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Improving Quality, Safety and Efficiency of Healthcare Through Information and Information Technolog

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Title: Improving Quality, Safety and Efficiency of Healthcare Through Information and Information Technolog


1
Improving Quality, Safety and Efficiency of
Healthcare Through Information and Information
TechnologyState and Local Health IT
  • Janet M. Marchibroda
  • Chief Executive Officer
  • eHealth Initiative and Foundation
  • June 12, 2007

2
Overview of Presentation
  • What Problem are We Trying to Solve?
  • Emerging National Standards and Policies Offer
    Foundational Building Blocks
  • State Leadership An Overview of Whats Happening
    in the Field
  • Getting Engaged What HBCUs Can Do

3
What Problems are We Trying to Solve?
  • A persons health record can be scattered among
  • Primary care provider
  • Specialists
  • Former healthcare providers
  • Labs
  • Pharmacies
  • Imaging centers
  • Insurance companies
  • Patients records/memory
  • Family members

4
What Problems Are We Trying to Solve
  • To improve quality..
  • With more complete information, healthcare
    providers can give better care
  • Providers need to know information about the
    patient
  • Existing conditions
  • Allergies
  • Medications
  • Providers also need access to clinical protocols
  • To reduce costs
  • Reduce medical errors
  • Duplicate tests
  • Lost time

5
What Problems Are We Trying to Solve
  • Without reliable information, markets cannot
    work1.
  • Physicians dont know how well they are doing
    compared to their peers,
  • Consumers dont know which doctor or hospital to
    pick,
  • Payers/purchasers cannot reward better
    performance.
  • Researchers dont have easy access to the
    information they need to identify new therapies,
    and assess the results of those theyve already
    developed

1. Arrow, Kenneth J., Uncertainty and the Welfare
Economics of Medical Care, The American Economic
Review, Vol. LIII, No. 5, December 1963, pp.
941-973.
6
Forces Emerging at Multiple Levels of the System
  • National
  • State
  • Local
  • Individual Organization
  • Consumer

7
Convergence of Forces Will Drive Change in U.S.
Healthcare at Multiple Levels of the System
  • Transparency in Quality and Efficiency
  • Alignment of Incentives (Pay for Performance)
  • Consumer Engagement and Activation
  • Health Information Technology

8
Wagners Four Strategies for Regional Quality
Improvement
  • Data-Sharing for Performance Measurement.
    Overcome barriers to enable data sharing for
    performance measurement.
  • Engaging Consumers. Produce informed, motivated
    consumers who will understand, demand and choose
    higher quality healthcare.
  • Improving Health Care Delivery. Motivate and help
    providers redesign their care system to provide
    more cost-effective care.
  • Aligning Benefits and Finances. Create incentives
    for consumers to seek, and providers to deliver,
    the most cost-effective care.

Source Wagner E, Austin B, Coleman C. It Takes
a Region Creating a Framework to Improve Chronic
Disease Care. California Healthcare Foundation,
November 2006.
9
National Level Policy Changes
10
National Policies Offer Foundational Building
Blocks
  • DHHS Secretary Leavitts Four Cornerstones
    Support Implementation Based on Presidents
    Executive Order
  • Connecting the System Every medical provider has
    some system for health records. Increasingly,
    those systems are electronic. Standards need to
    be set so all health information systems can
    quickly and securely communicate and exchange
    data.
  • Measure and Publish Quality Every case, every
    procedure, has an outcome. Some are better than
    others. To measure quality, we must work with
    doctors and hospitals to define benchmarks for
    what constitutes quality care.
  • Measure and Publish Price Price information is
    useless unless cost is calculated for identical
    services. Agreement is needed on what procedures
    and services are covered in each "episode of
    care".
  • Create Positive Incentives All
    parties--providers, patients, insurance plans,
    and payers--should participate in arrangements
    that reward both those who offer and those who
    purchase high-quality, competitively priced
    health care.

