Electronic Prescribing and Health Information Technology:The Environmental Landscape
The Role of Consumers
SOS Rx Coalition MeetingNational Consumers League
Washington, D.C.
Janet M. MarchibrodaChief Executive Officer, eHealth Initiative
Executive Director, Foundation for eHealth InitiativeExecutive Director, Connecting for Health
June 30, 2004
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What Problems are We Trying to Solve?
Looming Healthcare Crisis
Quality and Safety Challenges
Big Gap Between “What we Know” and “What We Do”
Public Health Threats Continue
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Patient Perspectives Our healthcare system is fragmented….care is
delivered by a variety of independent physicians, hospitals and other providers
We interact with many plans and providers over a lifetime making continuity of our personal health information a challenge
Clinicians sometimes provide care without knowing what has been done previously and by whom…which can lead to treatments that may be redundant, ineffective or even dangerous
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Patient Perspectives
Vital data sit in paper-based records that can neither be accessed easily nor combined into an integrated form to present a clear and complete picture of our care
Our paper hospital records are unavailable when needed about one-third of the time
Physicians spend an estimated 20-30% of their time searching for and organizing information
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Why Information Technology Matters
It Improves Quality and Saves Lives
Center for Information Technology Leadership recent study indicates prevention of more than 2 million adverse drug events and 190,000 hospitalizations per year could be realized from adoption of CPOE in the ambulatory care environment.
It Makes it Easier to Navigate the Healthcare System
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Why Information Technology Matters
It Saves Money
CITL study indicates $44 billion in savings per year could be realized from adoption of CPOE in the ambulatory care environment.
CITL also released research findings that indicate that standardized healthcare information exchange among healthcare IT systems would deliver national savings of $86.8 billion annually after full implementation and would result in significant direct financial benefits for providers and other stakeholders
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Increasing Demand from Consumers
A Harris consumer interactive poll found that:
80% want personalized medical information on-line from their physicians
69% want on-line charts for tracking chronic conditions
83% want to receive their lab tests on-line
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Increasing Demand from Consumers
Clinicians receiving computerized patient symptom assessments prior to a patient visit addressed 51% of their patients symptoms, compared with only 19% of those not receiving assessments
63% of consumers in a February 2004 survey agreed it would be “very valuable” to have their complete medical history stored in one computer file that can be accessed anywhere in the hospital
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Increasing Demand from Consumers
Foundation for Accountability Survey for Connecting for Health
In response to question: “if you could keep your medical records online, what would you do?”
Email doctor – 75%
Store immunization records – 69%
Transfer information to specialist – 65%
Look-up test results – 63%
Track medication use – 62%
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Despite Evidence Adoption Rates Low
More than 90 percent of the estimated 30 billion health transactions each year are conducted by phone, fax or mail
Healthcare lags behind all industries when it comes to spending on IT. While 11.10%, 8.10% and 6.5% of revenues were invested in IT in the financial services, insurance and consumer services industries, respectively in 2002, only 2.2% of healthcare industry revenues were spent on IT
Only a third of hospitals nationwide have computerized physician order entry (CPOE) systems completely or partially available. Of those, only 4.9% require their use.
Fewer than 5% of U.S. physicians prescribe medications electronically
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Barriers to Adoption of Information Technology Leadership - Within the public and private sectors…at the
national level, at the community level, within provider institutions and clinician practices
Funding and a Business Model - Misalignment of incentives among those who pay for IT and those who benefit from it. The need for upfront funding and a sustainable business model to support investment
Standards – The lack of interoperability and standards to support mobilization of information and connectivity across systems
Organizational and Work-Flow Change – Migrating to an electronic system is difficult
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eHealth Initiative Purpose
eHealth Initiative was formed to clear barriers to the adoption of information technology and a health information infrastructure to drive improvements in quality, safety and efficiency for patients…focusing on:
Leadership
Financing and Business Model
Standards
Organizational and Work-Flow Change
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eHealth Initiative Mission and Vision
