Department of Health and Human Services
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
National Health Information Infrastructure Workgroup
December 19, 2003
The National Health Information Infrastructure (NHII) Workgroup of the NCVHS was convened on December 19, 2003 at the Hubert H. Humphrey Building in Washingon, D.C. The meeting was open to the public. Present:
- John R. Lumpkin, M.D., M.P.H., Chair
- Jeffrey S. Blair, M.B.A.
- Simon P. Cohn, M.D.
- Richard K. Harding, M.D.
- John P. Houston, J.D.
- Stan M. Huff, M.D.
- Kepa Zubeldia, M.D.
Staff and liaisons
- Mary Jo Deering, Ph.D., OPHS, Lead Staff
- Jorge Ferrer, M.D., M.B.A., CMS
- Marjorie S. Greenberg, Executive Secretary, NCVHS, NCHS
- Robert Kambic, NHII, ASPE
- Eduardo Ortiz, M.D., M.P.H., AHRQ
- James Scanlon, ASPE, Executive Staff Director, NCVHS, OASPE. DHHS
- Steven J. Steindel, Ph.D., CDC
- Michelle Williamson, NCHS
- William Yasnoff, M.D., Ph.D., OS/ASPE, NHII Liaison
- Jackie Lee Adler, NCHS
- Bill Blakesly, Consultant
- Gary Christopherson, VA
- Linda Kloss, AHIMA
- Angela Lejonson, Amer Osteopathic Assoc.
- Karen Milgate, Medicare Payment Advisory Commission
- Susan Williams, Otarium Institute
- Thomas Wilder, AAHP/HIAA
STATUS OF ASPE NHII ACTIVITIES – William Yasnoff, M.D., Ph.D., OS/ASPE, NHII Liaison
Dr. Yasnoff reported on progress made in HHS on NHII. The Secretary announced in March adoption for federal government use of HL7, DICOM, IEEE 1073, NCPDP SCRIPT and LOINC. At the NHII national meeting, he announced licensing of SNOMED for federal government use and anyone in the U.S. free. Stakeholders participated in eight breakout tracks: privacy and confidentiality, architecture, standards and vocabulary, safety and quality, financial incentives, consumer health, homeland security, and research and population health. Recommendations were organized into major groups: management, enablers, implementation strategy, and targeted domains. Under management were recommendations for governance, education, shared resources and metrics. Enablers included financial incentives, standards and dealing with legal issues. Implementation covered demonstration projects, architecture and identifiers. Targeted domains were identified in consumer health and research.
THE VA’S IMPLEMENTATION OF NHII ELEMENTS – Gary Christopherson, Veterans Health Administration
Mr. Christopherson said VA was migrating through the technologies toward the repository model, building an enterprise person- and data-centric approach, health data repositories, and a more modularized standards-based system designed to exchange information with the outside world. DOD and VA committed to three key points that became the devices enabling two-way exchange: a good electronic health record (EHR), adopting standards so they could exchange at that level, and a repository.
VA estimated that no more then $50 to $70 billion dollars a year would be spent in information technology (IT) to produce the $120 billion dollars in benefits, producing at least a two-to-one benefits-to-cost ratio.
STATUS OF HIMSS NHII SURVEY – Steven J. Steindel, Ph.D., CDC
Dr. Steindel presented first results from the Health Information Management and Systems Society (HIMSS) NHII Task Force’s initial survey on how NHII was perceived. Resource constraints within institutions and a lack of defined return on investment (ROI) were the most significant barriers to forming local or national health information infrastructure. Dr. Steindel reported the HIMSS Task Group planned a budgeted, well publicized Web-based survey for March 2004 with yearly repeats.
