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Addressing the Healthcare Needs of our Aging Population with
Technology
6-4-04
Addressing the Healthcare Needs of our Aging Population with
Technology
6-4-04
Jennie HarvellOffice of the National Coordinator on
Health Information TechnologyDepartment of Health and Human Services
22
Challenges Facing U.S. HealthcareChallenges Facing U.S. Healthcare
Health care spending rising faster than inflation.
Despite spending $1.6 trillion on health care:
- medical errors abound; and- medical information is not communicated across providers.
Health care spending rising faster than inflation.
Despite spending $1.6 trillion on health care:
- medical errors abound; and- medical information is not communicated across providers.
33
Challenges (cont’d)Challenges (cont’d)
The population is aging
Population surviving until 65:- 1900 - 41%- 2004 - over 80%
2000: 35 million Americans are 65+
2050: increases to 82 million
Biggest expected increase: those 85+
The population is aging
Population surviving until 65:- 1900 - 41%- 2004 - over 80%
2000: 35 million Americans are 65+
2050: increases to 82 million
Biggest expected increase: those 85+
44
Life Expectancy (Older Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging Related Statistics)
Life Expectancy (Older Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging Related Statistics)
55
Chronic IllnessesChronic Illnesses
Approximately 40% of Americans have a chronic condition
Prevalence of chronic conditions is increasing (RAND):
2000- 125 million 2010 – 141 million
Approximately 40% of Americans have a chronic condition
Prevalence of chronic conditions is increasing (RAND):
2000- 125 million 2010 – 141 million
66
Chronic Conditions (Older Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging Related Statistics)
Chronic Conditions (Older Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging Related Statistics)
77
Multiple Chronic IllnessesMultiple Chronic IllnessesAs people age, the number suffering from chronic illnesses increase. Those
reporting 2+ chronic conditions: ages 45-64 = 35%
ages 65+ = 62%
Approximately half of those with a chronic illness have multiple chronic illnesses.
Prevalence of multiple chronic conditions is increasing (RAND):
2000- 60 million 2010 –70 million
As people age, the number suffering from chronic illnesses increase. Those reporting 2+ chronic conditions:
ages 45-64 = 35% ages 65+ = 62%
Approximately half of those with a chronic illness have multiple chronic illnesses.
Prevalence of multiple chronic conditions is increasing (RAND):
2000- 60 million 2010 –70 million
88
LTC Users TodayLTC Users Today
12.2% of Americans reported LTC needs in 1995
55% over 65 (3% are children)
25% community based LTC users are severely disabled
Older Americans with severe disabilities will more than double by 2050
12.2% of Americans reported LTC needs in 1995
55% over 65 (3% are children)
25% community based LTC users are severely disabled
Older Americans with severe disabilities will more than double by 2050
99
Health Care SpendingHealth Care Spending Health care spending (in 1998) for those
without a chronic illness: $680
Health care spending (in 1998) for thosewith chronic illness and ADLs.
# of chronic conditions and presence of ADL Limitation1 chronic illness - $1,500 $3,8302 chronic illnesses - $2,550 $5,650 3 chronic illnesses - $4,060 $7,8004 chronic illnesses - $5,650 $11,8905 chronic illnesses - $7,560 $12,420
(Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02)
Health care spending (in 1998) for thosewithout a chronic illness: $680
Health care spending (in 1998) for thosewith chronic illness and ADLs.
# of chronic conditions and presence of ADL Limitation1 chronic illness - $1,500 $3,8302 chronic illnesses - $2,550 $5,650 3 chronic illnesses - $4,060 $7,8004 chronic illnesses - $5,650 $11,8905 chronic illnesses - $7,560 $12,420
(Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02)
1010
Challenges in the Current Health Care SystemChallenges in the Current Health Care System
Physicians treating patients with chronic conditions report poor outcomes related to:
- receipt of contradictory information from multiple physicians- adverse drug interactions- unnecessary hospitalizations
(Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02)
Physicians treating patients with chronic conditions report poor outcomes related to:
- receipt of contradictory information from multiple physicians- adverse drug interactions- unnecessary hospitalizations
(Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02)
1111
Summary:Summary:
Persons with chronic illnesses and/or disabilities have:- more frequent contacts with health providers; and- higher health care costs.
Persons with chronic illnesses and disabilities are at higher risk of inefficient practice and medical errors.
Persons with chronic illnesses and/or disabilities have:- more frequent contacts with health providers; and- higher health care costs.
Persons with chronic illnesses and disabilities are at higher risk of inefficient practice and medical errors.