Our Mission: Drive improvement in the quality, safety, and efficiency of healthcare through information and information technology
Our Vision: Consumers, providers and those responsible for population health will have ready access to timely, relevant, reliable and secure health care information and services through an interconnected, electronic health information infrastructure to promote better health and healthcar
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eHealth Initiative’s Members
Health care information technology suppliers
Health systems and hospitals
Health plans
Employers and purchasers
Non-profit organizations and professional societies
Pharmaceutical and medical device manufacturers
Practicing clinician organizations
Public health organizations
Research and academic institutions
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A Number of Policy Changes are Emerging
There is Rapidly Increasing Momentum for the Use of IT in Healthcare to Address These Challenges
Congress
Administration
Private Sector
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IT Provisions in Medicare Modernization Act Electronic Prescription Program
Establishes a real-time electronic prescribing program for all physicians, pharmacies, and pharmacists who serve Medicare beneficiaries with Part D benefits
Requires following electronic information: drug being prescribed, patient’s medication history, drug interactions, dosage checking, and therapeutic alternatives
Requires DHHS to develop, adopt, recognize or modify initial uniform standards for e-prescribing
Establishes a safe harbor from penalties under the Medicare anti-kickback statute
Provides that these standards will pre-empt state law or regulation that are contrary to or restrict the ability to carry out the electronic prescribing program
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IT Provisions in Medicare Modernization Act
Grants to Physicians
Authorizes Secretary to make grants to physicians to defray costs of purchasing, leasing, installing software and hardware; making upgrades to enable eRx; and providing education and training
Requires 50% matching rate
Authorizes appropriation of $50 million for grants in FY 2007 and such sums as necessary for fiscal years 2008 and 2009
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IT Provisions in Medicare Modernization Act
Payment Demonstrations
Pay for performance demonstration program with physicians to meet needs of beneficiaries through adoption and use of IT and evidence based outcomes measures
Four demonstration sites – carried over three years
HHS Secretary shall pay a per beneficiary amount to each participating physician who meets or exceeds specific performance standards regarding clinical quality and outcomes
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Other Legislation Related to IT
National Health Information Infrastructure Act
Sponsor: Rep. Nancy Johnson (R-CT)
Within six months, NHII Officer (in cooperation with key stakeholders named in the Act) to develop an NHII strategic plan including public sector and private sector activities.
Within one year, NHII strategic plan submitted to Congress (also includes information on progress on interface recommendations, standards recommendations and required assessments).
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Other Legislation Related to IT
Health Information for Quality Improvement Act (S. 2003)
Sponsor: Sen. Hillary Clinton (D-NY)
Within six months, Office of NHII within Office of DHHS Secretary
Within two years, Secretary shall adopt a set of voluntary national data and communication standards to promote interoperability
Within 12 months, Secretary shall submit to Congress comprehensive NHII strategic plan
Grants to hospitals and other healthcare providers
DHHS, DoD and VA through e-gov initiative shall develop, implement and evaluate procedures to enable patients to access and append personal health data through personal health records
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Other Legislation Related to IT
Health Care Quality Modernization, Cost Reduction and Quality Improvement Act
Sponsor – Senator Edward M. Kennedy
Introduced May 13, 2004
Provides grants or cooperative agreements for clinical informatics systems – requires matching funds
Establishes a revolving loan fund for IT acquisition
Requires technical standards by January 1, 2006
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Other Legislation Related to IT
Senate HELP Committee Chair Gregg announced plans on April 27, 2004 to introduce bipartisan legislation to carry out Bush’s call for electronic health records for all patients within a decade
Federal leadership
Information standards
Clear barriers
Provide needed incentives
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Recognized Importance at Presidential Level
“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
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President Bush’s 10-Year Plan for EHR
April 26, 2004 President George W. Bush Announces 10-Year Plan to Assure that Most Americans Have Electronic Health Records:
Within the next ten years, electronic health records will ensure that complete health information is available for most Americans at the time and place of care, no matter where it originates. Participation by patients will be voluntary.
These electronic health records will be designed to share information privately and securely among and between healthcare providers when authorized by the patient.