DISCUSSION OF WORKGROUP PRIORITIES AND PLANS – Workgroup
The Workgroup discussed building national consensus about what NHII would be in ten years, pulling initiatives underway into that vision and giving guidance to funding projects that converged in that direction. Participants discussed advising and assisting an effort coordinating Dr. Yasnoff’s activity and both the initial and 2004 NHII national conferences, specific stakeholder group meetings, and hearings on financial models and dimensions. A follow-up report will be assembled including a model fleshing out multiple dimensions visualizing what NHII should look like in seven-to-ten years, a roadmap, and metrics for measuring progress. Financial models and incentives needed to continue in that direction and “views” of this info space held by interest groups’ that need to be brought into the fold will also be included. The Workgroup discussed opening up the planning and development process by giving certain stakeholders responsibility for taking a lead in the initial drafting. ASPE, working with CMS, will take the lead with the financial model and straw document. American Association of Health Plans and others might be asked to put together a similar document.
The details of all presentations and letters drafted can be found in the meeting transcript posted on the NCVHS Web site, ncvhs.roseliassociates.com
STATUS OF ASPE NHII ACTIVITIES – William Yasnoff, M.D., Ph.D., OS/ASPE, NHII Liaison
Dr. Yasnoff reported on progress made in HHS on NHII. HHS developed a six-point strategic outline: inform, collaborate, convene, standardize, demonstrate, and evaluate. HHS disseminated the NHII vision, catalogued NHII activities internally and on their Web site, and disseminated lessons. HHS collaborated with stakeholders and convened the national meeting. The Secretary announced in March adoption for federal government use of HL7, DICOM, IEEE 1073, NCPDP SCRIPT and LOINC. At the NHII meeting, he announced licensing of SNOMED for federal government use and anyone in the U.S. free. HHS is involved in the HL7 project to define standard functions of EHR. The FY 2004 budget has $50 million dollars for NHII demonstration projects through AHRQ. RFAs for grants were announced, subject to availability of funds. HHS is working with the eHealth Initiative Foundation, which received about $4 million dollars earmarked from FY 2003 for NHII demonstration projects, and Markle Foundation, which is moving towards phase two of their Connecting for Health Project. Dr. Yasnoff reported an important part of HHS activities was developing increasingly rigorous assessments of NHII benefits and considering policy options for aligning financial incentives that were key obstacles.
Given their voluntary approach, Dr. Yasnoff explained it seemed reasonable to ask what people would volunteer for, which led to a consensus action agenda. Over 580 representatives of all the stakeholders participated in eight breakout tracks at the June 30-July 2 national meeting: privacy and confidentiality, architecture, standards and vocabulary, safety and quality, financial incentives, consumer health, homeland security, and research and population health. Recommendations were organized into major groups: management, enablers, implementation strategy, and targeted domains. Under management were recommendations for governance, education, shared resources and metrics. Enablers included financial incentives, standards and dealing with legal issues. Implementation covered demonstration projects, architecture and identifiers. Targeted domains were identified in consumer health and research.
Management recommendations for governance called for: a public/private NHII task force with subgroups including for: steering, privacy oversight, architecture and patient safety task forces; regional, non-profit public/private health IT corporations to coordinate investment in community health information infrastructures; a consumer’s union type public/private partnership to rate the quality of health care, and a NCVHS a consumer representative. Education and communication recommendations included: informing the public about the NHII concept and implementation and privacy issues, educating senior executives about health IT and links between it, patient safety and quality; health IT education for consumers; and a requirement for more clinical informatics training for all health care professionals. Under shared resources were recommendations for shared repositories of information including rules and knowledge about health IT systems; nationally vetted clinical guidelines; a repository of information about biodefense preparedness, data definitions, datasets and metadata for research; a national quality measurement database; shared resources alliances in research and population health; and health promotion, prevention and treatment information available electronically to consumers. It was recommended that metrics be established to track NHII progress including specifically biodefense preparedness, availability of NHII to high-risk populations, consumer management of patient information, and development and use of standardized safety and quality measures. Funding should be tied to achievement of goals outlined in the metrics, and the credibility of health information resources should be measured to support that.