1212
Health Information TechnologyHealth Information Technology “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
“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
1313
Policy Goals:Policy Goals: Assure that most Americans have electronic health records
within the next 10 years by: coordinating public and private sector efforts that will accelerate
adoption of HIT; doubling funding (to $100 Million) for demonstration projects on
HIT; using the Government to foster the adoption of HIT (creating
incentives); and creating a new, sub-cabinet level position of National
Coordinator of Health Information Technology in HHS.
Assure that most Americans have electronic health records within the next 10 years by:
coordinating public and private sector efforts that will accelerate adoption of HIT;
doubling funding (to $100 Million) for demonstration projects on HIT;
using the Government to foster the adoption of HIT (creating incentives); and
creating a new, sub-cabinet level position of National Coordinator of Health Information Technology in HHS.
1414
Executive Order 4/27/04Executive Order 4/27/041. Establish the position of National Coordinator of Health Information
Technology (NCHIT).2. The NCHIT shall work to:
- ensure that appropriate information is available to guide medical decisions;
- improve quality,reduce errors, advance evidence-based care;
- reduce costs, errors, inappropriate care, incomplete information, and increase efficiency; and
- increase effective market place, competition, and available accurate information on costs, quality, and outcomes.
1. Establish the position of National Coordinator of Health Information Technology (NCHIT).
2. The NCHIT shall work to:
- ensure that appropriate information is available to guide medical decisions;
- improve quality,reduce errors, advance evidence-based care;
- reduce costs, errors, inappropriate care, incomplete information, and increase efficiency; and
- increase effective market place, competition, and available accurate information on costs, quality, and outcomes.
1515
Executive Order (cont’d)Executive Order (cont’d)Responsibilities- NCHIT shall develop, maintain, and direct a
strategic plan to guide national implementation of interoperable HIT which shall:
- advance implementation of IT standards;
- ensure technical, scientific, and other issues are addressed;
- address privacy and security issue of interoperable HIT; and
- include measurable outcomes.
Responsibilities- NCHIT shall develop, maintain, and direct a strategic plan to guide national implementation of interoperable HIT which shall:
- advance implementation of IT standards;
- ensure technical, scientific, and other issues are addressed;
- address privacy and security issue of interoperable HIT; and
- include measurable outcomes.
1616
Executive Order (cont’d)Executive Order (cont’d)
Reports:
- incentives report to promote interoperable HIT; - OPM report on FEHB on incentives to promote interoperable HIT; and
- VA/DoD report on working with the private sector to extend the HIT in rural and underserved areas.
Reports:
- incentives report to promote interoperable HIT; - OPM report on FEHB on incentives to promote interoperable HIT; and
- VA/DoD report on working with the private sector to extend the HIT in rural and underserved areas.
1717
EHRs: A Key to Improving Quality and Improving EfficiencyEHRs: A Key to Improving Quality and Improving Efficiency
Standardized Electronic Health Records (EHRs) are one of the essential building blocks for the evolution of a national health information infrastructure (NHII).
The NCVHS stated that “implementation of the NHII will have a dramatic impact on the effectiveness, efficiency and overall
quality of health and health care in the United States.”
NCVHS, 2001: pg 2
Standardized Electronic Health Records (EHRs) are one of the essential building blocks for the evolution of a national health information infrastructure (NHII).
The NCVHS stated that “implementation of the NHII will have a dramatic impact on the effectiveness, efficiency and overall
quality of health and health care in the United States.”
NCVHS, 2001: pg 2
1818
Why are standards needed for EHRs?Why are standards needed for EHRs?
The promise of an NHII is based in part on the ability of EHRs 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)
The promise of an NHII is based in part on the ability of EHRs 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)
1919
What standards are needed?What standards are needed?For interoperable exchange of information across clinicians, institutions, payers,
and vendor products standards are needed for:
- terminology (content)
- messaging standardized formats for the exchange of specific findings and electronic documents
- definition of EHR functions
For interoperable exchange of information across clinicians, institutions, payers, and vendor products standards are needed for:
- terminology (content)
- messaging standardized formats for the exchange of specific findings and electronic documents
- definition of EHR functions
2020
What does this mean for Post-Acute and Long-Term Care?What does this mean for Post-Acute and Long-Term Care?
In 2001, Congress was concerned about the noncomparable data in Medicare, particularly in post-acute care.
Required HHS to submit a report 1/05 on
the development of standard instruments for the assessment of health and functional status of patients for whom an array of Medicare services are provided (BIPA Section 545).
In 2001, Congress was concerned about the noncomparable data in Medicare, particularly in post-acute care.
