Moving the National Health Information Technology Agenda Forward

1. Moving the National Health Information Technology Agenda Forward Mayo Clinic: Centennial Of Informatics October 18, 2007 Robert M. Kolodner, MD National Coordinator Office of the National Coordinator for Health Information Technology (ONC)

2. Overview • Not the Usual ONC Presentation… • 2 complementary constructs & a range of ONC options • Transforming Health Care • Office of the National Coordinator for Health IT • Health IT’s Role • Puzzle Pieces Necessary to Reach the Tipping Point • Putting It All Together Mayo Clinic: Centennial Of Informatics

3. Transforming Health Care: Moving from Treating to Preventing to Predicting1 BIRTH Injury and Acute Illness Family History Genetics Environmental Exposures Death Chronic Illness Lifestyle Prevent Intervene Predict 1. Adapted from Perlin, Dr. Jonathan B, Healthcare 1015 & beyond: Some Thoughts on Planning Ahead, p. 95 Mayo Clinic: Centennial Of Informatics

4. Moving from Provider to Disease Management to Patient-Centric Health Care Achieving Personalized Health Care Heart Disease Diabetes Arthritis Cancer Control . . . Mayo Clinic: Centennial Of Informatics

5. The Future of Health Care – Personalized Medicine Leverage genetic information in research and routine practice • Genetic/genomic tests are used in current clinical practice for over 1,100 diseases1 • Can be used for prediction, prevention, and appropriate treatment selection Link genetic information to Electronic Health Record • EHRs can drive the uptake and adoption of new technologies such as pharmacogenetics 1. www.genetests.org Mayo Clinic: Centennial Of Informatics

6. Office of the National Coordinator (ONC) Executive Order, April 2004: The President created the National Coordinator position • To advance the vision of developing a nationwide interoperable health information technology infrastructure • To achieve the President’s goal of widespread adoption of interoperable electronic health records (EHR) by 2014 Key Role for ONC: Provide leadership for the development and nationwide implementation of an interoperable health information technology infrastructure to improve • The quality and efficiency of health care and • The ability of consumers to manage their health Key Role for ONC: Provide leadership for the development and nationwide implementation of an interoperable health information technology infrastructureto improve • The quality and efficiency of health care and • The ability of consumers to manage their health National Health IT Agenda Mayo Clinic: Centennial Of Informatics

7. Individual and Population Health & Wellbeing Coordinated Care Health IT solutions must support the needs of all three of these “perspectives.” Health Care Transformation “Through” Health IT Making health care information available electronically(reliably and securely) – a necessary step to improve the health of individuals and the nation • Perspective? Role? Other? ActivatedIndividual Community:PH, Quality, R&D Mayo Clinic: Centennial Of Informatics

8. Key Health IT Components to Enable Transformation A Robust, Interoperable, Health IT Environment that brings together: • Electronic Health Records (EHR) • Personal Health Records (PHR) • Population Health Information (Public Health, Quality Improvement, Research) • Standards (Data, Technical and Security) • Interoperable Health Information Exchange Network • (Nationwide Health Information Network - NHIN) Mayo Clinic: Centennial Of Informatics

9. EHR Adoption Transformational Change in Health Care Delivery & Health Moving Toward the Tipping Point: How Transformational Change Occurs Health IT Tipping Point 2014 TIME 2004 • Executive Order • Health IT Agenda Established Mayo Clinic: Centennial Of Informatics

10. Standards in HITProducts Privacy & Security Policies Adoption of Interoperable Health IT Nationwide Health Information Network Pieces of the Puzzle Necessary to Reachthe Health IT Adoption Tipping Point Governance

11. Privacy & SecurityPolicies Privacy & Security Issues and Activities State Level • Misinterpretation of HIPAA • Additional legal impediments to appropriate information flow • eSignature • CLIA • Liability Issues • Licensure Issues • Health Information Security & Privacy Collaboration (HISPC) • State Alliance for e-Health Mayo Clinic: Centennial Of Informatics

