for College of Management, Mahidol University's Healthcare Policy and Provider Payment Systems course

1. Policy Related to
Health Information Systems:
A U.S. Case Study
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Department of Community Medicine
Faculty of Medicine Ramathibodi Hospital
October 19, 2014
SlideShare.net/Nawanan nawanan.the@mahidol.ac.th
Except where referred
to or copied from
other works

2. Outline
• Electronic Health Records & Health IT
• U.S. eHealth Policy
• HITECH Act & “Meaningful Use” of EHRs
• Lessons for Thailand

3. Electronic Health Records
& Health IT

4. Electronic Health Records

5. Electronic Health Records (EHRs)
• Electronic documentation of health care provided to patients, as
recorded by providers
• Ideally longitudinal (e.g., life-long) records
• Electronic Medical Records (EMRs) vs.
Electronic Health Records (EHRs) often used interchangeably (or with
some minor distinctions)

6. • Are they just electronic documentation?
Diag-nosis
History
& PE
Treat-ments
• Or do they have some other values?
...
EHR Systems

7. Some Benefits of EHRs
• Ubiquitous availability (anytime, anywhere, everyone who is authorized)
• Multiple concurrent uses
• The end of “Where the heck is the patient’s record?!?”
• Ability to control & enforce access security
• Structured data entry possible
• Data presentation that is easier to understand (e.g. graphs)
• Efficiency in data entry? (but sometimes it slows users down!)
• Process improvement (business process reengineering/redesign, quality
improvement)
• No doctor’s handwriting!!!!!

8. Benefits of Health Information Technology
• Literature suggests improvement in health care through
– Guideline adherence (Shiffman et al, 1999;Chaudhry et al, 2006)
– Better documentation (Shiffman et al, 1999)
– Practitioner decision making or process of care
(Balas et al, 1996;Kaushal et al, 2003;Garg et al, 2005)
– Medication safety (Kaushal et al, 2003;Chaudhry et al, 2006;van Rosse et al, 2009)
– Patient surveillance & monitoring (Chaudhry et al, 2006)
– Patient education/reminder (Balas et al, 1996)
– Cost savings and better financial performance
(Parente & Dunbar, 2001;Chaudhry et al, 2006;Amarasingham et al, 2009;Borzekowski, 2009)

9. Functions that Should be Part of EHR Systems
• Computerized Medication Order Entry (IOM, 2003; Blumenthal et al, 2006)
• Computerized Laboratory Order Entry (IOM, 2003)
• Computerized Laboratory Results (IOM, 2003)
• Physician Notes (IOM, 2003)
• Patient Demographics (Blumenthal et al, 2006)
• Problem Lists (Blumenthal et al, 2006)
• Medication Lists (Blumenthal et al, 2006)
• Discharge Summaries (Blumenthal et al, 2006)
• Diagnostic Test Results (Blumenthal et al, 2006)
• Radiologic Reports (Blumenthal et al, 2006)

10. The Bigger Picture: Health Information Exchange
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

11. Common Denominator
• Health Information Technology
• Electronic Health Records
• Health Information Exchange

12. Ultimate Goal = Health
• Don’t implement technology just for technology’s sake.
(Yasnoff et al, 2001 and many others)
• “Don’t make use of excellent technology.
Make excellent use of technology.”
(Tangwongsan, Supachai. Personal communication, 2005.)

13. U.S. eHealth Policy

14. U.S. Public Policy Related to eHealth
1991: IOM’s CPR Report published
1996: HIPAA enacted
2000-2001: IOM’s To Err Is Human &
Crossing the Quality Chasm published
2004: George W. Bush’s Executive Order
establishing ONCHIT (ONC)
2009-2010: ARRA/HITECH Act &
“Meaningful Use” regulations

15. Landmark IOM Reports
(IOM, 2000) (IOM, 2001) (IOM, 2011)

16. Patient Safety
• To Err is Human (IOM, 2000) reported that:
– 44,000 to 98,000 people die in U.S. hospitals each year
as a result of preventable medical mistakes
– Mistakes cost U.S. hospitals $17 billion to $29 billion
yearly
– Individual errors are not the main problem
– Faulty systems, processes, and other conditions lead to
preventable errors
Health IT Workforce Curriculum Version
3.0/Spring 2012 Introduction to Healthcare and Public Health in the US: Regulating Healthcare - Lecture d

17. Landmark IOM Reports: Summary
• Humans are not perfect and are bound to make
errors
• Highlight problems in U.S. health care system
that systematically contributes to medical errors
and poor quality
• Recommends reform
• Health IT plays a role in improving patient
safety

18. Political Support Behind Health IT
“...We will make wider use of electronic records and other
health information technology, to help control costs and reduce
dangerous medical errors.”
Source: Wikisource.org Image Source: Wikipedia.org
President George W. Bush
Sixth State of the Union Address
January 31, 2006
?