11
National Policies Offer Foundational Building
Blocks
  • Tax Relief and Health Care Act of 2006 (H.R.
    6408)
  • Prevented Medicare physician payment reductions
    for 2007
  • Created voluntary quality reporting system
    beginning in July 2007, with incentive payments
  • Established three-year demonstration - medical
    home model

12
National Policies Offer Foundational Building
Blocks
  • Tax Relief and Health Care Act of 2006 (H.R.
    6408) Beginning July 1, 2007
  • Eligible professionals receive one time lump sum
    bonus in 2008
  • 1.5 of allowed charges for covered services
    billed July 2007-December 2007
  • Reporting is via G-Codes or CPT II codes
  • CMS examining ways to use EHRs and registries for
    reporting in 2008
  • CMS releases PQRI measures list April 3
  • 74 measures at http//www.cms.hhs.gov/PQRI

13
National Policies Offer Foundational Building
Blocks
  • Tax Relief and Health Care Act of 2006 (H.R.
    6408) In 2008
  • CMS directed to include structural measures such
    as the use of electronic health records and
    electronic prescribing technology
  • Clinical measures will be those adopted or
    endorsed by consensus organization (NQF or AQA)
    and published in federal register by Nov. 15,
    2007

14
Congressional Activity
  • Overall Landscape
  • Senate HIT bill draft in circulation
  • May be introduced by July 4th recess
  • Staff in negotiations now on final form
  • Senate more promising for action than House
  • Senate HELP committee most likely locus
  • House focused on SCHIP, FDA bill, SGR
  • House action on major HIT legislation less
    likely, but significant industry activity could
    change the dynamic.
  • Other committees could play a role

15
Congressional Activity
  • Draft Wired for Health Care Quality Act 2007
  • Codifies AHIC and authorizes policy framework
  • Codifies National Coordinator position in HHS
  • Creates Partnership for Health Care Improvement,
    similar to HITSP
  • Two grant programs-HIT for providers HIE
  • One state loan fund for providers to buy HIT
  • Authorizes certification process
  • Some privacy provisions
  • Quality provisions create NQF-like entity to
    advise Secretary on performance measures and
    priorities, including ensuring integration of
    performance measures with interoperability
    standards from Partnership

16
Congressional Activity
  • Rep. Wu (D-OR) 10,000 Trained by 2010 Act
  • Passed the House June 6th
  • Health informatics training and curriculum
  • Rep. Gordon (D-TN)
  • Authorize NIST to establish interoperability
    standards
  • Expect hearing end of June markup in July
  • Gordon is Chair of Commerce, Science, Tech
  • Rep. Gonzales (D-TX) Rep. Gingrey (R-GA)
  • Tax incentives for small practice purchase of HIT
    (10 FTEs or fewer)
  • Rep. Kennedy (D-RI)
  • PHR incentives for providers

17
Congressional Activity
  • Stabenow (D-MI) and Snowe (R-ME) "Health
    Information Technology Act of 2007
  • Grant program to assist providers in implementing
    healthcare informatics systems, interoperability
    standards, Stark provisions, add on reimbursement
    for providers, etc.
  • Sen. Whitehouse (D-RI)
  • Not for profit National HIT and Privacy
    Corporation
  • Supports adoption, implementation of HIT and HIE
  • Sen. Brownback (R-KS)
  • Expected to reintroduce Independent Health
    Records Trust Act shortly Revised version of
    Health Records Banks bill from 109th Congress

18
National Policies Offer Foundational Building
Blocks
  • Dept of Health and Human Services Supports
    Standards for Interoperability
  • Federally chartered public-private sector
    advisory commission, American Health Information
    Community (AHIC) launched in 2005 to recommend
    standards to DHHS Secretary
  • Federal contract issued to both collaborative
    standards consensus body (HITSP) and
    certification body (CCHIT)
  • Executive Order will drive compliance across the
    federal government
  • DHHS Secretary encouraging sign-on by the private
    sector, to increase impact (800 employers
    signed on)

