Opening Keynote: Connie Delaney, PhD, RN, Director, Biomedical Health Informatics, Dean, Nursing School, University of Minnesota, Member, ONC HITPC

Connie White Delaney, PhD, RN, FAAN, FACMI

May 18, 2011

iHT2 Health IT Summit in Phoenix

welcome

1. Discuss HIT challenges and potential

solutions in the months ahead.

2. Discuss leveraging data to drive evidence

based healthcare and improve outcomes

3. Discuss collaboration across care settings and

missions.

Industry leaders & senior executives,

CIO, CMO, CMIO, Physician, Practice Manager,

VP and Director of IT

4 Principles for Behavioral Change

1. Social norms

2. Foot in the Door

3. Reciprocity

4. “Diderot Effect”

Outcomes transforming care to improve outcomes manage transitions decrease costs assure care appropriateness engage in disease prevention/health promotion people centered

Sustainability 4 Principles for Behavioral Change 1. Social norms 2. Foot in the Door 3. Reciprocity 4. “Diderot Effect”

1. Social norms

2. Foot in the Door

3. Reciprocity


http://www.cms.gov/EHRIncentivePrograms/8

Implementation Report (1/12)

States launched as of January 2012: 42# of States that disbursed incentives: 33

Planning Territories

SMHPs Submitted AS

SMHPs Final Approval CNMI

IAPDs Pending GU

IAPDs Approval PR

Launched USVI

Incentives Disbursed

AL

AK

AZAR

CA

CO

CT

MD

FL

GA

HI

ID

IL IN

IA

KS KY

LA

ME

DC

NH

MI

MN

MS

MO

MT

NE

NV

NJ

NM

NY

NC

ND

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VT

VA

WA

WV

WI

WY

DE

MANote: ME, MA, DE, VT and NY have also disbursed incentives as of 12/31

1. Social norms

2. Foot in the Door

3. Reciprocity

4. “Diderot Effect” Robert Tagalicod, Robert Anthony, and Jessica Kahn

HIT Policy Committee, January 10, 2012

8

December 2011 Providers Paid

December 2011 Payments

YTD Providers Paid

YTD Payments

Eligible Professional 4,997 $ 86,946,000 15,255 $ 274,590,000

Medicare Only Hospital 4 $ 5,600,870 38 $ 56,782,557

Medicare & Medicaid Hospital (Medicare Payment) 189 $ 369,136,265 566 $ 1,052,839,955

TOTAL 5,190 $ 464,683,136 15,859 $ 1,384,212,512

For final CMS reports, please visit:

http://www.cms.gov/EHRIncentivePrograms/56_DataAndReports.asp

1. Social norms

2. Foot in the Door

3. Reciprocity



9

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Providers Paid by Month Providers Paid

1. Social norms

2. Foot in the Door

3. Reciprocity


Robert Tagalicod, Robert Anthony, and Jessica Kahn


$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

$600,000,000

$700,000,000

$800,000,000

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Incentive Payments by Month

Incentive Payments

1. Social norms

2. Foot in the Door

3. Reciprocity



Providers Included in MU Analysis

At the time of the analysis:

• 33,595 Medicare EPs had attested

• 33,240 Successfully

• 355 Unsuccessfully (89 previously unsuccessful resubmitted)

• 842 Acute Care and Critical Access Hospitals had attested

• All successfully

• Official data should be sourced and cited from the CMS website,

updated monthly

(http://www.cms.gov/EHRIncentivePrograms/56_DataAndReports.asp)

11

Robert Tagalicod, Robert Anthony, and Jessica Kahn


http://www.cms.gov/EHRIncentivePrograms/56_DataAndReports.asp

Updated Work Plan for

Developing Recommendations for Stage 3 (Tang et al, 2012 )