12. Coordinated Care Privacy & SecurityPolicies Privacy & Security Issues and Activities (2) Federal Level • HIPAA • Additional privacy & security challenges with robust exchange of electronic information health • Federal Advisory Committees (AHIC, NCVHS) • Confidentiality, Privacy & Security Workgroup (AHIC) • Developing a Privacy & Security Framework • Capabilities required for nationwide network participation ActivatedIndividual Community:PH, Quality, R&D Mayo Clinic: Centennial Of Informatics

13. Standards in HITProducts Privacy & Security Policies Adoption of Interoperable Health IT Nationwide Health Information Network Pieces of the Puzzle Necessary to Reachthe Health IT Adoption Tipping Point Governance

14. Scenarios Standards in HITProducts Priorities Coordinated Care Standards Certification Standards Summary of the Cyclical Process • Staffed the prioritization process (AHIC) • Developed the Scenarios • Established and funded public-private organizations • To identify and recommend “harmonized” standards • To create certification criteria ActivatedIndividual Community:PH, Quality, R&D Mayo Clinic: Centennial Of Informatics

15. Standards in HITProducts Priorities and Scenario (Use Case) Roadmap Mayo Clinic: Centennial Of Informatics

16. Standards in HITProducts More progress in the past 3 years than in TWO decades Standards in HIT Products Drivers For Using Standards • “Recognition” of standards by HHS Secretary • “Interoperability” required • Presidential Executive Order – August 2006 • Federal Health Information Systems • Contracts • Stark Exception and Anti-Kickback Safe Harbor • Certified deemed to be interoperable • First cycle: Spring 2006  Summer 2008 • 30 interoperability standards identified for use in health IT systems • New priority areas increasing with each cycle 3  4  6 • 92 ambulatory EHRs (>40% of the market) certified Mayo Clinic: Centennial Of Informatics

17. Standards in HITProducts Privacy & Security Policies Adoption of Interoperable Health IT Nationwide Health Information Network Pieces of the Puzzle Necessary to Reachthe Health IT Adoption Tipping Point Governance

18. Governance Governance • Inclusive of all stakeholders • Otherwise the solutions are sub-optimized • May replicate down to state, tribal, and local communities • Barrier is lack of trust across the stakeholder sectors • Manages prioritization and trade-offs • To achieve nationwide health IT infrastructure • Initial governance: HHS Secretary Michael Leavitt • Guided by recommendations from theAmerican Health Information Community (AHIC) • A Federal Advisory Committee • Transitioning to a public-private governance entity Mayo Clinic: Centennial Of Informatics

19. The AHIC Successor – Why Change? • Continuity of leadership is needed to sustain the momentum gained over the past 24 months • Government transition occurs every four years • Changes again 460 days from today • Uncertainty under new leadership places momentum at risk • Sustainable business model is needed to support perpetual operation • Congressional appropriations are a cyclical model • Decisive action is needed keep pace with large scale innovation and transformation • Government is necessarily a deliberate process Mayo Clinic: Centennial Of Informatics

20. AHIC Successor (2.0) - Principles for Governance • The entity should exist for the purpose of individual/ consumer benefit • The entity should establish and enhance trust among stakeholders • The entity should have broad participation across the health care industry stakeholders • The governing bodies of the entity should have necessary authority to make decisions, but only the authority that is necessary to do this • The entity should be feasible to establish and operate, and sustainable into the future • The entity should be adaptable over time and across future circumstances Mayo Clinic: Centennial Of Informatics

21. AHIC 2.0 – What It Will Do… • Provide continuity -- accelerate and coordinate current AHIC interoperability initiatives • Provide strong leadership in • determining priorities • harmonizing interoperability standards • certifying products and systems to those standards • overseeing and facilitating the NHIN • establishing criteria for assuring interoperability, privacy and security • Construct and champion a balanced view • that takes into account the needs of all stakeholder groups Mayo Clinic: Centennial Of Informatics

22. Governance Coordinated Care Governance of the Health IT Agenda Three Phases 1. Governance by HHS Secretary with AHIC guidance. ONC funds the standards processes 2. AHIC 2.0 – An early hybrid of a public, private partnership. ONC continues to fund standards processes 3. AHIC 2.0 – Self-sustaining Public Private Partnership. ONC continues to fund efforts related to population issues ActivatedIndividual Community:PH, Quality, R&D Mayo Clinic: Centennial Of Informatics