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President Bush’s 10-Year HIT Plan
Creation of new, sub-Cabinet level post reporting to DHHS Secretary – National Health Information Technology Coordinator
The federal government to complete the identification and adoption of standards that will allow medical information to be stored and shared electronically while assuring privacy and security
Doubling funding to $100 million for demonstration projects that will help test the effectiveness of HIT and establish best practices for more widespread adoption in the healthcare industry
Creating federal incentives and opportunities which encourage healthcare providers to use electronic medical records
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President Bush’s April 27 Executive Order
Establishment within Office of the DHHS Secretary the position of National Health Information Technology Coordinator – within 90 days
Within 90 Days:
DHHS Secretary will provide options to provide incentives to promote adoption of interoperable HIT
Director OPM will provide options to provide incentives to promote adoption of interoperable HIT
Secretary of VA and DoD will jointly report on approaches to to work more actively with private sector to make systems available as affordable option for providers in rural and medically underserved communities
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President Bush’s April 27 Executive Order
Policy consistent with vision of nation-wide interoperable HIT infrastructure that:
Ensures appropriate information to guide medical decisions at time and place of care
Improves quality, reduces errors and advances delivery of evidence-based care and reduces healthcare costs
Promotes a more effective marketplace, greater competition and increased choice
Improves coordination of care through secure and authorized exchange of healthcare information
Ensures patients’ individually identifiable health information is secure and protected
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President Bush’s April 27 Executive Order Responsibilities of National HIT Coordinator
Develop, maintain, and direct implementation of strategic plan in both public and private sectors
Advance the development, adoption and implementation of standards through collaboration of public and private sector interests
Ensure key technical, scientific, economic issues affecting adoption are addressed
Evaluate benefits on evidence and costs and to whom they accrue Address privacy and security issues and recommend methods to
ensure appropriate authorization, authentication and encryption for transmission over Internet
Not assume or rely upon additional Federal resources or spending to accomplish adoption
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Secretary Thompson May 6 Announcements
Summit of 100 leaders in healthcare
Announced David Brailer, MD, PhD as National Health Information Technology Coordinator
HHS and other federal agencies will adopt 15 additional standards agreed to by Consolidated Health Informatics Initiative
SNOMED now available for free use from National Library of Medicine web site
HL7 announced a favorable vote on a functional model and standards for an electronic health record
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Emerging Focus Areas
Incentives to encourage adoption
Electronic prescribing as a key building block
Stark exception
Certification of standards
Supporting clinicians with implementation
Health information exchange networks privately operated for secure data exchange and transport
State, regional or local health information exchange authorities to assure compliance with laws
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A Bi-Partisan Issue…
Democratic Presidential candidate John Kerry has several provisions related to information technology in his agenda...
Patrick Kennedy (D-RI) and Newt Gingrich joined together for May 3 NYT Op-Ed Piece and conference in RI
Considerable support by Sen. Clinton, Sen. Dodd, Sen. Kennedy and Rep. Kennedy
A Bi-Partisan Issue……
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Momentum Building in Administration
AHRQ $50 million HIT Program…planning and implementation grants with emphasis on multi-stakeholder involvement and matched funding…large rural component…also $10 million focused on evaluating value…
Additional $50 million for demonstration projects proposed for FY 05 in DHHS Secretary’s budget
AHRQ’s State and Regional HIT Demonstrations Program seeks to identify and support statewide data sharing and interoperability activities aimed at improving quality, safety, efficiency and effectiveness of healthcare
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Momentum Building in Administration
CMS launching four demonstration programs “DOQ-IT” to test incentives for quality outcomes and use of IT
CMS published Phase II of regulations to implement the Stark Law – creates new exceptions including “provision of community-wide health information services”.
President’s Information Technology Advisory Committee launches Health Subcommittee and issues report
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Momentum Building in Administration
CMS releases “Chronic Care Improvement Program Notice and Application”
CDC PHIN Program promotes integration and use of standards and leveraging data that already resides in the system – e.g. Biosense - $130 million in proposed FY 05 budget
NCVHS – several work groups focusing on these issues…Subcommittee on Standards and Security, Subcommittee on Privacy and Security, Work Group on the NHII
Considerable work within the DoD and the VA
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Momentum Building in Private Sector
HL7 developed functional model for electronic health record… ballot has passed
IOM issued report on patient safety data standards in Fall of 2003
A number of payment pilots and other incentive programs emerging from employer and plan communities, including Bridges to Excellence
Leapfrog Group announces Fourth Leap – comprehensive scoring survey to help patients rank hospital quality
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eHealth Initiative Focus for 2004: Overview
In our early years, we focused on raising general awareness of the need for IT and tackling one of the key barriers to adoption— data standards
In 2004, we will:
Expand our work on two other areas that will help to achieve our mission: “making the business case and securing financing” and “developing the field” in key challenge areas…
Continue to focus on data standards
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eHealth Initiative Focus for 2004 Align incentives and promote public and private sector investment in
improving America’s healthcare through IT and an electronic health information infrastructure