• Nov 9: Reported on Oct 5 Hearing; input from HITPC

• Nov 30: Sec announced intent to delay stage 2 to 2014

– => IF we were to assume stage 3 begins 2 years after stage 2

(await NPRM and Final Rule), HITPC MU recommendations

would be needed by mid-2013

• Need lead time for HITSC work if relevant standards

need to be adopted or developed

– 4Q12 for HITSC-sensitive MU recommendations

– 2Q13 for policy-only MU recommendations

• January 2012 @ HITPC: Initial HITSC

recommendations for HITPC review related to quality

measure development

– Planned joint workshop with HITSC/ONC/CMS on Quality

Measures

Initial Recommendations for

HITSC

Group 1 for Immediate Action – Could Impact

Stage 2

Recommendations for HITSC

Rec 1: Certification of CQM Reports (Tang et al, 2012)

• Problem: 1. Many healthcare organizations use reporting systems (vs. EHRs) to

generate quality reports for public reporting and quality improvement

2. MU certification rules state that the healthcare organizations must

use the certified EHR to report the CQM measures to CMS

3. EHR vendors hardwire CQM calculations without knowing local

clinical workflows, causing workflow work arounds

4. Not all CQMs are relevant to all certified HIT systems

• Proposed Solution: – HIT vendor products should be certified for all CQMs relevant to the

scope of the product

– Providers should be permitted to use non-certified systems to

generate CQM reports, as long as all the data used in the calculation

of the measure are derived from certified HIT systems

– All submitted CQMs are subject to audit

– CQM reporting systems should be tested (subject to audit) based on

a standardized test data set

Initial Recommendations for

HITSC

Group 2 – Longer Lead Time Required

Initial Recommendations for HITSC

Recommendation 2: “CQM Platform” (Tang et al, 2012)

• Problem: 1. Clinical Quality Measures (CQMs) are being “hard wired” into EHRs,

which require upgrades in order to implement or revise

2. EHR vendors are pre-defining data elements used in calculating

CQMs, which impact clinical workflows of clinicians

3. Healthcare organizations do not have an easy way to report on

quality-improvement measures (vs. just CQMs)

• Proposed Solution: – By stage 3, EHR vendors should develop a “CQM platform" onto

which new and evolving CQMs can be added to an EHR without

requiring an upgrade to the EHR system.

– Longer term, such platforms should be capable of incorporating CQM

"plug-ins" that can be shared, and that allow organizations to localize

data fields that fit local work flow.

– We recommend that HITSC develop certification criteria to

encourage/require this CQM platform as part of MU


Rec 3: Patient-Reported Data and CQMs (Tang, 2012)

• Problem: 1. Most CQMs are written for clinicians, pertinent to diseases

2. Most CQMs do not incorporate information meaningful for consumers

• Proposed Solution: – Some CQMs should incorporate patient-reported data and outcomes

– HIT vendors should develop secure, patient-friendly systems that

allow direct entry of patient-reported data that can be incorporated

into CQM reports

– Patients should be able to access CQM reports


Rec 4: Delta Measures (Tang et al, 2012)

• Problem: 1. Most CQMs report risk-adjusted population means

2. Patients seek measures that would apply to “people like me”

• Proposed Solution: – Some CQMs should report on percent of patients improving (“delta

measures”) vs. only reporting risk-adjusted population means

– EHR vendors should be able to calculate delta measures

Follow-Up Actions on

New CQM Recommendations (Tang et al, 2012)

• Form joint HITPC/HITSC work group, including CMS,

ONC, CQM stakeholders

• Conduct hearing on longer term CQM actions (CQM

platform, new CQM concepts)

– QM supply chain

– QM consumer issues (informed by NCVHS February hearing

on Measures that Matter to Consumers)

– HIT vendor considerations

• All-day working session following hearing

Summary (Tang et al, 2012)

• Re: Certification Policies: We recommend that clinical

quality measures should be based on clinical data

from certified EHRs, and reported using standard

definitions, subject to audit. CQMs can be reported to

CMS from non-certified systems as long as the above

is true.