19. U.S. Adoption of Health IT
Ambulatory (Hsiao et al, 2009) Hospitals (Jha et al, 2009)
Basic EHRs w/ notes 7.6%
Comprehensive EHRs 1.5%
CPOE 17%
• U.S. lags behind other Western countries
(Schoen et al, 2006;Jha et al, 2008)
• Money and misalignment of benefits is the biggest reason

20. American Recovery & Reinvestment Act (ARRA)
• Economic Stimulus Legislation
• Contains HITECH Act (Health Information Technology for
Economic and Clinical Health Act)
• ~ 20 billion dollars for Health IT investments
Goals:
1. Boost economy (economic health)
2. Widespread adoption of Health IT (clinical health)
Quality Patient Safety Costs

21. President Obama Backs Health IT
“...Our recovery plan will invest in
electronic health records and new technology
that will reduce errors, bring down costs,
ensure privacy, and save lives.”
President Barack Obama
Address to Joint Session of Congress
Source: WhiteHouse.gov February 24, 2009

22. U.S. National Leadership on Health IT
Office of the National Coordinator for Health Information Technology
(ONC -- formerly ONCHIT)
David Blumenthal, MD, MPP
National Coordinator for
Health Information Technology
(2009 - 2011)
Farzad Mostashari, MD, ScM
National Coordinator for
Health Information Technology
(2011 - 2013)
David Brailer, MD, PhD
National Coordinator for
Health Information Technology
(2004 - 2007)
Robert Kolodner, MD
National Coordinator for
Health Information Technology
(2006 - 2009)
Karen B. DeSalvo, MD, MPH, MSc
National Coordinator for
Health Information Technology
(2014 - Present)
Photos courtesy of U.S. Department of Health & Human Services

23. HITECH Act &
“Meaningful Use”
of EHRs

24. HITECH Act
Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.

25. “Meaningful Use” of EHRs
• Use of “Certified EHR Technology” (CEHRT) by
providers (eligible professionals, eligible hospitals
& critical access hospitals) to achieve significant
improvements in care
• Financial incentives & penalties

26. Incentives for Eligible Professionals (Doctors)
• Medicaid incentives for eligible professionals
– Maximum $63,750 over 6 years beginning in 2011
• Medicare payments for eligible professionals
– Maximum $44,000 over 5 years

27. Incentives for Eligible Hospitals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MLN_TipSheet_MedicareHospitals.pdf

28. “Meaningful Use” of A Pumpkin
“Meaningful Use”
of a Pumpkin
Pumpkin
Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

29. Meaningful Use of EHRs: ONC’s 3-Stage Approach
Stage 1
- Electronic capture of
health information
- Information sharing
- Data reporting
Stage 2
Use of EHRs
to improve
processes of
care
Stage 3
Use of
EHRs to
improve
outcomes
Better
Health
Blumenthal D, 2010

30. Components of Meaningful Use Regulations
• Medicare & Medicaid Incentives for Meaningful Use of EHRs
– Centers for Medicare and Medicaid Services (CMS)
• Rule on Standards, Implementation Specifications &
Certification Criteria
• Certification Programs
– Office of the National Coordinator for Health IT (ONC)

31. Meaningful Use Incentives: Stage 1
Proposed Rule
(Jan. 2010)
• 23 Criteria for Hospitals to Pass
• 25 Criteria for Professionals (Clinics) to Pass
Public Hearing
• Pace & Scope: too ambitious, demanding, inflexible
• Few providers would likely qualify -> Little adoption
Final Rule (2011)
• Core Objectives (14 criteria for Hospitals, 15 for Professionals, required)
• Menu Set (10 criteria, pick 5)
Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

32. Meaningful Use Stage 1 Criteria
Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

33. Meaningful Use Stage 1 Criteria
Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

34. Meaningful Use Stage 1 Criteria
Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

35. Meaningful Use Stage 1 Criteria
Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

36. Some Selected Meaningful Use Stage 1 Final Rule:
Core Objectives
• Electronic capture of information
– Demographics
– Vital signs
– Medication list
– Allergies
– Problem list
– Smoking
• Medication order entry
• Drug-allergy & drug-drug interaction checks
• Patient access to/copy of health information