19
National Policies Offer Foundational Building
Blocks
  • Some Funding Continuing to Emerge to Capitalize
    Early Efforts
  • Office of the National Coordinator will fund
    trial implementations of the Nationwide Health
    Information Network this year grants to go to
    state and regional initiatives
  • AHRQ Quality/HIT grants
  • CMS Medicaid Transformation grants focused on
    health IT are moving forward
  • RFI for CDC grants reach out to state and local
    efforts to support surveillance just out
  • DHHS Value Exchange charter in Federal Register
  • ONC RFI announced last week

20
National Policies Offer Foundational Building
Blocks
  • Technical Assistance Being Offered
  • AHRQ National Resource Center for Health IT
  • AHRQ Learning Network for Value Exchanges
  • CMS QIO Eighth Scope of Work
  • HRSA Technical Assistance Resources
  • eHI Connecting Communities Toolkit funded by
    cooperative agreement with HRSA

21
Private Sector Initiatives Kicking Into High Gear
  • Purchasers Beginning to Consolidate Expectations
    (in sync with Four Cornerstones) Employer
    Toolkit released in Feb 2007
  • Incentives Initiatives Getting Traction Bridges
    to Excellence and IHA focus on quality
    improvement, performance measurement and use of
    health IT
  • Personal Health Record Initiatives Abound
    Dossia, AHIP and BCBSA, others rolling out as we
    speak, as market leaders such as WebMD continue
    to increase penetration

22
State Level Policy Changes
23
State-Level Efforts Focused on Health IT are Also
Rapidly Increasing
  • Over half the states in the country are
    developing or implementing plans related to
    health information technology
  • Emphasis on quality, patient safety and curbing
    rising healthcare costs rank high as the primary
    drivers for state leadership around health
    information technology.

24
eHI 2006 Analysis of State Activity
Stage 1 AWARENESS 15
Stage 2 REGIONAL ACTIVITY 17
Stage 3 STATE LEADERSHIP 25
Stage 4 STATEWIDE PLANNING 29
Stage 5 STATEWIDE PLAN 8
Stage 6 STATEWIDE IMPLEMENTATION 6
  • Recognition of the need for HIE among multiple
    stakeholders in your state, region, or community
  • No coordinated, statewide activity
  • Regional or community-specific HIE activity
  • Silos of HIE activity with possibly some
    cross-over
  • No coordinated, statewide activity
  • Either legislation has been passed or an
    executive order issued
  • Statewide planning initiative being formulated
  • Well underway with coordinated, statewide
    planning
  • Structures in place have statewide representation
  • Clear on how to deliver statewide plan
  • Implementation of state plan or Roadmap is well
    underway, with key milestones completed
  • Plan / Roadmap complete and accepted
  • Plan / Roadmap communicated to the public

source
25
State Governors Demonstrating Leadership
  • 20 Executive Orders issued by U.S. governors in
    15 states, calling for health IT (seven in 2007
    alone!)
  • Arizona, 2005
  • California, 2006, 2007
  • Florida, 2004
  • Georgia, 2006, 2007
  • Illinois, 2006
  • Indiana 2007
  • Kansas, 2004, 2007
  • Mississippi, 2007
  • Missouri, 2006, 2007
  • North Carolina, 1994
  • Tennessee, 2006
  • Texas, 2006
  • Virginia, 2006, 2007
  • Wisconsin, 2005
  • Washington, 2007

Source www.ehealthinitiative.org, State
Legislative Tracking System
26
State Legislative Activity on the Rise
  • In 2005 and 20061
  • 38 state legislatures introduced 121 bills which
    specifically focus on health IT
  • 36 bills were passed in 24 state legislatures and
    signed into law.

