policy related to health information systems: a u.s. case study

Policy Related to

Health Information Systems:

A U.S. Case Study

Nawanan Theera-Ampornpunt, M.D., Ph.D.Department of Community Medicine

Faculty of Medicine Ramathibodi Hospital

October 19, 2014

SlideShare.net/Nawanan [email protected]

Except where referred

to or copied from

other works

Outline

• Electronic Health Records & Health IT

• U.S. eHealth Policy

• HITECH Act & “Meaningful Use” of EHRs

• Lessons for Thailand

Electronic Health Records

& Health IT

Electronic Health Records

• Electronic documentation of health care provided to patients, as

recorded by providers

• Ideally longitudinal (e.g., life-long) records

• Electronic Medical Records (EMRs) vs.

Electronic Health Records (EHRs) often used interchangeably (or with

some minor distinctions)

Electronic Health Records (EHRs)

• Are they just electronic documentation?

• Or do they have some other values?

Diag-nosis

History & PE

Treat-ments ...

EHR Systems

• Ubiquitous availability (anytime, anywhere, everyone who is authorized)

• Multiple concurrent uses

• The end of “Where the heck is the patient’s record?!?”

• Ability to control & enforce access security

• Structured data entry possible

• Data presentation that is easier to understand (e.g. graphs)

• Efficiency in data entry? (but sometimes it slows users down!)

• Process improvement (business process reengineering/redesign, quality

improvement)

• No doctor’s handwriting!!!!!

Some Benefits of EHRs

Benefits of Health Information Technology

• Literature suggests improvement in health care through

– Guideline adherence (Shiffman et al, 1999;Chaudhry et al, 2006)

– Better documentation (Shiffman et al, 1999)

– Practitioner decision making or process of care (Balas et al, 1996;Kaushal et al, 2003;Garg et al, 2005)

– Medication safety (Kaushal et al, 2003;Chaudhry et al, 2006;van Rosse et al, 2009)

– Patient surveillance & monitoring (Chaudhry et al, 2006)

– Patient education/reminder (Balas et al, 1996)

– Cost savings and better financial performance (Parente & Dunbar, 2001;Chaudhry et al, 2006;Amarasingham et al, 2009;Borzekowski, 2009)

Functions that Should be Part of EHR Systems

• Computerized Medication Order Entry (IOM, 2003; Blumenthal et al, 2006)

• Computerized Laboratory Order Entry (IOM, 2003)

• Computerized Laboratory Results (IOM, 2003)

• Physician Notes (IOM, 2003)

• Patient Demographics (Blumenthal et al, 2006)

• Problem Lists (Blumenthal et al, 2006)

• Medication Lists (Blumenthal et al, 2006)

• Discharge Summaries (Blumenthal et al, 2006)

• Diagnostic Test Results (Blumenthal et al, 2006)

• Radiologic Reports (Blumenthal et al, 2006)

The Bigger Picture: Health Information Exchange

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Common Denominator

• Health Information Technology

• Electronic Health Records

• Health Information Exchange

Ultimate Goal = Health

• Don’t implement technology just for technology’s sake.(Yasnoff et al, 2001 and many others)

• “Don’t make use of excellent technology.

Make excellent use of technology.”(Tangwongsan, Supachai. Personal communication, 2005.)

U.S. eHealth Policy

1991: IOM’s CPR Report published

1996: HIPAA enacted

2000-2001: IOM’s To Err Is Human &

Crossing the Quality Chasm published

2004: George W. Bush’s Executive Order

establishing ONCHIT (ONC)

2009-2010: ARRA/HITECH Act &

“Meaningful Use” regulations

U.S. Public Policy Related to eHealth

(IOM, 2001)(IOM, 2000) (IOM, 2011)

Landmark IOM Reports

• To Err is Human (IOM, 2000) reported that:

– 44,000 to 98,000 people die in U.S. hospitals each year

as a result of preventable medical mistakes

– Mistakes cost U.S. hospitals $17 billion to $29 billion

yearly

– Individual errors are not the main problem

– Faulty systems, processes, and other conditions lead to

preventable errors

Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US: Regulating Healthcare - Lecture d

Patient Safety

• Humans are not perfect and are bound to make

errors

• Highlight problems in U.S. health care system

that systematically contributes to medical errors

and poor quality

• Recommends reform

• Health IT plays a role in improving patient

safety

Landmark IOM Reports: Summary

“...We will make wider use of electronic records and other

health information technology, to help control costs and reduce

dangerous medical errors.”

