The Future of Health Data Standards and the Business

Perspective:The National Health Information

Infrastructure (NHII)

The Future of Health Data Standards and the Business

Perspective:The National Health Information

Infrastructure (NHII)

Helga E. Rippen, MD, PhD, MPHDeputy Senior Advisor

National Health Information InfrastructureDepartment of Health and Human Services

Fifth Annual Public Health Data Standards ConsortiumSteering Committee Meeting

Bethesda, Maryland; March 17, 2004

22

“The committee believes that establishing this information

technology infrastructure [NHII] should be the highest priority

for all health care stakeholders.”

-- Committee on Data Standards for Patient Safety: “Patient Safety: Achieving a New Standard for Care”

Institute of Medicine, November, 2003(Executive Summary)

33

OverviewOverviewI. Why does health care need NHII?II. What is NHII?III. How will the NHII Influence

Standards?IV. Moving the NHII Forward with

Standardization

I. Why does health care need NHII?II. What is NHII?III. How will the NHII Influence

Standards?IV. Moving the NHII Forward with

Standardization

44

I. Health Care System ChallengesI. Health Care System Challenges

Error rates are too high Quality is inconsistent Research results are not rapidly used Costs are escalating New technologies continue to drive

up costs Demographics of baby boomers will

greatly increase demand Capacity for early detection of

bioterrorism is minimal

Error rates are too high Quality is inconsistent Research results are not rapidly used Costs are escalating New technologies continue to drive

up costs Demographics of baby boomers will

greatly increase demand Capacity for early detection of

bioterrorism is minimal

55

Solution: Information Technology (IT) for Health CareSolution: Information Technology (IT) for Health Care 20% of labs and x-rays done because

prior results unavailable 1 in 7 hospitalizations occur because

information about patient not available “NHII is required to make patient safety

a standard of care” – IOM, 2003 Ambulatory CPOE could save $44 B/yr Potential net efficiency gain from use of

information technology in health care: > $87 Billion/yr

20% of labs and x-rays done because prior results unavailable

1 in 7 hospitalizations occur because information about patient not available

“NHII is required to make patient safety a standard of care” – IOM, 2003

Ambulatory CPOE could save $44 B/yr Potential net efficiency gain from use of

information technology in health care: > $87 Billion/yr

66

II. What is NHII?II. What is NHII?

“Anywhere, anytime health care information and decision support” Comprehensive knowledge-based

network of interoperable systems Capable of providing information for

sound decisions about health when and where needed

NOT a central database of medical records

“Anywhere, anytime health care information and decision support” Comprehensive knowledge-based

network of interoperable systems Capable of providing information for

sound decisions about health when and where needed

NOT a central database of medical records

77

What is NHII? (continued)What is NHII? (continued)

Includes technologies, practices, relationships, laws, standards, and applications, e.g. Communication networks Message & content standards Computer applications Confidentiality protections

Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII

Includes technologies, practices, relationships, laws, standards, and applications, e.g. Communication networks Message & content standards Computer applications Confidentiality protections

Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII

88

Four Domains of NHIIFour Domains of NHII

Personal/Consumer

PublicHealth/

Community

NHII

Research/Policy

Clinical

99

NHII Requirements: FunctionsNHII Requirements: FunctionsOverall: “Anytime, anywhere health care

information and decision support” Immediate availability of complete

medical record (compiled from all sources) to any point-of-care

Enable up-to-date decision support at any point of care

Enable selective reporting (e.g. for public health)

Enable use of tools to facilitate delivery of care (e.g. e-prescribing)

Allow patients to control access to their information

Overall: “Anytime, anywhere health care information and decision support”

Immediate availability of complete medical record (compiled from all sources) to any point-of-care

Enable up-to-date decision support at any point of care

Enable selective reporting (e.g. for public health)

Enable use of tools to facilitate delivery of care (e.g. e-prescribing)