1 Source www.ehealthinitiative.org, State
Legislative Tracking System eHealth Initiative.
States Getting Connected State Policy Makers
Drive Improvements in Healthcare Quality and
Safety Through IT. Washington, D.C. eHealth
Initiative August 2006.
27
State Legislative Activity on the Rise
  • In 2007 So Far
  • 168 bills introduced in 41 states, focused on HIT
  • up from 125 bills last month
  • 13 bills have been passed in 11 states and signed
    by the Governor and are law
  • Source
  • eHI State Legislation Tracker www.ehealthinitiativ
    e.org
  • Bills now law
  • Arkansas, HB 1354
  • Idaho, H 238 and H 159
  • Indiana, SB 0551
  • Kentucky, HB 185
  • Maryland, HB 979
  • Michigan, S 404
  • New Mexico, HB 428
  • North Dakota, H 1021
  • Vermont, H 380
  • Virginia, HB 2198
  • Washington, S 5640, S 5930

28
Focus of State Legislative Action
  • The authorization of a commission, committee,
    council or task force to develop recommendations
  • The development of a study, set of
    recommendations, or a plan for HIT
  • The integration of quality goals within
    HIT-related activities or
  • The authorization of a grant or loan program
    designed to support HIT

Source eHealth Initiative. States Getting
Connected State Policy Makers Drive Improvements
in Healthcare Quality and Safety Through IT.
Washington, D.C. eHealth Initiative August
2006.
29
Activity Within Communities
30
Healthcare Improvement Activities at the Local
Level Stimulated by DHHS Action
  • DHHS Secretary Leavitt calls for value
    exchanges that will support improvement at the
    local levels
  • Value exchanges will be chartered by DHHS
    (AHRQ)
  • Many, but not all, chartered exchanges will be
    able to access Medicare data to support
    performance measurement and improvement
    activities

31
Number of Community-Based Health IT Initiatives
on the Rise
  • eHI 2006 Survey included 165 responses from
    health information exchange (HIE) initiatives
    located in 49 states, the District of Columbia
    and Puerto Rico
  • eHIs Connecting Communities Coalition has 250
    members and its members are maturing.

32
Who is at the Table?
  • Primary Care Physicians (91)
  • Hospitals (96)
  • Community and Public Health Clinics (84)
  • Local Public Health Department (70)
  • State Medicaid Program (57)
  • Health Plans (68)
  • State Public Health Department (64)
  • Employers (54)
  • Consumers (49)
  • Laboratories (49)
  • Pharmacies (47)
  • School-based Clinics (77)

eHealth Initiative. Improving the Quality of
Healthcare through Health Information Exchange
Selected Findings from eHealth Initiative's Third
Annual Survey of Health Information Exchange
Activities at the State, Regional and Local
Levels. Washington, D.C. eHealth Initiative
September 2006.
33
Types of Data Exchanged
  • Laboratory (26 percent)
  • Claims (26 percent)
  • ED Episodes (23 percent)
  • Dictation (22 percent)
  • Inpatient Episodes (22 percent)
  • Outpatient Lab (22 percent)
  • Radiology (20 percent)
  • Outpatient Prescriptions (18 percent)

eHealth Initiative. Improving the Quality of
Healthcare through Health Information Exchange
Selected Findings from eHealth Initiative's Third
Annual Survey of Health Information Exchange
Activities at the State, Regional and Local
Levels. Washington, D.C. eHealth Initiative
September 2006.
34
As We Move to Implementation Some Critical
Questions
  • How to leverage the initial capital/grants
    received to develop a sustainable business model
    for health IT and health information exchange?
  • eHI survey shows 44 rate this as most difficult
    challenge
  • What should communities do first? What provides
    the most value?

35
Getting to SustainabilityEarly Findings From Our
Research
  • Provided funding support for 12 health
    information exchange learning laboratories in ten
    communities
  • Engaged an expert panel, including experts in
    healthcare, economics, business, and financing
  • Took a very close look at three advanced stage
    communities in IN, OH and NY

36
Getting to SustainabilityKey Findings
  • Sustainability of health information exchange is
    indeed possible, and probable if certain factors
    are in place.
  • No one-size-fits-all approach or silver bullet,
    it depends on the markets needs and requirements
  • Social capital formation is necessary for leaders
    to identify and coalesce divergent interests in a
    common cause .due to fragmentation of our
    healthcare system and current payment policy
  • Time, commitment, charisma and honesty are
    required to keep a large, diverse stakeholder
    group at the table.