Required HHS to submit a report 1/05 on
the development of standard instruments for the assessment of health and functional status of patients for whom an array of Medicare services are provided (BIPA Section 545).
2121
BIPA Section 545BIPA Section 545
Requires that the Secretary design standard health and functional assessment instruments so that:
1. elements that are common may be readily comparable and statistically compatible; and
2. only elements necessary to meet program objectives are collected.
Requires that the Secretary design standard health and functional assessment instruments so that:
1. elements that are common may be readily comparable and statistically compatible; and
2. only elements necessary to meet program objectives are collected.
2222
Framing the BIPA MandateFraming the BIPA MandateASPE sponsored and partnered with CMS to develop
a framework for this mandate.
Issues that emerged included:
- a common data dictionary for functional status measurement is needed;
- federally required assessments should be more clinically useful while balancing provider burden;
- real-time exchange of comparable data across settings would promote continuity and coordination of care; and
- HIT is needed to promote comparability of data across the continuum.
ASPE sponsored and partnered with CMS to develop a framework for this mandate.
Issues that emerged included:
- a common data dictionary for functional status measurement is needed;
- federally required assessments should be more clinically useful while balancing provider burden;
- real-time exchange of comparable data across settings would promote continuity and coordination of care; and
- HIT is needed to promote comparability of data across the continuum.
2323
Federal Efforts to Encourage EHRs, Particularly in Post-Acute and Long-Term Care (PAC/LTC)
Federal Efforts to Encourage EHRs, Particularly in Post-Acute and Long-Term Care (PAC/LTC)
- Mayo Study - SNOMED-CT license - Consolidated Health Informatics (CHI) Initiative- Council for the Application of Health Information Technology (CAHIT)- HL7 EHR Functional Model and Standard- Study on the status of EHR implementation in PAC/LTC- Apelon Study- Modify patient assessment content and conform with CHI standards- upcoming NHII conference
- Mayo Study - SNOMED-CT license - Consolidated Health Informatics (CHI) Initiative- Council for the Application of Health Information Technology (CAHIT)- HL7 EHR Functional Model and Standard- Study on the status of EHR implementation in PAC/LTC- Apelon Study- Modify patient assessment content and conform with CHI standards- upcoming NHII conference
2424
Mayo StudyMayo StudyASPE 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 (SNOMED-CT, ICF, and ICNP).
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 (SNOMED-CT, ICF, and ICNP).
2525
Mayo Study Findings – Coverage Provided by Terminologies and Classifications
Mayo Study Findings – Coverage Provided by Terminologies and Classifications SNOMED CT provides relatively complete coverage of
terms suggested by the experts and the literature as needed to understand quality in the domains of pressure ulcers, pain, and incontinence (77% - 95% match rates).
ICF and ICNP provided less than 20% complete match rates of the terms suggested by experts
SNOMED CT provides relatively complete coverage of terms suggested by the experts and the literature as needed to understand quality in the domains of pressure ulcers, pain, and incontinence (77% - 95% match rates).
ICF and ICNP provided less than 20% complete match rates of the terms suggested by experts
2626
MDS FindingsMDS Findings MDS provides limited coverage of terms needed to
understand nursing home quality in the domains of incontinence and pain; better coverage for the domain of pressure ulcers.
Most MDS data is not captured by SNOMED CT, ICF, or ICNP:
- SNOMED CT provided a complete match for 46% of the MDS terms; and
- ICF and ICNP were found to provide a complete match for terms in the MDS 2% and 12% of the time, respectively.
MDS provides limited coverage of terms needed to understand nursing home quality in the domains of incontinence and pain; better coverage for the domain of pressure ulcers.
Most MDS data is not captured by SNOMED CT, ICF, or ICNP:
- SNOMED CT provided a complete match for 46% of the MDS terms; and
- ICF and ICNP were found to provide a complete match for terms in the MDS 2% and 12% of the time, respectively.
2727
SNOMED-CTSNOMED-CT
HHS acquired a licensed with the College of American Pathologists (CAP) to make SNOMED-CT freely available to U.S. health care entities.
SNOMED-CT is recognized as the world’s most comprehensive clinical terminology database (350,000+ terms).
SNOMED-CT is available via the Unified Medical Language System (UMLS) at the NLM/HHS.
HHS acquired a licensed with the College of American Pathologists (CAP) to make SNOMED-CT freely available to U.S. health care entities.
SNOMED-CT is recognized as the world’s most comprehensive clinical terminology database (350,000+ terms).
SNOMED-CT is available via the Unified Medical Language System (UMLS) at the NLM/HHS.
