What’s On the Horizon? A National Perspective

1. What’s On the Horizon?A National Perspective Chris Muir Acting Director State Health Information Exchange Program ONC

2. E-Patient Dave Cancer Survivor and Proud Father

3. It is About Life! BIRTH Injury and Acute Illness Family History Genetics Environmental Exposures Death Chronic Illness Lifestyle Intervene Predict & Prevent Manage 1. Adapted from Dr. Jonathan B Perlin, Healthcare 2015 & beyond: Some Thoughts on Planning Ahead, p. 95

4. HIT is the Foundation • Intervene during sickness or injury • Manage health and conditions • Predict and prevent future problems

5. National Quality Strategy • 2nd Annual Report • Developed with significant stakeholder input • Process managed by AHRQ • Goals: • Improve the delivery of health care services, patient health outcomes, and population health • Build a consensus on how to measure quality so that stakeholders can align their efforts for maximum results • Serves as a framework for quality measurement, measure development, and analysis of where everyone can do more, including across HHS agencies and programs as well as in the private sector

6. National Quality Strategy Three aims for the health care system: • Better Care: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible, and safe • Healthy People and Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants • Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government

7. National Quality Strategy Six priorities: • Making care safer by reducing harm caused in the delivery of care • Ensuring that each person and family are engaged as partners in their care • Promoting effective communication and coordination of care • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease • Working with communities to promote wide use of best practices to enable healthy living • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models

8. National Quality Strategy HHS Actions since the original report: • Nationwide Initiatives to Advance Quality Improvement • Alignment of Measurements • Key Measures to Track National Progress • State Adoption of the National Quality Strategy

9. National Quality Strategy HIT is a necessary part of the infrastructure to support NQS: • Population Health • Quality Measures • Care Coordination • Consumer Engagement • Improving Quality and Efficiency

10. Major ONC Activities • Privacy and Security • Meaningful Use • Consumer Engagement • Interoperability

11. Privacy and Security • Privacy and Security associated with Meaningful Use phase I, II and III • EHRs • Server based v. Cloud based EHR models • Health Information Exchange • Provider-to-provider • Decentralized with a record locator service • Centralized data bases Different models raise different privacy concerns • Developing trust across the HIT spectrum “Adoption at the Speed of Trust”

12. Meaningful Use • ONC’s Major policy imperative for the foreseeable future • Stage 2 – requirements recently released • Hospitals can qualify October 2013 • Eligible Providers can qualify January 2014 • Additional requirements for exchange , such as: • Summary of Care • Lab Results • Immunizations • Reportable Lab Conditions • Cancer Registries • Stage 3 – currently under development

13. Engaging Consumers 90% of care needed to manage a chronic disease must come directly from the patient (CGCF) 10% to 20% of outcomes are determined by health care.

14. Three A’s for Consumer Engagement

15. Consumer Outreach Major accomplishments: • Meaningful Use Stage 2 requirements for providers and hospitals advances patient access to data through view, download & transmit. • The ONC Pledge Program has grown more than 10 fold -- to 400 participating organizations. • The Blue Button has evolved beyond its roots at the VA to reach 1 million members and is poised to go much bigger--management of it has now transferred over to HHS

16. ONC’s Health Information Exchange StrategyHealth Affairs - March 5th, 2012

17. Information Securely Follows Patients Whenever and Wherever They Seek Care QUERY-BASED EXCHANGE MULTIPLE MODELS DIRECTED CONSUMER-MEDIATED EXCHANGE

18. HIE Market Reality • HIE facilitated by a variety of organizations including: • HIOs • EHR vendors • National services providers • Hospitals • ACOs • Others

19. ONC’s Approach • Interoperability is a journey, not a destination • Leverage government as a platform for innovation to create conditions of interoperability • Health information exchange is not one-size-fits-all • Multiple approaches will exist side-by-side • Build in incremental steps – “don’t let the perfect be the enemy of the good”

