  information being sent so computers can read a
  message and know
• - Who is the sender and intended receiver
• - What information is being sent
• - Where is the information in the message

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Activities Related to HIT Standards

• Public and private sectors have worked to develop
  and endorse various standards, including
• Federal Government entered into a licensed with
  the College of American Pathologists (CAP) to
  make SNOMED-CT freely available to U.S. health
  care entities.
• The Federal Consolidated Health Informatics (CHI)
  Initiative worked in sync with the healthcare
  industry and endorsed content and messaging
  standards for use in federal healthcare
  enterprise.

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Four Major HHS RFPs

• To implement the Department's health IT strategy,
  HHS issued four requests for proposals (RFPs).
  http//www.hhs.gov/healthit/contracts.html
• Develop, create prototypes for, and evaluate a
  process to unify and harmonize industry-wide
  health IT standards
• Develop, create prototypes for, and evaluate a
  conformance certification process for health IT,
  including the infrastructure or network
  components through which health IT systems
  interoperate.
• Assess and develop plans to address variations in
  organization-level business policies and state
  laws that affect privacy and security practices
  which may pose challenges to interoperable health
  information exchange.
• Develop, and create prototypes for, and evaluate
  a nationwide health information network (NHIN)
  architecture for widespread health information
  exchange that can be used to test specialized
  network functions, security protections and
  monitoring, and demonstrate feasibility of
  scalable models.

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Other HHS HIT Activities

• DOQ-IT - promote adoption and use of IT in
  small/medium physician offices via QIOs
• Medicare Care Management Performance
  Demonstration (MMA Section 649) Demonstration
  to reward reward physicians for using HIT and
  clinical outcomes add-on to the fee schedule
• Medicare Chronic Care Improvement (MMA Section
  721) Population-based chronic care management
  with reimbursement based on clinical improvement,
  patient satisfaction, and cost savings results

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HHS Research

• Federal Patient Assessment Tools (starting with
  the NH Minimum Data Set)
• CMS Research Enhancing clinical utility of the
  MDS
• ASPE/CMS Research Standardizing MDSv3 content
• Upcoming
• RFP to pilot test additional standards needed for
  e-prescribing as required under the MMA (CMS)
• Convene e-prescribing meetings to discuss next
  steps (including in NHs) (AHRQ)
• Evaluation Design of the Business Case for Health
  Information Technology in LTC (ASPE)
• Information Exchange at Times of Transition (ASPE)

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Selected FY 04 AHRQ HIT Initiatives

• Transforming Healthcare Quality through
  Information Technology (THQIT)
• 3 Grant Solicitations planning, implementation,
  and value assessment
• Focused on community partnerships
• http//www.ahrq.gov/research/hitfact.htm
• 60M initiative
• 26M to implement proven technologies in small
  and rural communities where HIT penetration has
  been low
• 24M targeted for developing, implementing, and
  evaluating the use of new and innovative
  technologies to improve patient safety and
  quality of care in diverse health care settings
• 10M targeted for clinical data standards and
  interoperability

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State and Regional HIT Demonstrations

• Five-year state-based contracts
• Help states develop secure statewide networks
• Ensure privacy of health information
• Make an individuals health information more
  available to health care providers
• FY04 Five states awarded 1M/year
• Colorado
• Indiana
• Rhode Island
• Tennessee
• Utah

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AHRQ National Resource Center for Health
Information Technology

• Provides technical and expert support to health
  IT grantees, contractors, and selected other
  federal grantees (HRSA, CMS, IHS)
• Contract award to NORC (up to 18.5M over 5
  years), In partnership with
• Vanderbilt University
• Center for IT Leadership (Partners)
• Indiana University
• Foundation for the eHealth Initiative
• CSC
• Burness Communications
• http//healthit.ahrq.gov/home/index.html

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AHRQ Activities Today

• AHRQ is in process of contracting for a national
  assessment of privacy and security practices at
  the business level, developed in response to
  HIPAA, state law, and other concerns, that
  challenge the development of interoperable health
  information exchange
• Likely single contractor to manage subcontracted
  work in up to 40 states
• Stakeholders at the local/regional level will
  work to identify these practices and to develop
  solutions that can be generalized to the national
  level

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HIT Research in LTC

• Private Sector Research
• - EHR functional model and standards (HL7 DSTU)
  and MFS for LTC (HL7)
• EHR implementation in 1 NH (Cherry)
• AHRQ Research
• HIT applications (e.g., CPOE), transitions across
  care settings, and care planning
• E-prescribing in NHs (e.g., Gurwitz)
• ASPE Research
• Pilot test to standardize NH MDS (Apelon)

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ASPE Research Mayo Study

• Toward a National Health Information
  Infrastructure A Key Strategy for Improving
  Quality in Long-Term Care
• Do leading terminology and classification systems
  provided content coverage to support clinical
  decision-making and quality of care oversight in
  nursing homes as recommended by clinical experts
  and as reflected in the literature?
• SNOMED CT relatively complete
• ICF and ICNP very little
• Does the content of the federally required
  nursing home minimum data set (MDS) provide the
  information needed to understand quality of care
  in nursing homes in the three selected domains?
  Very limited coverage
• To what extent is the content of MDS captured by
  three terminology systems? Most is not captured

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ASPE Research Colorado Study

• Case Studies of Electronic Health Records in
  Post-Acute and Long-Term Care Recommendations
• The content of federally-required patient
  assessments instruments data sets should be
  information that would otherwise be routinely
  collected
• Integrate health information technology standards
  into the development and modification of
  federally mandated data sets
• Work to fill the gaps in the disability content
  in existing standardized, codeable terminologies.