2828
Consolidated Health Informatics InitiativeConsolidated Health Informatics Initiative
President’s e-Gov initiative includes the CHI Initiative. Goal: Working in sync with the health industry, adopt standards that enable
inter-operability in federal health care enterprise.
Involved agencies include: HHS, VA, DoD
Process: For specified domains, workgroups identified and made recommendations for standards that meet federal health information needs.
President’s e-Gov initiative includes the CHI Initiative. Goal: Working in sync with the health industry, adopt standards that enable
inter-operability in federal health care enterprise.
Involved agencies include: HHS, VA, DoD
Process: For specified domains, workgroups identified and made recommendations for standards that meet federal health information needs.
2929
CHI Standards AdoptedCHI Standards AdoptedAdopted March 20031. Laboratory Results Names: LOINC® adopted2. Messaging Standards: Includes scheduling, medical
record/image management, patient administration, observation reporting, financial management, patient care: HL7® adopted
3. Messaging Standards: Includes retail pharmacy transactions NCPDP SCRIPT® adopted
4. Messaging Standards: Connectivity: IEEE™ 1073 adopted5. Messaging Standards: Includes Image Information to
Workstations: DICOM® adopted
Adopted March 20031. Laboratory Results Names: LOINC® adopted2. Messaging Standards: Includes scheduling, medical
record/image management, patient administration, observation reporting, financial management, patient care: HL7® adopted
3. Messaging Standards: Includes retail pharmacy transactions NCPDP SCRIPT® adopted
4. Messaging Standards: Connectivity: IEEE™ 1073 adopted5. Messaging Standards: Includes Image Information to
Workstations: DICOM® adopted
3030
CHI Standards Adopted May 2004CHI Standards Adopted May 2004
Demographics (HL7®) Lab Result Contents (SNOMED CT®)
Units (HL7®) Immunizations (HL7®) Medications (Federal Drug Terminologies, FDA Standards, RxNorm, VA’s
National Drug File Reference Terminology) Interventions/Procedures: Lab Test Order Names (LOINC®) Interventions/Procedures: Non-Lab (SNOMED-CT®)
Demographics (HL7®) Lab Result Contents (SNOMED CT®)
Units (HL7®) Immunizations (HL7®) Medications (Federal Drug Terminologies, FDA Standards, RxNorm, VA’s
National Drug File Reference Terminology) Interventions/Procedures: Lab Test Order Names (LOINC®) Interventions/Procedures: Non-Lab (SNOMED-CT®)
3131
CHI Standards Adopted May 2004CHI Standards Adopted May 2004
Anatomy (SNOMED CT® and NCI Thesaurus) Diagnosis/Problem Lists (SNOMED CT®) Nursing (SNOMED CT®) Financial/Payment (HIPAA Transactions and Code Sets) Genes and Proteins (Human Genome Nomenclature – HUGN) Clinical Encounters (HL7®) Text-Based Reports (HL7® – Clinical Document Architecture) Chemicals (EPA’s Substance Registry
System)
Anatomy (SNOMED CT® and NCI Thesaurus) Diagnosis/Problem Lists (SNOMED CT®) Nursing (SNOMED CT®) Financial/Payment (HIPAA Transactions and Code Sets) Genes and Proteins (Human Genome Nomenclature – HUGN) Clinical Encounters (HL7®) Text-Based Reports (HL7® – Clinical Document Architecture) Chemicals (EPA’s Substance Registry
System)
3232
CHI Domains with No StandardCHI Domains with No Standard
Physiology Medical Devices and SuppliesHistory and PhysicalDisabilityMultimediaPopulation Health
Physiology Medical Devices and SuppliesHistory and PhysicalDisabilityMultimediaPopulation Health
3333
CHI - Disability DomainCHI - Disability Domain Workgroup lead by ASPE and comprised of representatives from: CMS, NCHS, VA, SSA
Extended content coverage analyses of SNOMED-CT, ICF, and other sources in the UMLS Metathesaurus for terms sampled from:
- NH MDS - HH OASIS - FIM (used by the VA and included in the Medicare Rehab Hospital patient assessment
instrument) - Social Security Administration - National Center for Health Statistics
Workgroup lead by ASPE and comprised of representatives from: CMS, NCHS, VA, SSA
Extended content coverage analyses of SNOMED-CT, ICF, and other sources in the UMLS Metathesaurus for terms sampled from:
- NH MDS - HH OASIS - FIM (used by the VA and included in the Medicare Rehab Hospital patient assessment
instrument) - Social Security Administration - National Center for Health Statistics
3434
Disability Workgroup (cont’d)Disability Workgroup (cont’d)Findings:
neither SNOMED CT nor ICF adequately address the disability data or scaling needs of involved federal agencies.