Allow patients to control access to their information

1010

NHII Requirements: Implementation StrategyNHII Requirements: Implementation Strategy No national database or identifier Alignment of incentives Allow each care facility to maintain its

own data Minimize cost & risk Use proven implementation strategies

(where possible), e.g. incremental approach Each implementation step benefits all

participants Implementation scope coincides with

benefits scope

No national database or identifier Alignment of incentives Allow each care facility to maintain its

own data Minimize cost & risk Use proven implementation strategies

(where possible), e.g. incremental approach Each implementation step benefits all

participants Implementation scope coincides with

benefits scope

1111

NHII Net National SavingsNHII Net National Savings

Community Health

InformationExchange

Outpatient EHR

InptEHR

Source:Center forInformationTechnologyLeadership,PartnersHealthCare,Harvard(2004)

TOTAL$121.04

~6

~25

~55

TOTAL $87

1212

Inpatient EHRInpatient EHR

Community Health

InformationExchange

Outpatient EHR

InptEHR

• Benefits go to hospital

• Larger hospitals are investing

• Capital is obstacle for small & rural institutions

~6

~25

~55

1313

Outpatient EHROutpatient EHR

Community Health

InformationExchange

Outpatient EHR

InptEHR

• Benefits go to payer

• No business case for physicians (especially small practices)

• Payer incentives needed (e.g. Maine)

~6

~25

~55

1414

Community Health Information ExchangeCommunity Health Information Exchange

Community Health

InformationExchange

Outpatient EHR

InptEHR

• Substantial benefits to all

• First mover disadvantage

• Seed funding needed

• Focus of current Federal initiatives

~6

~25

~55

1515 Clinical Encounter

Index of where patients have records Temporary Aggregate

Patient History

Patient Authorized

Inquiry

Hospital Record Laboratory Results Specialist Record

Patient data delivered to Physician

LHII system

RecordsReturned

Requests for Records

community

1616

Index of where patients have records Temporary Aggregate

Patient History

Authorized Inquiry

from LHII

Hospital Record Laboratory Results Specialist Record

Patient data delivered to other LHII

LHII system

RecordsReturned

Requests for Records

U.S.

anotherLHII

1717

Advantages of LHII ApproachAdvantages of LHII Approach Existing HII systems are local Health care is local benefits are local Facilitates high level of trust needed Easier to align local incentives Local scope increases probability of

success Specific local needs can be addressed Can develop a repeatable

implementation process Parallel implementation more rapid

progress Use of standards allows connectivity

between LHIIs NHII

Existing HII systems are local Health care is local benefits are local Facilitates high level of trust needed Easier to align local incentives Local scope increases probability of

success Specific local needs can be addressed Can develop a repeatable

implementation process Parallel implementation more rapid

progress Use of standards allows connectivity

between LHIIs NHII

1818

What will NHII Enable?What will NHII Enable?

1. Linkage between medical care & public health (e.g. for bioterrorism detection)

2. Test results and x-rays always available eliminate repeat studies

3. Complete medical record always available

4. Decision support always available: guidelines & research results

5. Quality & payment information derived from record of care – not separate reporting systems

6. Consumers have access to their own records

1. Linkage between medical care & public health (e.g. for bioterrorism detection)

2. Test results and x-rays always available eliminate repeat studies

3. Complete medical record always available

4. Decision support always available: guidelines & research results

5. Quality & payment information derived from record of care – not separate reporting systems

6. Consumers have access to their own records

1919

Elements of NHII (1 of 3)Elements of NHII (1 of 3)

Standards: Messaging & Content Foundation for remainder of NHII

Electronic Health Record (EHR) Systems Hospital Outpatient Post acute and long-term care

Consumer Health Information Systems Personal health record Electronic patient-provider communication Support groups Authoritative information

Standards: Messaging & Content Foundation for remainder of NHII

Electronic Health Record (EHR) Systems Hospital Outpatient Post acute and long-term care

Consumer Health Information Systems Personal health record Electronic patient-provider communication Support groups Authoritative information

2020

Elements of NHII (2 of 3)Elements of NHII (2 of 3)