20. ONC’s Role Reduce Cost and Increase Trust and Value To Mobilize Exchange ONC

21. We Made Big Strides to Enable Exchange in Stage 1 The first challenge was to make sure that information produced by every EHR was understandable by another clinician and could be incorporated into his EHR With the vocabularies, code sets and content structure standards in Stage 1 meaningful use every certified EHR can produce the standardized content needed: • Produce and consume a standardized care summary • Maintain standardized medication lists • Consistently report quality measures and public health results • Consume structured lab results

22. Additional Critical Pieces Are Now In Place Next we needed a common approach to transport, allowing information to move from one point to another • We now have two easily adopted standards for transporting information – NwHIN Direct and the transport protocol used in NwHIN Exchange And it was clear that we needed more highly specified standards to support care transitions and lab results delivery • For the first time in our country’s history there is a single, broadly-supported electronic data standard for patient care transitions

23. This Year We Are Addressing Components to Support Scalable Exchange • Directories – standards and policies to make them consistent, reliable, findable and open to be queried • Certificate management and discovery - common guidelines for establishing and managing digital certificates and making the public keys “findable” • Creating Trust - baseline set of standards and policies that will accelerate exchange by assuring trust and reducing the cost and burden of negotiations among exchange participants

24. Building Blocks for Exchange Vocabulary & Code Sets How should well-defined values be coded so that they are universally understood? Content Structure How should the message be formatted so that it is computable? Transport How does the message move from A to B? Services How do health information exchange participants find each other? Policies What are the policies needed to assure trust and protect information?

25. Standards, Services and Policy Building Blocks Vocabulary & Code Sets SNOMED CT (Problems) ICD-9-PCS/ HCPCS & CPT-4 (Procedures) ICD-9-CM (Prelim Cause of Death & Encounter Diagnoses) RxNorm (Medications) LOINC Content Structure Consolidated CDA (Sum. Record) HL7 2.5.1 IG – Lab Result Interface Direct Specifications SOAP – Secure Transport (NwHIN Exchange Spec) Transport Services Provider Directory MPI Queryable Data Repository Consumer Controlled Data Platform Certificate Management and Discovery RLS Policies HIPAA Provider authentication Meaningful Patient Choice Populating RLS, MPI Governance Data platform policies Consumer authentication/matching Electronic patient access Audit and correction 24

26. State HIE Program FOCUS Give providers viable options to meet MU exchange requirements • E-prescribing • Care summary exchange • Lab results exchange • Public health reporting • Patient engagement APPROACH • Make rapid progress • Build on existing assets and private sector investments • Every state different, cannot take a cookie cutter approach • Leverage full portfolio of national standards

27. Making Progress: Directed Exchange Implementation Status as of June 30, 2012 Office of the National Coordinator for Health Information Technology

28. Making Progress: Organizations and Staff Enabled for Query-based Exchange as of June 30, 2012 Office of the National Coordinator for Health Information Technology

29. Near Term Challenges • Taking standards from the S&I Framework and support community-driven implementation initiatives to advance adoption of standards • ONC striving to provide: • Identify workable approaches • Implementation guidelines • Provide outreach and dissemination

30. Key Takeaways for HIE • Although not perfect, does it represent the best we have so far? • Does it support our policy objectives? • Interoperability is not “one size fits all”: • Create modular standards and specifications that allow for innovation • Internet Metaphore: we’re not building AOL; we’re creating the building blocks to make it possible for Facebook and Twitter to flourish • We are on a journey together! 29

31. Some Ideas about the future • Supporting ACO and other payment reform models to improve efficiencies • Enable patients to make better health decisions through access and tools: • Predict and prevent medical conditions • Manage chronic conditions • Identify impacts of lifestyle choices • Enable better tools for providers to help patients manage chronic conditions, acute injuries and illnesses • Better support transitions of care • Automatically populating personal health records • Enable home health care • Enable population health studies for predicting and preventing medical conditions • Aggregating and analyzing data

32. Donna Cryer Liver Transplant Survivor and Style Maven