The CHI Council recommended that:- work proceed to refine an existing granular terminology;
- consider whether and how incorporation into LOINC of disability questions could contribute to future standardization of disability questions; and
- enhance LOINC coverage of disability questions used by the Federal government.
Findings:
neither SNOMED CT nor ICF adequately address the disability data or scaling needs of involved federal agencies.
The CHI Council recommended that:- work proceed to refine an existing granular terminology;
- consider whether and how incorporation into LOINC of disability questions could contribute to future standardization of disability questions; and
- enhance LOINC coverage of disability questions used by the Federal government.
3535
Council for the Application of Health Information TechnologyCouncil for the Application of Health Information Technology
The Secretary of HHS created CAHIT in 6/03 to promote a timely exchange of information about and across relevant HHS activities and opportunities.
CAHIT establishes the Department’s position on health information technology issues after considering opinions and perspectives from HHS agencies and offices.
The Secretary of HHS created CAHIT in 6/03 to promote a timely exchange of information about and across relevant HHS activities and opportunities.
CAHIT establishes the Department’s position on health information technology issues after considering opinions and perspectives from HHS agencies and offices.
3636
CAHIT Coordination Role – Example:CAHIT Coordination Role – Example:
- Coordinated efforts to modify the MDS to support implementation of EHRs.
- CMS is funding work to enhance the clinical content of the MDS.
- CMS and ASPE will fund work to embed CHI standards in the MDS to maximally support EHR implementation.
- Coordinated efforts to modify the MDS to support implementation of EHRs.
- CMS is funding work to enhance the clinical content of the MDS.
- CMS and ASPE will fund work to embed CHI standards in the MDS to maximally support EHR implementation.
3737
Study on Electronic Health Information in Post-Acute and Long-Term Care
Study on Electronic Health Information in Post-Acute and Long-Term Care
ASPE funded UCHSC to study the current status of implementation of interoperable electronic health information systems (EHIS) in nursing homes, home health agencies, and rehabilitation facilities.
A written report will be available 7/04 summarizing findings and recommendations the public and private sectors could pursue to accelerate the adoption of EHRs in post-acute and long-term
care.
ASPE funded UCHSC to study the current status of implementation of interoperable electronic health information systems (EHIS) in nursing homes, home health agencies, and rehabilitation facilities.
A written report will be available 7/04 summarizing findings and recommendations the public and private sectors could pursue to accelerate the adoption of EHRs in post-acute and long-term
care.
3838
Study on Content and Messaging Standards and the MDS Study on Content and Messaging Standards and the MDS
ASPE is funding Apelon to examine the applicability of terminology and messaging standards for selected MDS items. Specifically, we have asked Apelon to:
- Examine, for selected MDS v.2 and v. 3 items, the ability to encode MDS questions and answers in LOINC and standardized terminologies (e.g., SNOMED and CHI-endorsed standards); and
- advance options for how an MDS redesign could use terminology and messaging standards.
Study to be complete in July 2004.
ASPE is funding Apelon to examine the applicability of terminology and messaging standards for selected MDS items. Specifically, we have asked Apelon to:
- Examine, for selected MDS v.2 and v. 3 items, the ability to encode MDS questions and answers in LOINC and standardized terminologies (e.g., SNOMED and CHI-endorsed standards); and
- advance options for how an MDS redesign could use terminology and messaging standards.
Study to be complete in July 2004.
3939
Technology WebsiteTechnology Website ASPE funded "Technology for Long Term Care" to
develop a website to on information on technologies that can help improve quality of life and care for the elderly and the disabled in LTC residential settings.
www.TechForLTC.org provides information for professionals in NHs, ALFs, board and care facilities, ADC facilities, and CCRC.
ASPE funded "Technology for Long Term Care" to develop a website to on information on technologies that can help improve quality of life and care for the elderly and the disabled in LTC residential settings.
www.TechForLTC.org provides information for professionals in NHs, ALFs, board and care facilities, ADC facilities, and CCRC.
4040
Upcoming NHII Conference Upcoming NHII Conference Participation is important
NHII Website: http://aspe.hhs.gov/sp/nhii
Participation is important
NHII Website: http://aspe.hhs.gov/sp/nhii
4141
Jennie Harvell Office of the National Coordinator on Health Information Technology/ HHS
[email protected]/690-6443
http://aspe.hhs.gov/daltcp/home.shtml
Jennie Harvell Office of the National Coordinator on Health Information Technology/ HHS
[email protected]/690-6443
http://aspe.hhs.gov/daltcp/home.shtml