iHT2 Health IT Summit in Phoenix  Connie White Delaney, PhD, RN, FAAN, FACMI                 May 18, 2011
welco    me           Industry leaders & senior executives,            CIO, CMO, CMIO, Physician, Practice Manager,       ...
4 Principles for Behavioral Change1. Social norms2. Foot in the Door3. Reciprocity4. “Diderot Effect”
Outcomes    Sustainability                      transforming care to improve4 Principles for      outcomesBehavioral Chang...
1. Social norms2. Foot in the Door3. Reciprocity4. “Diderot Effect”
1. Social norms                                                                                                           ...
1. Social norms                                                                                                   2. Foot ...
1. Social norms                                                                       2. Foot in the Door                 ...
1. Social norms                                                                    2. Foot in the Door               Rober...
Providers Included in MU Analysis                Robert Tagalicod, Robert Anthony, and Jessica Kahn                      H...
Updated Work Plan for  Developing Recommendations for Stage 3 (Tang et al, 2012 )• Nov 9: Reported on Oct 5 Hearing; input...
Initial Recommendations for            HITSCGroup 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...
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 Qua...
Initial Recommendations for HITSC            Rec 3: Patient-Reported Data and CQMs (Tang, 2012)• Problem:   1. Most CQMs a...
Initial Recommendations for HITSC                       Rec 4: Delta Measures (Tang et al, 2012)• Problem:   1. Most CQMs ...
Follow-Up Actions on              New CQM Recommendations (Tang et al, 2012)• Form joint HITPC/HITSC work group, including...
Summary (Tang et al, 2012)• Re: Certification Policies: We recommend that clinical  quality measures should be based on cl...
microscopic                                             macroscopic                                   Clinical        Cons...
What is the CTSI?CTSI is part of is part of a national Clinical and TranslationalScience Award (CTSA) consortium created t...
Health Knowledge Discovery & Dissemination             CommunityBench                       Practice              Bedside
CTSA Institutions, 2006 - 2011NCRR 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 inBiomedical Informatics.•...
U of Minnesota AHC Information Exchange (AHC IE)
Complete the Informatics Infrastructure• Network All Care Sites   – Tie all Providers into the Health Information     Infr...
How do we achieve interoperable                  healthcare information systems?                    (Fridsma/ Humphreys, 2...
How do we achieve interoperable         healthcare information systems?           (Fridsma/ Humphreys, 2012)•Enable stakeh...
Defining the Nationwide Health     Information Network (Fridsma/ Humphreys, 2012)            A set of services, standards ...
Diagram of NwHIN Portfolio 1.0                                 (Fridsma/ Humphreys, 2012)INTEROPERABILITY     STACK       ...
NLM Vocabulary Portfolio                              (Fridsma/ Humphreys, 2012)•   Support maintenance, dissemination, fr...
ONC-NLM Interagency Agreement                           (Fridsma/ Humphreys, 2012)•   Sets priorities for NLM vocabulary w...
• Health People 2020• HealthyPeople.gov• National Quality Strategy (March 21 2011)• http://www.hhs.gov/news/press/2011pres...
National Quality Strategy
• Two goals of Partnership for Patients (HealthCare.gov)  April 12, 2011 are to:• Keep patients from getting injured or si...
21st Century Healthcare System• Robust information infrastructure• Widespread use of evidence-based medicine• Aligned ince...
Future: Manage Change    Supported by Information Technology & Informatics•    Build Knowledgeable Teams      •   Manage t...
Policy                       Federal Advisory Committees• Health IT Policy Committee   – Makes recommendations to the Nati...
Vision [framework] A system that is designed to generate and apply the best evidence forthe collaborative health care choi...
Health IT in the HHS Strategic Plan                                               HHS’ Strategic PlanHealth IT objective i...
Federal Health IT Strategic Plan: 2011-2015         Federal Health IT Strategic Plan      Pre-decisional Draft – Do Not Di...
Evolution of the Strategic Framework                                 to the Strategic PlanContext• The Framework was well ...
4 Principles for Behavioral Change1. Social norms2. Foot in the Door3. Reciprocity4. “Diderot Effect”
Opening Keynote: Connie Delaney, PhD, RN, Director, Biomedical Health Informatics, Dean, Nursing School, University of Min...
Opening Keynote: Connie Delaney, PhD, RN, Director, Biomedical Health Informatics, Dean, Nursing School, University of Min...