23. Standards in HITProducts Privacy & Security Policies Adoption of Interoperable Health IT Nationwide Health Information Network Pieces of the Puzzle Necessary to Reachthe Health IT Adoption Tipping Point Governance

24. Level of Function Size of Practice 25% 25 25 Using some functions 20.8% 20 20 11 or more in practice 15 15 Percentage Percentage 10% 10 10 With (1) electronic note keeping,(2) lab order, (3) med orders, & (4) ability to obtain lab results Adoption of Interoperable Health IT 4.4% 5 5 1 or 2 in practice 0 0 Physicians* Physicians* Current State EHR Adoption: US Physicians (2005) *3 times more prevalent in metropolitan areas Mayo Clinic: Centennial Of Informatics

25. Level of Function Size of Hospital 100 100 80 80 68% 60 60 Full or partial adoption Percentage Percentage 40 40 Adoption of Interoperable Health IT 23% > 500 beds 20 20 11% Fully implemented EHRs 3% 0 0 Hospital* Hospital* Current State EHR Adoption: Hospitals (2007) < 50 beds *Rate of hospital use does not represent physician use; only ¼ of implemented hospitals report 50% MD use (or more) Mayo Clinic: Centennial Of Informatics

26. Coordinated Care Adoption of Interoperable Health IT Adoption of Interoperable Health IT • Barriers to adoption • Misalignment of incentives • Doubts remain about the quality benefits of EHRs in small practices • Lack of interoperability • Necessary workflow changes • Lack of adequately skilled national workforce • Product certification decreases perceived risk • Stark & Anti-Kickback for donations to small providers • Decreased malpractice insurance being explored • Pay for performance? ActivatedIndividual As a driver? Mayo Clinic: Centennial Of Informatics

27. Standards in HITProducts Privacy & Security Policies Adoption of Interoperable Health IT Nationwide Health Information Network Pieces of the Puzzle Necessary to Reachthe Health IT Adoption Tipping Point Governance

28. Nationwide Health Information Network NHIN Trial Implementations • Awards to 9 state & regional Health Information Exchanges (HIEs) • Forming the NHIN Cooperative to implement, test, and demonstrate core services by September 2008 • Support of consumer access controls • Lookup and retrieval of clinical information • Exchange of patient summary records • Test implementations of the first 7 priority scenarios • Lab result reporting ; medication history exchange; quality and public health, etc. • Expanding to include other types of HIEs, such as • Multi-community Integrated Delivery Systems • Health plans • Health data banks Mayo Clinic: Centennial Of Informatics

29. NHIN Awardees CareSpark Tricities region of Eastern Tennessee and Southwestern Virginia Delaware Health Information Network Delaware Indiana University Indianapolis metroplex Long Beach Network for Health Long Beach and Los Angeles, California Lovelace Clinic Foundation New Mexico MedVirginia Central Virginia New York eHealth Collaborative New York North Carolina Healthcare Information and Communications Alliance, Inc. North Carolina West Virginia Health Information Network West Virginia Nationwide Health Information Network Mayo Clinic: Centennial Of Informatics

30. Standards in HITProducts Privacy & Security Policies Adoption of Interoperable Health IT Nationwide Health Information Network Bringing It All Together to Reachthe Health IT Adoption Tipping Point Governance

31. Personalized Health Care AHIC A Healthier, Safer Nation Fraud Detection and Deterrence High Quality, Safe Health Care Individuals Manage their Health Establish Enabling Policies Foster Adoption Establish Nationwide Health Information Network (network of networks) Encourage and Guide Interoperability Foster Interoperability Standards Improved Public Health Add Value for Patients Institute Certification Lower Cost Health Care Add Value for Providers and Health IT Support for Transforming Health Care Care ^ PRIVACY, SECURITY, and CONFIDENTIALITY Health IT Mayo Clinic: Centennial Of Informatics

32. The Ultimate Reason for Health IT Health IT is a key enabler for us ALL to get: The quality of healthwe want and deserve The quality and value of health care serviceswe demand Mayo Clinic: Centennial Of Informatics

33. For More Information: www.hhs.gov/healthit Mayo Clinic: Centennial Of Informatics