The Transformation of Health and The Transformation of Health and Health CareHealth Care

The Role of the NHIIThe Role of the NHII

John Lumpkin, M.D., M.P.H., John Lumpkin, M.D., M.P.H.,

Senior Vice President, Senior Vice President,

Director of Health Care GroupDirector of Health Care Group

Robert Wood Johnson FoundationRobert Wood Johnson Foundation

June 10, 2003June 10, 2003

IOM Panel ReportsIOM Panel Reports November 2002November 2002

• “The American health care system is confronting a crisis.”

• “The health care delivery system is incapable of meeting the present, let alone the future, needs of the American public.”

““Perfect Storm” Forming Around Perfect Storm” Forming Around Health and Health CareHealth and Health Care

• 41 Million + Uninsured in America41 Million + Uninsured in America• Health Care Costs Rapidly RisingHealth Care Costs Rapidly Rising• Those Covered Paying More for Their Those Covered Paying More for Their

Coverage and More Out-of-PocketCoverage and More Out-of-Pocket• State Budget Crises Threatening CoverageState Budget Crises Threatening Coverage• Quality is not a givenQuality is not a given• Public Health System is StressedPublic Health System is Stressed• Seeking Health Information is a Major Internet Seeking Health Information is a Major Internet

TaskTask

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ists

0.00.0

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

0.00.0 2.52.5 5.05.0 7.57.5 10.010.0 12.512.5 15.015.0

Number of Cardiologists per 100,000Number of Cardiologists per 100,000

Capacity Determines Need?Capacity Determines Need?

Jack WennbergDartmouthAtlas of Health Care

Hip FractureR2 = 0.06

All MedicalConditionsR2 = 0.54

00

5050

100100

150150

200200

250250

300300

350350

400400

1.01.0 2.02.0 3.03.0 4.04.0 5.05.0 6.06.0Acute Care BedsAcute Care Beds

Dis

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rge

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ate

Capacity Determines Need?Capacity Determines Need?

Jack WennbergDartmouthAtlas of Health Care

What does Greater Per Capita Spending What does Greater Per Capita Spending BUY?BUY?

not more effective or preference sensitive carenot more effective or preference sensitive care1.

00

1.00

1.00

1.18

0.98 1.04

1.38

0.97 1.03

1.66

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0.80.8

1.21.2

1.61.6

2.02.0

Medicare ReimbursementsMedicare Reimbursements Effective CareEffective Care Preference-Sensitive CarePreference-Sensitive Care(Discretionary Surgery)(Discretionary Surgery)

Rat

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est

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est

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More than 15% Below Average

0-15% Below Average

0-15% Above Average

More than 15% Above Average

Jack WennbergDartmouthAtlas of Health Care

Medicare Reimbursements (Part A and B) in Medicare Reimbursements (Part A and B) in Relation to the National Average (2000)Relation to the National Average (2000)

More than 15% Above AverageMore than 15% Above Average (36)(36)00 - 15% Above Average- 15% Above Average (68)(68)00 - 15% Below Average- 15% Below Average (112)(112)More than 15% Below AverageMore than 15% Below Average (90)(90)Not PopulatedNot Populated

Jack WennbergDartmouthAtlas of Health Care

Quality of Health Care in US??Quality of Health Care in US??

• Overall Care 54.9%

• Preventive 54.9%

• Acute 53.4%

• Chronic 56.1%

• History 43.4%

• Counseling or Ed 18.3%

• Immunization 65.7%

Elizabeth McGlynn, et al NEJM June 26, 2003 348:26

The focus must shift from blaming The focus must shift from blaming individuals for past errors to a focus on individuals for past errors to a focus on

preventing future errors by designing safety preventing future errors by designing safety into the systeminto the system

To Err is Human

- Institute of Medicine

Back Surgery per 1,000 Medicare Enrollees Back Surgery per 1,000 Medicare Enrollees on a Race-Specific Basis (1999-2000)on a Race-Specific Basis (1999-2000)

1.01.0

2.02.0

3.03.0

4.04.0

5.05.0

6.06.0

7.07.0

8.08.0

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ac

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Black Non-Black

A. Sehgal- JAMA 2003;289:996-1000

Current practice Current practice depends upon the depends upon the

clinical decision-making clinical decision-making capacity and reliability capacity and reliability

of autonomous of autonomous individual practitioners, individual practitioners, for classes of problems for classes of problems that routinely exceeds that routinely exceeds the bounds of unaided the bounds of unaided

human cognitionhuman cognitionDaniel R. Masys, M.D.

2001 IOM Annual Meeting

“We have wonderful technology, but some grocery stores have better

technology than our hospitals and clinics.”