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Colorado Study, contd

• Engineer, implement, refine, and disseminate to
  the public, the specifications for an electronic
  care transfer document that would embed the
  clinical content needed at times of transfers
  from acute care hospitals to nursing homes
• Develop a method for the timely exchange of this
  information in environments with or without
  interoperable EHRs.
• Examine the costs and benefits to nursing home
  patients, providers, the health system, and
  payers of implementing interoperable electronic
  medication management and administration systems
  in nursing homes and develop options for
  promoting the use of these systems.

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Other Study Findings Include

• Federal patient assessment forms create a barrier
  to HIT interoperation because content is not
  comparable across settings, always clinically
  relevant, and standardized (Mayo).
• Health information systems in PAC/LTC were not
  interoperable with more robust EHRs (UCHSC).
• Highly valued functions of the EHRs in PAC/LTC
  include real time information at times of
  transition, CPOE, and automated medication
  administration record (UCHSC).
• Patient assessment tools can be conformed with
  HIT standards (Apelon).

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Legislation Senate (S. 1418)

• Establishes American Health Information
  Collaborative - public-private consultation on
  standards development
• Codifies Office of the National Coordinator for
  HIT (ONCHIT)
• Provides grant funding for
• Implementation of regional/local HIT Plans
• Physicians, hospitals or other healthcare
  providers
• State loan programs for sustainability
• Total grants 125 million in FY06, 150 million
  in FY07 and such sums as needed thereafter
• Establishes Center for Best Practices to provide
  technical assistance and develop best practices
  to support and accelerate efforts to adopt,
  implement, and effectively use interoperable HIT
• Reauthorizes incentive grants for telemedicine

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Legislation House

• Health Information Technology Promotion Act
  Ways Means Health Subcommittee still in
  draft/not introduced yet
• Codifies ONCHIT, establishes safe harbor,
  requires adoption of ICD-10-CM and -PCS codes
• Study of state privacy/confidentiality laws and
  report on recommendations for harmonization
• No upfront or ongoing funding for health
  information exchanges or providers
• Introduction after recess
• Energy Commerce Committee drafting bill may
  include funding/grant provisions
• Follow legislation at thomas.loc.gov

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Resources

• 1. ASPE/Disability, Aging, and LTC Policy
  Reports http//aspe.hhs.gov/_/office_specific/dal
  tcp.cfm
• 2. HL7 http//www.hl7.org
• 3. CHI Reports
• http//www.whitehouse.gov/omb/egov/c-3-6-chi.html
• 4. Executive Order http//www.whitehouse.gov/news
  /releases/2004/04/20040427-4.html
• 5. ONCHIT http//www.hhs.gov/healthit/
• 6. CCHIT www.cchit.org

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• For additional information, please contact
• Susan Christensen, schristensen_at_ahrq.gov
• 703.489.2284

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CHI

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

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Implications

• What are the implications of the standards
  development activity for patients with chronic
  illness and disability who are served by multiple
  providers across settings?
• Example most NH residents are treated by
  attending physicians not employed by the NH and
  have community and hospital-based practices.
• When acquiring health IT products, physicians and
  LTC providers (e.g., NH, HHA) should consider
  standards-based software products that will
  support and promote electronic information
  exchange across providers/settings.

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Implications

• What are the implications for clinicians who
  treat patients with chronic illnesses/disabilities
  if physicians use certain HIT and/or designated
  health service entities exchange HIT items or
  services with physicians?
• To support low-cost interfacing and maximize HIT
  functionality, use of standards-based systems
  will be essential.

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HHS E-Rx NPRM (2/4/05)

• Proposed MMA Part D E-Rx standards include
• Standards to support messaging between
  prescribers, dispensers, and Part D sponsors.
• Standards support the exchange of information for
  all prescribing transactions (except the
  prescription fill status notification
  transaction) including prescription requests and
  responses related to new, refills, change, and
  cancellation prescription request and response
  transactions.

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Implications

• What are the implications for e-prescribing on
  behalf of patients in LTC or PAC?
• Prescription workflow in NHs includes physician,
  NH, pharmacy, insurer(s)
• Are additional standards needed to support these
  communications?

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NCPDP LTC Workgroup (WG14)

• NCPDP creates and promotes standards for data
  transfer to and from the pharmacy. ncpdp.org
• WG 14 guides and advises payers and providers of
  the LTC industry and institutional pharmacy
  programs and their agents on standards
  implementation, supports data processing
  initiatives, and provides design alternatives for
  standards used within the LTC
• NCPDP WG 14 is examining the LTC prescribing
  workflow and identifying gaps in standards.