Drive investment in research related to the value of IT in addressing quality, safety and efficiency challenges
Fund strategic demonstration projects through Connecting Communities for Better Health that evaluate and demonstrate impact of IT and further development of strategies and tools for accelerating IT adoption and electronic connectivity
Develop and promote policy options to align incentives and enable public and private sector investment in IT and health information infrastructure
Dramatically increase national awareness of the role of IT in addressing healthcare challenges through the Investing in America’s Health campaign
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eHealth Initiative Focus for 2004
Develop the field to enable more widespread and effective implementation of IT and an electronic health information infrastructure
Engage national experts to aggregate and develop knowledge, resources and tools for key challenge areas related to IT and a health information infrastructure
Provide resources and tools to help communities and stakeholders implement IT and a health information infrastructure through the Connecting Communities for Better Health Learning Network and Resource Center and several meetings including Community Learning Forum in June
Expand information sharing beyond the U.S. by facilitating a global dialogue on the challenges and strategies for implementing an electronic health information infrastructure through the Leadership in Global Health Technology Initiative
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eHealth Initiative Focus for 2004
Continue to drive adoption of standards to promote an interoperable, interconnected healthcare system through work with key partners
Leverage the work of the Connecting for Health, a public-private sector collaboration funded the Markle and Robert Wood Johnson Foundations, that is developing an incremental roadmap for U.S. electronic health information infrastructure, and addressing key issue areas such as data standards; organization and sustainability; linking patient data; and the personal health record
Through the EHR Collaborative, a coalition made up of AHIMA, AMA, AMIA, CHIME, eHI, HIMSS and NAHIT, facilitate collaboration among HIT organizations to achieve common goals related to the adoption of standards
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Our Approach
Review, Evaluate &
DevelopModels
EngageThose Who Can Effect
Change
Educate andAdvocate
ForChange
Provide Resources and Tools
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Areas of Interest
Areas Critical to IT and Health Information Infrastructure
Upfront Funding and Sustainable Incentive Models
Technical (Architecture, Standards, Security)
Protecting Patient Privacy
Clinician Adoption and Clinical Process Change
Application of Clinical Knowledge
Organization and Governance
Legal Issues
Engaging Patients and Consumers
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FINANCING(Incentives, Funding)
PRIVACY
CLINICIAN ADOPTION AND PROCESS CHANGE
LEGAL(Data Use, Stark Issues)
AGGREGATE AND DEVELOP
KNOWLEDGE IN KEY ISSUE AREAS
VET WITH AND DISSEMINATE
TO STAKEHOLDERS
Operating Model
CLINICIANS
HOSPITALS ANDOTHER PROVIDERS
HEALTHCARE ITPHARMA AND DEVICE MFR
PUBLIC HEALTH
PAYERSEMPLOYERS, PURCHASERS
PATIENTS, CONSUMERS
CLINICAL KNOWLEDGECHRONIC CARE
TECHNICAL (STDS, SECURITY, ARCHITECTURE)
PRIMARYDISSEMINATION
VEHICLES
ONLINE RESOURCE CENTER
PUBLICATIONS
TARGETED BRIEFINGS
FACE TO FACE CONFERENCES
VIDEO, WEB, PHONECONFERENCES
POLICY-MAKERS
MEMBER ORGANIZATIONS
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Connecting Communities for Better Health
Goal is to catalyze activities on a national, regional, and local basis that will lay the foundation for electronic connectivity and a health information infrastructure
Funded under Foundation for eHealth Initiative cooperative agreement with HRSA - $6.9 million in funding and augmenting with other funding sources
Provide seed funding to multi-stakeholder collaboratives within communities that are using electronic health information exchange and other IT tools to drive improvements in healthcare, with the goal of evaluating and widely disseminating lessons learned
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Connecting Communities for Better Health
Gaining critical input from experts, “on-the-ground implementers”, and key stakeholders on key areas related to health information exchange: technical, organizational, financial and clinical
Through Community Learning Network and Online Resource Center, provide communities and other healthcare stakeholders with help on financial, technical, organizational, clinical issues related to health information exchange
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Connecting Communities for Better Health
Through meetings such as Community Learning Forum and Resource Exhibition, and other communications vehicles, extend our reach further
Creating and widely publicizing a pool of “electronic health information exchange-ready” communities to facilitate interest and public and private sector investment in such initiatives
Building national awareness regarding why this is important and the steps that need to be taken to get there
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Response to Request for Capabilities What We Asked For in our 2003 Request for Capabilities
Statements:
Multi-stakeholder initiatives involving at least three stakeholder groups
Matched funding
Use of standards and a clinical component
What We Received:
134 responses representing 42 states and the District of Columbia proposing collaborative health information exchange projects across the country
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Organization Types Involvement
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pe
rce
nta
ge
of R
esp
on
de
nts
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Functions Provided
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
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Communities to be Funded
To be announced on July 21, 2004 as part of DHHS Event
Strategically focused on critical areas that need to be addressed to implement health information exchange
Replicable and sustainable technical architecture models
Alignment of incentive models
Use of replicable data exchange standards
Addressing ways to accurately link patient data
Multi-jurisdictional models
Electronic prescribing issues
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Connecting Communities Learning Network
Key partnering organizations
Center for Information Technology Leadership – Partners Healthcare System – John Glaser, PhD; Blackford Middleton, MD
Regenstrief Institute – J. Marc Overhage, MD, PhD
Others in the process of being finalized
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Connecting Communities Learning Forum
June 24 – 25, 2004, Washington, D.C.
