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Connie White Delaney is Professor & Dean, School of Nursing, University of Minnesota. She also serves as Director, Biomedical Health Informatics (BMHI), Associate Director of the CTSI-BMI, and Acting Director of the Institute for Health Informatics (IHI) in the Academic Health Center. Delaney is the first Fellow in the College of Medical Informatics to serve as a Dean of Nursing. Delaney is an appointee to the Health Information Technology Policy Committee, an advisory body established by the American Recovery and Reinvestment Act within the U.S. Government Accountability Office (GAO). Delaney serves on numerous boards, including the Board of the American Association of Colleges of Nursing, Board of LifeScience Alley, the American Medical Informatics Association (AMIA), Premiere Quest National Advisory Panel. ! She is an active researcher and writer in the areas of national standards development for essential nursing care and outcomes/safety data. She holds a BSN with majors in nursing and mathematics, MA in Nursing – Adult Health, Ph.D. Educational Administration and Computer Applications, and completed postdoctoral study in nursing & medical informatics at the University of Utah.
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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
4. “Diderot Effect”
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
4. “Diderot Effect” Robert Tagalicod, Robert Anthony, and Jessica Kahn
HIT Policy Committee, January 10, 2012
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
4. “Diderot Effect”
Robert Tagalicod, Robert Anthony, and Jessica Kahn
HIT Policy Committee, January 10, 2012
$0
$100,000,000
$200,000,000
$300,000,000
$400,000,000
$500,000,000
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$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
4. “Diderot Effect” Robert Tagalicod, Robert Anthony, and Jessica Kahn
HIT Policy Committee, January 10, 2012
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
HIT Policy Committee, January 10, 2012
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
Initial Recommendations for HITSC
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
Initial Recommendations for HITSC
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
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?
(Fridsma/ Humphreys, 2012)
•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
(Fridsma/ Humphreys, 2012)
A set of services, standards and
policies that enable secure health
information exchange over the Internet.
Office of the National Coordinator for
Health Information Technology 31
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
Office of the National Coordinator for
Health Information Technology 32
Diagram of NwHIN Portfolio 1.0
(Fridsma/ Humphreys, 2012)
SAML
INTEROPERABILITY
STACK
NLM Vocabulary Portfolio
(Fridsma/ Humphreys, 2012)
• 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
(Fridsma/ Humphreys, 2012)
• 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.
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
4. “Diderot Effect”