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Opening Keynote: Connie Delaney, PhD, RN, Director, Biomedical Health Informatics, Dean, Nursing School, University of Minnesota, Member, ONC HITPC

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

  1. 1. iHT2 Health IT Summit in Phoenix Connie White Delaney, PhD, RN, FAAN, FACMI May 18, 2011
  2. 2. welco me Industry leaders & senior executives, CIO, CMO, CMIO, Physician, Practice Manager, VP and Director of IT1. Discuss HIT challenges and potentialsolutions in the months ahead.2. Discuss leveraging data to drive evidencebased healthcare and improve outcomes3. Discuss collaboration across care settings andmissions.
  3. 3. 4 Principles for Behavioral Change1. Social norms2. Foot in the Door3. Reciprocity4. “Diderot Effect”
  4. 4. Outcomes Sustainability transforming care to improve4 Principles for outcomesBehavioral Change manage transitions decrease costs1. Social norms assure care appropriateness2. Foot in the Door engage in disease3. Reciprocity prevention/health promotion4. “Diderot Effect” people centered
  5. 5. 1. Social norms2. Foot in the Door3. Reciprocity4. “Diderot Effect”
  6. 6. 1. Social norms 2. Foot in the Door Robert Tagalicod, Robert Anthony, and Jessica Kahn 3. Reciprocity HIT Policy Committee, January 10, 2012 4. “Diderot Effect” Implementation Report (1/12) States launched as of January 2012: 42 # of States that disbursed incentives: 33 VT ME WA MT ND NH MN MA Note: ME, OR NY ID SD WI RI MA, DE, VT MI WY PA CT and NY IA NE OH NJ have also IN DE NV UT IL WV VA MD disbursed CO CA KS MO KY DC incentives NC TN as of 12/31 OK SC AR AZ NM GA MS AL TX LA FL AK Planning Territories SMHPs Submitted AS HI SMHPs Final Approval CNMI IAPDs Pending GU IAPDs Approval PR Launched USVI 8http://www.cms.gov/EHRIncentivePrograms/ Incentives Disbursed
  7. 7. 1. Social norms 2. Foot in the Door Robert Tagalicod, Robert Anthony, and Jessica Kahn 3. Reciprocity HIT Policy Committee, January 10, 2012 4. “Diderot Effect” December 2011 December 2011 YTD YTD Providers Paid Payments Providers Paid PaymentsEligible Professional 4,997 $ 86,946,000 15,255 $ 274,590,000Medicare Only Hospital 4 $ 5,600,870 38 $ 56,782,557Medicare & Medicaid Hospital(Medicare Payment) 189 $ 369,136,265 566 $ 1,052,839,955TOTAL 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 8
  8. 8. 1. Social norms 2. Foot in the Door Robert Tagalicod, Robert Anthony, and Jessica Kahn HIT Policy Committee, January 10, 2012 3. Reciprocity 4. “Diderot Effect” Providers Paid by Month Providers Paid9,0008,0007,0006,0005,0004,0003,0002,0001,000 0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 9
  9. 9. 1. Social norms 2. Foot in the Door Robert Tagalicod, Robert Anthony, and Jessica Kahn 3. Reciprocity HIT Policy Committee, January 10, 2012 4. “Diderot Effect” Incentive Payments by Month$800,000,000 Incentive Payments$700,000,000$600,000,000$500,000,000$400,000,000$300,000,000$200,000,000$100,000,000 $0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
  10. 10. Providers Included in MU Analysis Robert Tagalicod, Robert Anthony, and Jessica Kahn HIT Policy Committee, January 10, 2012At 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
  11. 11. 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
  12. 12. Initial Recommendations for HITSCGroup 1 for Immediate Action – Could Impact Stage 2
  13. 13. 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
  14. 14. Initial Recommendations for HITSC Group 2 – Longer Lead Time Required
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. microscopic macroscopic Clinical Consumer Research Health Informatics Informatics Human Health & Disease [translational bioinformatics]molecular and tissues & individual populationscellular processes organs patients
  21. 21. What is the CTSI?CTSI is part of is part of a national Clinical and TranslationalScience Award (CTSA) consortium created to acceleratelaboratory discoveries into treatments for patients. The CTSAprogram is led by the National Institutes of Healths NationalCenter for Research Resources.