37
Getting to SustainabilityKey Findings
  • Strong leadership team with good business acumen
    is one of the key criteria for success as
    communities move to the implementation stage
  • Rigorous analysis of the value that potential
    services provide to each customer is crucial
  • Two stages of HIE functionality Stage 1
    Transaction Models involving transaction
    processing and basic exchange capabilities and
    Stage 2 Infomediary Models, representing more
    advanced exchange functionality in which value
    accrues from HIES acting as infomediaries

38
Getting to SustainabilityPublicly Available
Tools to Provide Support
  • A market readiness assessment tool
  • A tool estimating the value created by any HIE
    network
  • An estimator of risk involving investors,
    community HIE returns and level of HIE
    subsidization and
  • A business plan pro forma, complete with
    interactive HIE financial statements

39
Services Primarily Focuson Care Delivery
  • Clinical documentation (26 percent)
  • Results delivery (25 percent)
  • Consultation/referral (24 percent)
  • Electronic referral processing (23 percent)
  • Alerts to providers (20 percent)

eHealth Initiative. Improving the Quality of
Healthcare through Health Information Exchange
Selected Findings from eHealth Initiative's Third
Annual Survey of Health Information Exchange
Activities at the State, Regional and Local
Levels. Washington, D.C. eHealth Initiative
September 2006.
40
eHI 2006 SurveyShows Operational Funding Sources
are Emerging
  • Hospitals (24 percent)
  • Payers (21 percent)
  • Physician practices (16 percent)
  • Labs (13 percent)

41
New Services are Emerging
  • Chronic or Disease Management (20)
  • Quality Performance Reporting for Purchasers or
    Payers (11)
  • Quality Performance Reporting for Clinicians
    (10)
  • Public Health Surveillance
  • Consumer Access to Information (in light of
    rapidly emerging PHR initiatives)

eHealth Initiative. Improving the Quality of
Healthcare through Health Information Exchange
Selected Findings from eHealth Initiative's Third
Annual Survey of Health Information Exchange
Activities at the State, Regional and Local
Levels. Washington, D.C. eHealth Initiative
September 2006.
42
Measures That Produce Improvements in Cost and
Quality Require Clinical Health IT Systems
  • HTN 42 BPlt140/90
  • HTN 43 SBPlt140
  • HTN 44 DBPlt90
  • DM 23 BPlt140/90
  • DM 21 HbA1cgt9
  • DM 22 HbA1clt7
  • DM 25 LDLlt100
  • DM 26 LDLlt130
  • CAD 6 LDLlt100 after discharge for AMI, CABG, PCI
  • CAD 7 LDLlt130 after discharge for AMI, CABG, PCI
  • CAD 8 LDLlt100 any CAD
  • CAD 9 LDLlt130 any CAD

43
You Really Need Clinical and Claims Data to Make
This all Work
Plan A
Plan B
Health Information Exchange
Claims Data Aggregation
Plan C
Medicaid
Medicare
44
Unique Point in Time
  • Policies and actions at the national, state, and
    local levels are moving quickly
  • Multiple forces are moving in parallel
  • Transparency in Quality and Efficiency
  • Alignment of Incentives (pay for performance)
  • Consumer Engagement and Activation
  • Health Information Technology
  • Its in the intersections that we can make great
    leaps in achieving our goals around improving
    quality, safety and efficiency

45
Questions and Discussion
46
  • Janet M. Marchibroda
  • Chief Executive Officer
  • eHealth Initiative and Foundation
  • www.ehealthinitiative.org
  • 818 Connecticut Avenue, N.W., Suite 500
  • Washington, D.C. 20006
  • 202.624.3270
  • Janet.marchibroda_at_ehealthinitiative.org
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