Source: Wikisource.org Image Source: Wikipedia.org

President George W. Bush

Sixth State of the Union Address

January 31, 2006

?

Political Support Behind Health IT

U.S. Adoption of Health IT

• U.S. lags behind other Western countries (Schoen et al, 2006;Jha et al, 2008)

• Money and misalignment of benefits is the biggest reason

Ambulatory (Hsiao et al, 2009) Hospitals (Jha et al, 2009)

Basic EHRs w/ notes 7.6%

Comprehensive EHRs 1.5%

CPOE 17%

American Recovery & Reinvestment Act (ARRA)

• Economic Stimulus Legislation

• Contains HITECH Act (Health Information Technology for

Economic and Clinical Health Act)

• ~ 20 billion dollars for Health IT investments

Goals:

1. Boost economy (economic health)

2. Widespread adoption of Health IT (clinical health)

Quality Patient Safety Costs

President Obama Backs Health IT

“...Our recovery plan will invest in

electronic health records and new technology

that will reduce errors, bring down costs,

ensure privacy, and save lives.”President Barack Obama

Address to Joint Session of Congress

February 24, 2009Source: WhiteHouse.gov

U.S. National Leadership on Health IT

David Blumenthal, MD, MPPNational Coordinator for

Health Information Technology

(2009 - 2011)

Farzad Mostashari, MD, ScMNational Coordinator for


(2011 - 2013)

Robert Kolodner, MDNational Coordinator for


(2006 - 2009)

David Brailer, MD, PhDNational Coordinator for


(2004 - 2007)

Office of the National Coordinator for Health Information Technology

(ONC -- formerly ONCHIT)

Photos courtesy of U.S. Department of Health & Human Services

Karen B. DeSalvo, MD, MPH, MScNational Coordinator for


(2014 - Present)

HITECH Act &

“Meaningful Use”

of EHRs

Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.

HITECH Act

“Meaningful Use” of EHRs

• Use of “Certified EHR Technology” (CEHRT) by

providers (eligible professionals, eligible hospitals

& critical access hospitals) to achieve significant

improvements in care

• Financial incentives & penalties

Incentives for Eligible Professionals (Doctors)

• Medicaid incentives for eligible professionals– Maximum $63,750 over 6 years beginning in 2011

• Medicare payments for eligible professionals– Maximum $44,000 over 5 years

Incentives for Eligible Hospitals

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MLN_TipSheet_MedicareHospitals.pdf

“Meaningful Use” of A Pumpkin

“Meaningful Use”

of a PumpkinPumpkin

Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

Meaningful Use of EHRs: ONC’s 3-Stage Approach

Stage 1

- Electronic capture of

health information

- Information sharing

- Data reportingStage 2

Use of EHRs

to improve

processes of

care

Stage 3

Use of

EHRs to

improve

outcomes

Better

Health

Blumenthal D, 2010

Components of Meaningful Use Regulations

• Medicare & Medicaid Incentives for Meaningful Use of EHRs– Centers for Medicare and Medicaid Services (CMS)

• Rule on Standards, Implementation Specifications &

Certification Criteria

• Certification Programs– Office of the National Coordinator for Health IT (ONC)

Meaningful Use Incentives: Stage 1

Proposed Rule

(Jan. 2010)

• 23 Criteria for Hospitals to Pass

• 25 Criteria for Professionals (Clinics) to Pass

Public Hearing

• Pace & Scope: too ambitious, demanding, inflexible

• Few providers would likely qualify -> Little adoption

Final Rule (2011)

• Core Objectives (14 criteria for Hospitals, 15 for Professionals, required)

• Menu Set (10 criteria, pick 5)

Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

Meaningful Use Stage 1 Criteria

Some Selected Meaningful Use Stage 1 Final Rule:

Core Objectives• Electronic capture of information

– Demographics

– Vital signs

– Medication list

– Allergies

– Problem list

– Smoking

• Medication order entry

• Drug-allergy & drug-drug interaction checks

• Patient access to/copy of health information

Some Selected Meaningful Use Stage 1 Final Rule:

Menu Set• Drug formulary checks

• Lab results incorporation into EHRs

• Generate lists of patients by specific conditions

• Medication reconciliation

• Electronic reporting to governmental agencies

• Advanced directives for elderly patients

• Patient reminders for certain services (for clinics)

• Patient access to health information (for clinics)

Final Rule on Standards & Certification Criteria (Selected)

• Content Exchange Standards– HL7 CDA Release 2 & CCD

– NCPDP SCRIPT

• Vocabularies• SNOMED CT

– LOINC®

– RxNorm®

• Security– NIST-certified encryption algorithms

• Etc.

