The AHQA 2005 Annual Meeting and Technical Conference February 23 25, 2005

1. The AHQA 2005 Annual Meeting and Technical ConferenceFebruary 23�25, 2005 Jennie Harvell

2. The Problem Growing number of persons with chronic illnesses and disabilities. Single Condition Multiple Conditions 2000 125 million 60 million 2010 141 million 70 million Persons with chronic illnesses and disabilities need and use a variety of health care services from a variety of health care providers over extended periods of time.

3. Implications - Costs The majority (70%) of health care expenditures arise from chronic conditions (RWJF). Annual health care expenditures: Health Services NH and HH 1999: $1.2 Trillion $123 billion 2001: $1.4 billion $135 billion 2003: $1.6 Trillion $151 billion 2013a: $3.2 Trillion $258 billion a projected Source: CMS/OACT (Health Affairs)

4. Implications- Negative effects on safety, quality, and costs Health care delivery is siloed across providers, over time, and payers, creating opportunities for errors that threaten patient safety, quality of care, and increase costs, including: - incomplete/contradictory health information over time and at points of transition - medication errors - unnecessary hospitalizations - delivery of unnecessary services

5. Health Information Technology Part of the Solution �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 �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.� --President George W. Bush, April 27, 2004 C President announced the goal of assuring that most Americans have EHRs within the next 10 years. (4/27/04)

6. HIT: A Key Policy Initiative President�s Executive Order (4/27/04): - requires development of a nationwide interoperable HIT infrastructure - calls for the use HIT standards - creates the National Health Information Technology Coordinator in HHS - requires key issues affecting the adoption of HIT be addressed (including the evidence on the benefits and costs and privacy and security issues).

7. Evidence for HIT Increasing evidence that use of HIT improves patient safety, quality, and continuity of care. For example: - Computerized Physician Order Entry (CPOE): several studies found CPOE prevents unnecessary hospital admissions, lowers hospital costs and lengths of stay, and allows more complete discharge summaries; and - In several studies, electronic clinical decision support systems increased clinician�s compliance with guidelines, and decreased unnecessary laboratory testing and medication use.

8. Interoperable Health Information Technology The promise of interoperable HIT is based in part on the ability of computers to exchange and reuse health information. Interoperable health information requires: - clear, unambiguous data - data that can be encoded -ability of computers to send and receive electronic information (i.e., messaging)

9. HIT Standards For interoperable exchange of information across clinicians, institutions, payers, and vendors standards are needed for: - content (terminology) - messaging standardized formats for the electronic exchange of specific findings and documents - definition of EHR functions

10. Standards (cont�d) Public and private sectors have worked to develop and endorse various standards, including: Federal Government entered into a license 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 health industry and endorsed content and messaging standards for use in federal health care enterprise.

11. CHI Standards CHI adopted standards across 20 clinical domains including:

12. CHI adopted standards (cont�d) Messaging standards scheduling, medical record/image management, patient administration, observation reporting, financial management, patient care (HL7�) Retail pharmacy transactions (NCPDP SCRIPT�) Connectivity (IEEE� 1073) Image Information to Workstations (DICOM�)

13. Why are content standards important? Standards are a mechanism by which there can be a common, agreed-upon, detailed vocabulary for all medical terminology. Without a standard: �high blood pressure� �elevated blood pressure� �hypertension� With a standard C487231, hypertension Unambiguous meaning for both sender and receiver

14. Why are messaging standards important? Messaging standards provide a format for the information being sent so computers can �read� a message. Messaging standards include: - Who is the intended sender and receiver - What information is being sent - Where is the information in the message Partial example: �phone number� message If first digit is 1, then long distance, otherwise local First 3 digits area code; next seven digits telephone number

15. HL7 Message Segments � An Example MSH|^~\&|||||19981105131523||ORU^R01| PID|||100928782^9^M11||Smith^John^J| OBR||||Z0063-0^BP^LN| OBX||CE|8361-^POSITION^LN||SIT^Sitting| OBX||NM|8479-8^SBP^LN||138|mmHg| Source: Susan Matney (modified)

16. EHR Standards Public/private sponsorship of HL7 to develop EHR standards HL7 EHR Functional Model and Standards DSTU is divided into three sections: - Direct Care - Supportive - Information Infrastructure The EHR Model and Standards specify 125 functions that may be present in an EHR. http://www.hl7.org/ehr/downloads/index.asp

17. HIT Research in LTC ASPE Research: -��Toward the NHII: A Key Strategy for Improving Quality in LTC�(Mayo) Case Studies in EHRs in PAC/LTC (UCHSC) EHR functional model and standards (HL7) Pilot Test to Standardize the NH Minimum Data Set (MDS) �(Apelon) ASPE/CMS Research: - Standardizing MDSv3 content Private Sector Research: - Develop minimum function set for EHR model in LTC (HL7) Some e-prescribing research in nursing homes (e.g., Gurwitz) Impact of EHR implementation in 1 NH (Cherry) AHRQ Research: HIT applications (e.g., CPOE), transitions across care settings, and care planning CMS Research: - Refining the MDS

18. 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.