• Re: CQM Reporting: Vendor-neutral CQM platforms

that accept “CQM plug-ins” should be developed to

support evolving quality measurement

• Re: Patient-centered CQMs: New CQMs that are

meaningful to patients should be developed, and

patient-reported data should be captured and

reported using HIT

microscopic macroscopic

molecular and

cellular processes tissues &

organs

individual

patients populations

Human Health

& Disease

[translational

bioinformatics]

Clinical

Research

Informatics

Consumer

Health

Informatics

What is the CTSI?

CTSI is part of is part of a national Clinical and Translational

Science Award (CTSA) consortium created to accelerate

laboratory discoveries into treatments for patients. The CTSA

program is led by the National Institutes of Health's National

Center for Research Resources.

Health Knowledge Discovery & Dissemination

Bench

Bedside

Practice

Community

CTSA Institutions, 2006 - 2011

NCRR Fact Sheet: Clinical and Translational Science Awards, Summer 2011, www.ncrr.nih.gov

http://www.ncrr.nih.gov/

CTSA UMN: What We Do • Biomedical Informatics – Provides infrastructure, expertise, and training in Biomedical Informatics.

• Clinical Translational Research Services – Provides research services, support, and collaboration, including project management, research coordination, clinical procedures, and biostatistics.

• Education, Training, and Research Career Development – Provides trainees with opportunities to enhance quality and productivity.

• Office of Community Engagement for Health – Helps researchers link to community interests and researcher partners.

• Office of Discovery and Translation - Develops novel research methods, tools, and technologies.

U of Minnesota AHC Information Exchange (AHC IE)

Complete the Informatics Infrastructure

• Network All Care Sites

– Tie all Providers into the Health Information

Infrastructure

• Information Exchange

• Standards

• Link Care Teams

– All Health Workers plus Citizens/Patients as real

Partners on the Care Team

How do we achieve interoperable

healthcare information systems?

(Fridsma/ Humphreys, 2012)

Team

convened to

solve problem

Solutions

& Usability

Accuracy &

Compliance

Enable

stakeholders to

come up with

simple, shared

solutions to

common

information

exchange

challenges

Curate a

portfolio of

standards,

services, and

policies that

accelerate

information

exchange

Enforce compliance with

validated information exchange

standards, services and policies

to assure interoperability

between validated systems

How do we achieve interoperable

healthcare information systems?


•Enable stakeholders to come up with simple, shared solutions to common information exchange challenges

•Curate a portfolio of standards, services, and policies that accelerate information exchange

•Enforce Compliance with validated information exchange standards, services and policies to assure interoperability between validated systems

Office of the National Coordinator for

Health Information Technology 30

Defining the Nationwide Health

Information Network


A set of services, standards and

policies that enable secure health

information exchange over the Internet.



Vocabulary &

Code Sets

NwHIN Building Blocks

Content

Structure

Transport

Security

Services

SNOMED-CT

Consolidated

CDA

Care Summaries

UDDI-Certificate

& Service

Discovery

SOAP-Secure

Web Services

Certificate

Authority

X.509 - Digital

Certificates

SMTP-Direct Based Exchange

DNS, LDAP-

Certificate

Discovery

Provider

Directories

LOINC

Quality Reporting

ICD-10

Lab Results IG

Lab Results

RxNorm

HL7 v.2.5.1 Public Health

Reporting



Diagram of NwHIN Portfolio 1.0


SAML

INTEROPERABILITY

STACK

NLM Vocabulary Portfolio


• Support maintenance, dissemination, free US use – SNOMED CT

– LOINC

• Develop, maintain, disseminate, use in services research – RxNorm (in cooperation with FDA, VA, drug information providers)

– MeSH, NCBI Taxonomy

– UMLS Metathesaurus (includes all above, HIPAA codes, many more)

• Create associated products, tools for users, e.g., – Vocabulary subsets, mappings, extensions

– Lexical & mapping tools, browsers, download sites, APIs

• Provide customer service – Documentation, training materials, query response, licensing

• Contribute to US HIT standards coordination, policy development

ONC-NLM Interagency Agreement


• Sets priorities for NLM vocabulary work in

support of meaningful use, e.g.,

– Additions to SNOMED CT, LOINC,

RxNorm

– High priority subsets and mappings

– Tools for value set development,

maintenance

– Enhanced APIs

• Provides additional funding for some

activities

• Health People 2020

• HealthyPeople.gov

• National Quality Strategy (March 21 2011)

• http://www.hhs.gov/news/press/2011pres/03/20110321a.html

• Improve the overall quality, by making health care more patient-centered,

reliable, accessible, and safe.

• Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.

• Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

http://www.hhs.gov/news/press/2011pres/03/20110321a.html

http://www.hhs.gov/news/press/2011pres/03/20110321a.html

National Quality Strategy

• Two goals of Partnership for Patients (HealthCare.gov) April 12, 2011 are to:

• Keep patients from getting injured or sicker.

• 2013, preventable hospital-acquired conditions decrease by 40% compared to 2010

• ~1.8 million fewer injuries to patients (> 60,000 lives saved over three years)

• Help patients heal without complication.

• 2013, preventable complications during a transition from one care setting to another decreased so that all hospital readmissions reduced by 20% compared to 2010

• ~1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

21st Century Healthcare System

• Robust information infrastructure

• Widespread use of evidence-based medicine

• Aligned incentives & regulatory requirements

• Workforce skilled in:

– Evidence-based health

– Information &

communication technologies

– Process improvement

“”

Future: Manage Change

Supported by Information Technology & Informatics

• Build Knowledgeable Teams

• Reinvent Workflow

• Integrate Innovations

• Remove ‘Outdated’ Practices

• Reduce Variation

• Improve Safety/Quality while

Reducing Costs

• Manage the Base of

Knowledge

• Complete the HIT &

Informatics Infrastructure

• Change Management &

Work Redesign

• Enhance Clinical Decision

Support

Policy

Federal Advisory Committees

• Health IT Policy Committee

– Makes recommendations to the National

Coordinator for Health IT on a policy framework for

the development and adoption of a nationwide

health information infrastructure, including

standards for the exchange of patient medical

information.

• Health IT Standards Committee

– Focuses on the standards to implement the

policies recommended by the Health IT Policy

Committee

Relationship to CMS

Vision [framework] A system that is designed to generate and apply the best evidence for

the collaborative health care choices of each patient and provider; to

drive the process of new discovery as a natural outgrowth of patient

care; and to ensure innovation, quality, safety, and value in health care.

(Charter of the Institute of Medicine Roundtable on Value & Science-

Driven Health Care)

Health IT in the HHS Strategic Plan

Goal 2: Advance Scientific Knowledge and

Innovation

Goal 3: Advance the Health, Safety, and Well-

Being of the American People

Goal 4: Increase Efficiency, Transparency, and

Accountability of HHS Programs

Goal 5: Strengthen the Nation’s Health and

Human Services Infrastructure and Workforce

HHS’ Strategic Plan

Goal 1: Transform Health Care Health IT objective in HHS Plan

42

43 Federal Health IT Strategic Plan

Pre-decisional Draft – Do Not Disclose

Federal Health IT Strategic Plan: 2011-2015

Context

• The Framework was well underway prior to the release of the Affordable Care Act

Similarities:

• Largely the same priorities and vision

• Focus on Outcomes

Differences:

• Structurally different

• Reflects impact of the Affordable Care Act

• Makes empowering individuals a goal

44

Evolution of the Strategic Framework to the Strategic Plan

Goal I: Achieve Adoption and Information

Exchange through Meaningful Use of Health IT

Goal II: Improve Care, Improve Population

Health, and Reduce Health Care Costs through

the Use of Health IT

Goal III: Inspire Confidence and Trust in Health

IT

Goal IV: Empower Individuals with Health IT to

Improve their Health and the Health Care System

Goal V: Achieve Rapid Learning and

Technological Advancement

Strategic Plan

4 Principles for Behavioral Change

1. Social norms

2. Foot in the Door

3. Reciprocity