Secretary Tommy ThompsonChicago Medical School CommencementJune 7, 2002

We stand on the “tipping point” of We stand on the “tipping point” of the rapid enhancement of the health the rapid enhancement of the health

care system into a high quality, care system into a high quality, efficient and effective system. efficient and effective system.

Automation of information systems is Automation of information systems is the transforming technologythe transforming technology

NHIINHII

Population Health

(Preparedness)

Healthcare ProviderPersonalHealth

NHIINHII

Population Health

(Preparedness)

Healthcare ProviderHealthcare ProviderPersonalHealth

Framework for Framework for PMRI StandardsPMRI Standards

InteroperabilityInteroperability

Data

Data

Quality

Quality

ComparabilityComparability

HL7 &

DICOM HL7 & ASTM

HL7

HL7

ASTM

& HL7

IEEE

PMRIPMRI

Laboratories

ASC

X12N &

NCPDP

NCPDP &

ASC X12N

NCPDP &

X12N

Radiology

Hospital

Pharmacy

Knowledge

bases

Physiological

monitors

Medical

devicesBedside

computer

Patient

Registration/

Admissions

Billing

Clinical

content

Orders

&

results

Community

Pharmacies

Pharmacy

Benefits Mgrs

Payers

HL7

HL7

&

ASTM

HL7

IEEE

(Adapted from Electronic Health Records: Changing the Vision, Eds. GF Murphy,MA Hanken, and KA Waters. Philadelphia: W. B. Saunders Company, 1999)

Interoperability StatusInteroperability Status

Comparability Comparability IssuesIssues

• Comparability requires that the meaning of data is consistent when shared among different parties

Vocabulary Set of highly granular, specialized terms

ClassificationOrganization of related terms

Coderepresentation

of term

Terminology

The Health Informatics The Health Informatics PipelinePipeline

Foundation Foundation HIPAA StandardsHIPAA Standards

Financial &

Administrative

Interoperability

Comparability

Dat

a Q

ualit

y

Privacy &Security

NHIINHII

Population Population HealthHealth

(Preparedness)(Preparedness)

Healthcare ProviderPersonalHealth

ClincalSite

State PHDept

LocalPH Dept

CDC

CDCResponse

Team

LocalResponse

Team

FBIResponse

Team

ContractorResponse

Team

HHSLRN

Level ALab

LRNLevel B,C

Lab

Contaminated Bldg.Outbreak Community

RegularLab

2.1 - suspicion

1

2N

34N

4.11

4P

4.124.1 - suspicion

5

6N6P

6.1 - new case

4.13

4.2

6.11

6.12

6.2

6.13

0 - specimen

2P

FBI

7 8 9

1010

11

12

13

10 - New Event

14

1415

14

15

15

Hospital

Vaccination Center

Example Data Flow

C. Broome - CDC

The Need for The Need for Solutions is UrgentSolutions is Urgent

Third Wave of Public Health Information Third Wave of Public Health Information System DevelopmentSystem Development

• Federal Centric– State developed prototype – Installed in many states

• State Centric– System Development by Consortium of States

• Web enabled Immunization Registry

• Reuse Model

• ASP Model

NHIINHII

Population Health

(Preparedness)

Healthcare ProviderPersonalPersonalHealthHealth

Personal Health DimensionPersonal Health Dimension

• Supports the management of individual Supports the management of individual wellness and health care decision-makingwellness and health care decision-making

• Includes a personal health record, created and controlled by the individual or family

• Includes non-clinical information such Includes non-clinical information such as self-care trackers, health materials, as self-care trackers, health materials, local public health and health care local public health and health care servicesservices

General attitudes toward PHRGeneral attitudes toward PHR

When asked about specific aspects of a PHR, consumers react favorably:

• 83% of healthcare consumers want lab tests available online (Harris)

• 69% want online charts for managing chronic conditions (Harris)

• 80% want to receive personalized medical information online from their doctor after an office visit (Harris)

I always knew that Data was a I always knew that Data was a four letter word, four letter word,

I just never knew it was spelled I just never knew it was spelled

T-U-R-FT-U-R-F

Phil Lee, MD

HHS Agencies with NHII HHS Agencies with NHII ResponsibilitiesResponsibilities

• AHRQ

• ASIRM

• ASPE

• CDC

• CMS

• Data Council

• FDA

• HRSA

• NCHS • NIH• NLM• OCR• OPHS

In the modern era, every century has had its

major advance that has brought medical

science another giant step forward. …. What will

the major advance of the 21st century be?

I am convinced that the medical revolution

of our children’s lifetimes will be the

application of information technology to

health care.

Secretary ThompsonMarch 21, 2003

A Word of CautionA Word of Caution

The real danger is not that computers will begin to think

like men, but that men will begin to think like computers

Sidney J. Harris

A Word of EncouragementA Word of Encouragement

Not only strike while the iron is hot,

make it hot by striking –

Oliver Cromwell