37. Some Selected Meaningful Use Stage 1 Final Rule:
Menu Set
• Drug formulary checks
• Lab results incorporation into EHRs
• Generate lists of patients by specific conditions
• Medication reconciliation
• Electronic reporting to governmental agencies
• Advanced directives for elderly patients
• Patient reminders for certain services (for clinics)
• Patient access to health information (for clinics)

38. Final Rule on Standards & Certification Criteria (Selected)
• Content Exchange Standards
– HL7 CDA Release 2 & CCD
– NCPDP SCRIPT
• Vocabularies
• SNOMED CT
– LOINC®
– RxNorm®
• Security
– NIST-certified encryption algorithms
• Etc.

39. Stages & Timeline of Meaningful Use
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

40. Evolution of Meaningful Use Objectives in Each Stage
• 2011 Definition Stage 1:
– 14 Core Objectives for Hospitals
– 15 Core Objectives for Professionals
– Pick 5 of 10 Menu Set Objectives
• 2013 Definition Stage 1:
– 12 Core Objectives for Hospitals
– 13 Core Objectives for Professionals
– Pick 5 of 10 Menu Set Objectives

41. Evolution of Meaningful Use Objectives in Each Stage
• 2014 Definition Stage 1:
– 11 Core Objectives for Hospitals
– 13 Core Objectives for Professionals
– Pick 5 of 10 Menu Set Objectives for Hospitals
– Pick 5 of 9 Menu Set Objectives for Professionals
• 2014 Definition Stage 2:
– 16 Core Objectives for Hospitals
– 17 Core Objectives for Professionals
– Pick 3 of 6 Menu Set Objectives

42. Meaningful Use Stage 2 Objectives (2014)
for Eligible Professionals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

43. Meaningful Use Stage 2 Objectives (2014)
for Eligible Professionals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

44. Meaningful Use Stage 2 Objectives (2014) for Hospitals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

45. Meaningful Use Stage 2 Objectives (2014) for Hospitals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

46. Critique:
Lessons for Thailand
Disclaimer: Personal opinions of the speaker

47. Lesson #1
Clear aim toward improved quality &
efficiency of health care.

48. Lesson #2
Large health IT initiatives require
leadership from the highest level
of government.

49. Lesson #3
To achieve widespread health IT
adoption, substantial financial
investment is necessary.

50. Lesson #4
Leadership from a national
organization with health informatics
expertise is vital to success.

51. Lesson #5
Criteria for “Meaningful Use” should
be evidence-based
to the extent possible.

52. Lesson #6
Criteria for incentives should be
realistic and flexible.

53. Lesson #7
Criteria for incentives should be
evolutionary.

54. Lesson #8
Accept local diversity in technologies
& requirements.
Don’t aim for homogeneous
environment.

55. Lesson #9
Leverage existing standards
to the extent possible.
Don’t reinvent the wheel.

56. Lesson #10
Acknowledge that more than one
level of interoperability needs to be
achieved.

57. Lesson #11
A policy that attempts to move too
fast or be too dynamic will greatly
burden providers

58. Lesson #12
“Meaningful Use” focuses too much
on functionality, with questions on
true interoperability, and with little
attention on usability, ease of use &
provider acceptance of technology

59. Take Home Message
• Adoption of health IT still work in progress, even
in developed countries
• We can learn something from other countries
• We need to do something, soon.
• Don’t forget to build the workforce!!

60. Useful Online Resources
• www.healthit.gov
• www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/index.html
• www.himss.org/EconomicStimulus/
• www.amia.org/public-policy/testimony-comments-reports
• www.nejm.org/doi/full/10.1056/NEJMp0912825
• www.nejm.org/doi/full/10.1056/NEJMp1006114

61. References (1)
• Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and
inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108-14.
• Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Brown GD. The clinical value of computerized
information services. A review of 98 randomized clinical trials. Arch Fam Med. 1996;5(5):271-8.
• Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.
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• Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010
Aug 5;363(6):501-4.
• Borzekowski R. Measuring the cost impact of hospital information systems: 1987-1994. J Health Econ.
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62. References (2)
• Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized
clinical decision support systems on practitioner performance and patient outcomes: a systematic review.
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http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf
• Institute of Medicine, Board on Health Care Services, Committee on Data Standards for Patient Safety. Key
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63. References (3)
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