19. Mayo Findings Codeable vocabularies provide limited coverage of terms and concepts important for NH quality. MDS not based on standardized terminology, does not support coding of needed clinical data captured at the point of care, and provides limited coverage of terms needed to understand NH quality. SNOMED-CT covered about 50% of the sampled MDS terms. Other studied vocabularies provided very little coverage.

20. Study on EHRs in Post-Acute and Long-Term Care ASPE funded UCHSC to study the current status of implementation of interoperable electronic health information systems in nursing homes, home health agencies, and rehabilitation facilities. Conducted site visits to four leading-edge health systems that used HIT to exchange patient data across settings and over time.

21. UCHSC EHR Study -- Findings Each health system was able to exchange information within its system generally without HIT standards. Failure to use standards contributed to inability exchange electronic information with unaffiliated providers. Early adopters will be challenged to conform HIT systems with national HIT standards.

22. UCHSC EHR Study -- Findings Information systems for PAC/LTC were not interoperable with more robust EHR. None of the sites were able to import information from their EHRs and populate federally data sets. Federal assessment forms were identified as a barrier to HIT interoperation because they: - are not comparable across settings, - are not always clinically relevant, and - are not standardized.

23. UCHSC EHR Study -- Findings Most highly valued function of the EHRs in PAC/LTC settings reported to be: Real time information from the hospital, pharmacists, and physicians to PAC/LTC, including at times of transition. Automated medication administration record CPOE including drug alert systems to review dosages, drug interactions, and sometimes laboratory data.

24. Benefits of HIT implementation included: Reduction in ordering time Reduction in medication error rates Improved risk management Enhanced communication across disciplines More timely clinical information

25. Standardizing the MDS ASPE sponsored Apelon to conduct a pilot study on conforming the MDS v.2 with content and messaging standards.

26. Apelon Findings It is possible to conform some MDS content with content and messaging standards. Work is needed to: enhance, clarify, and standardize clinical content. It is possible to construct HL7 messages from MDS content. Work will be needed to construct HL7 messages from MDS content. Incorporating CHI-endorsed vocabularies and messaging standards in future revisions to federally-required patient assessment forms will facilitate information exchange across settings.

27. On-Going Research: MDS v.3 CMS is sponsoring work to enhance the clinical content of the MDS. CMS and ASPE are co-sponsoring work to conform the content of a clinically enhanced MDS with CHI content and messaging standards.

28. Possible ASPE Research in HIT and PAC/LTC in 2005 1. Evaluation Design of the Business Case for Health Information Technology in Long-Term Care 2.Description of Non-Automated Medication Ordering Practices in Nursing Homes and Market Assessment of HIT Products that Could be Used for These Practices 3. Information Exchange at Times of Transition 4. Description of the Impact on Physician and Nursing Home Practices when Physicians Use Health Information Technology

29. Promoting Systems Changes through use of IT Technical assistance to providers to promote the use of HIT should reflect an understanding of the: - Provider�s work flow; Available HIT solutions and: - how they will improve work flow and how (e.g., increase efficiency, improve quality, etc.); how they use HIT standards and support information exchange; and the costs to implement and maintain.

30. 1. The Decade of Health Information Technology- Delivery Consumer-Centric and Information Rich Health Care http://www.hhs.gov/healthit/documents/hitframework.pdf 2. Information for Health - A Strategy for Building the National Health Information Infrastructure. http://aspe.hhs.gov/sp/nhii/Documents/nhiilayo.pdf 3. Case Studies of EHRs in PAC/LTC (Kramer) http://aspe.hhs.gov/daltcp/reports-c.shtml#Kramer1 4. Toward a NHII: A Key Strategy for Improving Quality in LTC (Mayo) http://aspe.hhs.gov/daltcp/reports-t.shtml#Harris1 5. CHI: Disability Domain: http://www.ncvhs.hhs.gov/031209p6.pdf Contact information: Jennie.Harvell@hhs.gov 202/690-6443