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

Stages & Timeline of Meaningful Use

Evolution of Meaningful Use Objectives in Each Stage

• 2011 Definition Stage 1:– 14 Core Objectives for Hospitals

– 15 Core Objectives for Professionals

– Pick 5 of 10 Menu Set Objectives




Evolution of Meaningful Use Objectives in Each Stage



– Pick 5 of 10 Menu Set Objectives for Hospitals

– Pick 5 of 9 Menu Set Objectives for Professionals




Meaningful Use Stage 2 Objectives (2014)

for Eligible Professionals


Meaningful Use Stage 2 Objectives (2014) for Hospitals


Critique:

Lessons for Thailand

Disclaimer: Personal opinions of the speaker

Lesson #1

Clear aim toward improved quality &

efficiency of health care.

Lesson #2

Large health IT initiatives require

leadership from the highest level

of government.

Lesson #3

To achieve widespread health IT

adoption, substantial financial

investment is necessary.

Lesson #4

Leadership from a national

organization with health informatics

expertise is vital to success.

Lesson #5

Criteria for “Meaningful Use” should

be evidence-based

to the extent possible.

Lesson #6

Criteria for incentives should be

realistic and flexible.

Lesson #7

Criteria for incentives should be

evolutionary.

Lesson #8

Accept local diversity in technologies

& requirements.

Don’t aim for homogeneous

environment.

Lesson #9

Leverage existing standards

to the extent possible.

Don’t reinvent the wheel.

Lesson #10

Acknowledge that more than one

level of interoperability needs to be

achieved.

Lesson #11

A policy that attempts to move too

fast or be too dynamic will greatly

burden providers

Lesson #12

“Meaningful Use” focuses too much

on functionality, with questions on

true interoperability, and with little

attention on usability, ease of use &

provider acceptance of technology

Take Home Message

• Adoption of health IT still work in progress, even

in developed countries

• We can learn something from other countries

• We need to do something, soon.

• Don’t forget to build the workforce!!

Useful Online Resources• www.healthit.gov

• www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/index.html

• www.himss.org/EconomicStimulus/

• www.amia.org/public-policy/testimony-comments-reports

• www.nejm.org/doi/full/10.1056/NEJMp0912825

• www.nejm.org/doi/full/10.1056/NEJMp1006114

References (1)• Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and

inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108-14.

• Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Brown GD. The clinical value of computerized

information services. A review of 98 randomized clinical trials. Arch Fam Med. 1996;5(5):271-8.

• Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.

• Blumenthal D, DesRoches C, Donelan K, Ferris T, Jha A, Kaushal R, Rao S, Rosenbaum S. Health information

technology in the United States: the information base for progress [Internet]. Princeton (NJ): Robert Wood

Johnson Foundation; 2006 [cited 2010 Oct 14]. 81 p. Available from:

http://www.rwjf.org/files/publications/other/EHRReport0609.pdf

• Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010

Aug 5;363(6):501-4.

• Borzekowski R. Measuring the cost impact of hospital information systems: 1987-1994. J Health Econ.

2009;28(5):939-49.

• Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG. Systematic review: impact

of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med.

2006;144(10):742-52.

References (2)• Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized

clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

JAMA. 2005;293(10):1223-38.

• Hsiao C, Beatty PC, Hing ES, Woodwell DA. Electronic medical record/electronic health record use by office-

based physicians: United States, 2008 and preliminary 2009 [Internet]. 2009 [cited 2010 Apr 12]; Available from:

http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf

• Institute of Medicine, Board on Health Care Services, Committee on Data Standards for Patient Safety. Key

Capabilities of an electronic health record system: letter report [Internet]. Washington, DC: National Academy

of Sciences; 2003 [cited 2010 Oct 14]. 31 p. Available from: http://www.nap.edu/catalog/10781.html

• Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D.

Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628-38.

• Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int

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