Practical, hands-on, interactive meeting designed to help communities implement IT and health information exchange
Very few general sessions, mostly break-outs led by the best in the field in each targeted area
Tackled key issues related to health information exchange: technical, clinical, financial, organizational, legal
Laid the groundwork for “a community of communities” to learn from experts and each other…..
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Electronic Prescribing Initiative - Goals
Rapidly expand the adoption of electronic prescribing to drive quality, safety and efficiency improvements
Develop and promote design and implementation guidelines and principles that:
Facilitate rapid development of usable, implementable, high value prescribing tools
Support workflow of clinicians
Support safety and optimal care
Develop and promote adoption of incentives to accelerate adoption
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Electronic Prescribing Initiative
More than 70 of the nation’s leading experts on electronic prescribing from every stakeholder group involved in or impacted by the prescribing chain – Co-Chair Jonathan Teich, MD, PhD
Got consensus amongst a diverse group regarding key principles
Three Groups….
Steering Group
Incentives Working Group
Design and Implementation Working Group
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Electronic Prescribing Initiative Connectivity providers
Hospitals and other healthcare organizations
Health plans, employers and third party payers
Healthcare IT suppliers
Patient and consumer groups
Pharmacies
Pharmaceutical manufacturers
Patient and consumer groups
Pharmacy benefit managers
Practicing clinicians
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Electronic Prescribing Initiative – Take-aways
Ambulatory errors are common and preventable
Electronic prescribing can address quality, safety and efficiency challenges
Making the transition is difficult
The design and implementation recommendations presented today can help…immensely
Everyone must play a part…incentives are critical to assist with transition
The timing could not be more important, given the upcoming implementation of the Medicare Modernization Act
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Electronic Prescribing Initiative Recommendations
Levels of electronic prescribing and benefits that accrue at each level
Current barriers to physician adoption
Recommendations
Usability for prescriber
Clinical decision support
Communication
Standards and Vocabularies
Implementation
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Connecting for Health
Connecting for Health was created in September 2002 to catalyze the creation of an information technology infrastructure in healthcare. It has the following strategic objectives:
1. Put the need for interoperability and information mobility at the forefront of the public policy agenda related to IT
2. Secure a patient role in the IT agenda by defining and establishing a role for them to access and control their own health information
3. Engage a broad level of public and private sector collaboration and leadership behind this agenda
Funded and led by Markle Foundation with support from the Robert Wood Johnson Foundation
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Connecting for Health Deliverables
Incremental “Roadmap” or “shared path” for achieving electronic connectivity– near-term actions the public and private sectors can get behind – first draft to be released in July 2004
Working Group Recommendations – to be released July – Sept 04
Technical Architecture, Incremental Applications, and Data Standards including Security Standards
Accurately Linking Patient Information
Organizational and Sustainability Models for Community-Based Health Information Exchange
Policies for Electronic Information Sharing between Clinicians and Patients
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The Role of the Consumer
Our vision is about putting the patient in the center and mobilizing information in a patient-centric way to support the health and healthcare of patients
Currently there is a gap between consumer perception of reality in the healthcare system and reality itself
A thoughtful, carefully executed awareness campaign targeted to consumers is needed to increase understanding of the role of HIT in healthcare (why do we care?) and to stimulate demand for actions that will improve quality, improve safety and increase efficiency
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The Role of the Consumer
The consumer’s role is critical and the role of consumer organizations is critical to moving us towards a safer, higher quality healthcare system
How you can help
Convert the language we ordinarily use to describe why this is important, to language that is easy to understand by consumers…leverage the work of Connecting for Health…report to be released in July 2004
Develop and implement a communications strategy that will help “take these messages to America”
Leverage the insights and expertise of all of the stakeholders in the system…the voice of clinicians is especially important
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What Does All of this Mean?
“Never doubt that a group of thoughtful, committed people can change the world. Indeed it’s the only thing that ever has.”
Margaret Mead
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Closing
We are finally building momentum…the “stars and planets are aligning” which is due to leadership in public and private sectors
The focus has shifted from “whether we should” to “how will we do this?”
This work will create lasting and significant changes in the U.S. healthcare system…how clinicians practice…how hospitals operate….how healthcare gets paid for…how patients manage their health and navigate our healthcare system