Ancillary health care systems Pharmacy Laboratory Physical therapy Post-acute care Public health reporting

Communication/networking systems Information moves with patient Integrated information from all

types of providers Electronic consultation

(telemedicine)

Ancillary health care systems Pharmacy Laboratory Physical therapy Post-acute care Public health reporting

Communication/networking systems Information moves with patient Integrated information from all

types of providers Electronic consultation

(telemedicine)

2121

Elements of NHII (3 of 3)Elements of NHII (3 of 3)

Decision Support & Education Professional Consumer

Confidentiality protections Information available on need-to-know

basis Authentication of all users Encryption of data in transit Audit trails of all usage Penalties for violations

Decision Support & Education Professional Consumer

Confidentiality protections Information available on need-to-know

basis Authentication of all users Encryption of data in transit Audit trails of all usage Penalties for violations

2222

Benefits of NHIIBenefits of NHII Monitor and Protect Public Health (e.g. rapid disease detection) Improve Patient Safety

IOM: 44,000-98,000 preventable deaths/year (more than motor vehicle accidents, breast cancer, or AIDS)

Improve Quality of Care Effectively Share Decision Support Understand Health Care Costs Better-informed Health Care Consumers

Monitor and Protect Public Health (e.g. rapid disease detection) Improve Patient Safety

IOM: 44,000-98,000 preventable deaths/year (more than motor vehicle accidents, breast cancer, or AIDS)

Improve Quality of Care Effectively Share Decision Support Understand Health Care Costs Better-informed Health Care Consumers

2323

III. How will the NHII Influence Standards?III. How will the NHII Influence Standards?

Personal/Consumer

PublicHealth/

Community

NHII

Research/Policy

Clinical

Wide reach requires standards that are

complementary and integrated

2424

Health Information is ComplexHealth Information is Complex

Death

Family Health

Birth

Clinical encounters

Health events

Environmental events

Lifestyle

Etc....

Public Health ResearchIn

div

idu

al healt

h r

eco

rd

2525

Health Information is ComplexHealth Information is Complex

Public Health Research

Ind

ivid

ual healt

h r

eco

rd

Consumer Healthcare

Decision Support

2626

Some Standard RequirementsSome Standard Requirements

Common vocabulary Messaging standard Security and authentification standards Coding standards for decision support Standards for health record portability

Common vocabulary Messaging standard Security and authentification standards Coding standards for decision support Standards for health record portability

2727

Messaging StandardsMessaging Standards What information is requested Where is the information in the

message Example: “phone number” message

Pick up phone Listen for dial tone Dial number

– If first digit is 1, then long distance, otherwise local

What information is requested Where is the information in the

message Example: “phone number” message

Pick up phone Listen for dial tone Dial number

– If first digit is 1, then long distance, otherwise local

2828

Content StandardsContent Standards

A common, agreed-upon, detailed vocabulary for all medical terminology

Without a standard: “high blood pressure” “elevated blood pressure” “hypertension”

With a standard C487231, hypertension Unambiguous meaning for both

sender and receiver

A common, agreed-upon, detailed vocabulary for all medical terminology

Without a standard: “high blood pressure” “elevated blood pressure” “hypertension”

With a standard C487231, hypertension Unambiguous meaning for both

sender and receiver

2929

IV: Moving the NHII Forward with StandardizationIV: Moving the NHII Forward with Standardization Adoption of standards across

government agencies (PHIN/CHI/FHA) HL7, DICOM, IEEE 1073, NCPDP

SCRIPT SNOMED, LOINC

Facilitating standards development by HL7 EHR functions EHR interchange standard

Adoption of standards across government agencies (PHIN/CHI/FHA) HL7, DICOM, IEEE 1073, NCPDP

SCRIPT SNOMED, LOINC

Facilitating standards development by HL7 EHR functions EHR interchange standard

3030

Questions?Questions?

Helga E. Rippen, MD, PhD, MPHHelga.rippen@hhs.gov202/205-8678

For more information about NHII

http://aspe.hhs.gov/sp/nhii