  22. 22. Health Knowledge Discovery & Dissemination CommunityBench Practice Bedside
  23. 23. CTSA Institutions, 2006 - 2011NCRR Fact Sheet: Clinical and Translational Science Awards, Summer 2011, www.ncrr.nih.gov
  24. 24. CTSA UMN: What We Do• Biomedical Informatics – Provides infrastructure, expertise, and training inBiomedical Informatics.• Clinical Translational Research Services – Provides research services,support, and collaboration, including project management, researchcoordination, clinical procedures, and biostatistics.• Education, Training, and Research Career Development – Provides traineeswith opportunities to enhance quality and productivity.• Office of Community Engagement for Health – Helps researchers link tocommunity interests and researcher partners.• Office of Discovery and Translation - Develops novel research methods,tools, and technologies.
  25. 25. U of Minnesota AHC Information Exchange (AHC IE)
  26. 26. 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
  27. 27. How do we achieve interoperable healthcare information systems? (Fridsma/ Humphreys, 2012) Enable Curate astakeholders to portfolio of come up with standards, simple, shared services, and solutions to policies that common accelerate information Team information Accuracy & exchange Compliance convened to exchange challenges solve problem Solutions & Usability Enforce compliance with validated information exchange standards, services and policies to assure interoperability between validated systems
  28. 28. How do we achieve interoperable healthcare information systems? (Fridsma/ Humphreys, 2012)•Enable stakeholders to come up with simple, sharedsolutions to common information exchange challenges•Curate a portfolio of standards, services, and policiesthat accelerate information exchange•Enforce Compliance with validated information exchangestandards, services and policies to assure interoperabilitybetween validated systems Office of the National Coordinator for 30 Health Information Technology
  29. 29. 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 31 Health Information Technology
  30. 30. Diagram of NwHIN Portfolio 1.0 (Fridsma/ Humphreys, 2012)INTEROPERABILITY STACK NwHIN Building Blocks Vocabulary & SNOMED-CT LOINC ICD-10 RxNorm Code Sets Consolidated Lab Results IG HL7 v.2.5.1 Content CDA Quality Reporting Public Health Structure Lab Results Reporting Care Summaries Transport SMTP-Direct SOAP-Secure Based Exchange Web Services Security X.509 - Digital SAML Certificates DNS, LDAP- UDDI-Certificate Certificate Provider Services Certificate & Service Authority Directories Discovery Discovery Office of the National Coordinator for 32 Health Information Technology
  31. 31. 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
  32. 32. 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
  33. 33. • Health People 2020• HealthyPeople.gov• National Quality Strategy (March 21 2011)• http://www.hhs.gov/news/press/2011pres/03/20110321a.ht ml• 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.
  34. 34. National Quality Strategy
  35. 35. • 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.
  36. 36. 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 “ ”
  37. 37. Future: Manage Change Supported by Information Technology & Informatics• Build Knowledgeable Teams • Manage the Base of• Reinvent Workflow Knowledge• Integrate Innovations • Complete the HIT &• Remove ‘Outdated’ Practices Informatics Infrastructure• Reduce Variation • Change Management & Work Redesign• Improve Safety/Quality while Reducing Costs • Enhance Clinical Decision Support
  38. 38. 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
  39. 39. Vision [framework] A system that is designed to generate and apply the best evidence forthe collaborative health care choices of each patient and provider; todrive the process of new discovery as a natural outgrowth of patientcare; and to ensure innovation, quality, safety, and value in health care.(Charter of the Institute of Medicine Roundtable on Value & Science-Driven Health Care)
  40. 40. Health IT in the HHS Strategic Plan HHS’ Strategic PlanHealth IT objective in HHS Plan Goal 1: Transform Health Care 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 42
  41. 41. Federal Health IT Strategic Plan: 2011-2015 Federal Health IT Strategic Plan Pre-decisional Draft – Do Not Disclose 43
  42. 42. Evolution of the Strategic Framework to the Strategic PlanContext• The Framework was well underway prior to the release of the Affordable Care ActSimilarities:• Largely the same priorities and vision• Focus on OutcomesDifferences:• Structurally different• Reflects impact of the Affordable Care Act• Makes empowering individuals a goal 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 44
  43. 43. 4 Principles for Behavioral Change1. Social norms2. Foot in the Door3. Reciprocity4. “Diderot Effect”

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