Under enablers were recommendations for financial incentives for acquiring and sustaining health IT. Public/private financing of $10 billion dollars should immediately be available to help acquire health IT leading to improved quality of care. Efforts should stimulate private investment. All payers needed to provide reimbursement for IT driven care, continuing incentives for using health IT, and reimbursement for improved quality and safety. Financial incentives for the use of standards and private/government research funding to make standard data available were recommended. Recommendations for standards included: reliable and consistent funding, decreasing barriers to and increasing benefits of adoption, improving dissemination, and requiring standards-based labeling for medication tests and devices and coding clinical data with reference standards at its source. Recommendations for standards maintenance included: (1) a robust, nimble process for maintenance standards with designation of core reference terminologies, inter-vocabulary mapping, alignment of message and terminology standards; (2) continuation of the Consolidated Health Informatics Initiative; (3) and it was noted that consumer data elements and consideration related to privacy had to be included in standards development. Legal barriers were noted for health IT investment, health information sharing, collaboration, and with respect to liability related to safety and quality reporting. A formal process to evaluate state and federal laws affecting NHII with respect to architecture development and implementation were recommended.
Implementation strategy recommendations included: 40-to-50 projects developing community health information exchanges (CHIE) supporting safety and quality led by regional steering committees aggressively sharing lessons learned, local health information infrastructures (LHII) coordinated with a national investment plan, an incremental approach to interoperability, including consumers and those involved in biodefense preparedness, and clearly addressing privacy issues. Recommendations for architecture included: a task force following good practices for developing architecture with privacy, confidentiality and security prime considerations; standards-based, non-proprietary, scalable architecture with low barriers to entry and allowing for incremental growth; simple, easy-to-use technology; aligning CDC’s Public Health Information Network (PHIN) with NHII, recognition that full implementation of NHII would likely require affordable broadband internet access in homes. Recommendations called for proceeding with NHII without a national unique patient identifier along with a review of existing mechanisms used for patient matching and ongoing commitment to developing and establishing as soon as possible a viable national unique patient identifier and a patient linkage algorithm developed for research. Two targeted domains were identified for special action. For consumer health it was recommended that: personal health records (PHR) be established and available free to consumers from a trusted authority using a well defined basic platform, eHealth tools be promoted (e.g., linking PHR to relevant information resources and providing health alerts and decision support to consumers), and ongoing evaluation of the role of individuals in the control and management of medical information. In the other targeted domain, research on the impact of health IT, safety and quality, it was recommended that a billion dollars be earmarked each year for: evaluating existing systems, improving adverse event detection algorithms, improving methods for maximizing effectiveness of communicated information, establishing ethical, legal, and social issues programs for NHII informed by public surveys, and other projects. Dr. Yasnoff said a report on the recommendations hopefully would be published in a well-recognized journal.
Dr. Yasnoff noted consistent implementation recommendations for developing LHII specified the beginnings of that architecture. One governance recommendation called for a public/private NHII task force with an architecture task force as a subgroup that used the principles to further specify what architecture for NHII would look like. Dr. Steindel considered the recommendations thorough and ambitious, but expressed concern with the phrasing. Noting a growing number of groups strove to identify standards for the interchange of health care information; he asked that the report stress the difference between standards, terminology and their use.
Dr. Yasnoff clarified that domains mentioned in the original NCVHS report on the NHII were already included. What were presented were the best logical categories. While no major specific recommendations were made related to public health, except one related to PHIN, he emphasized that should not be interpreted as meaning there was no recognition of public health or its importance for NHII.
Observing that life moved quicker then these recommendations, Dr. Cohn said his reading of the ePrescribing section of the Medicare Reform legislation revealed a breakthrough in further clarifying STARK rules. Dr. Yasnoff considered that a sign of progress. His staff will make every effort to reference the extent these recommendations move forward.
Participants confirmed that even if all the views represented the Department, the report would follow standard policy and include a disclaimer noting that these recommendations were the meeting’s and did not indicate views of the government, HHS, or organizations represented. Dr. Yasnoff said the clearance process for written reports of consensus meetings differed from the process for HHS publications. Criteria were it accurately reflected what was said. Participants suggested a letter from the Workgroup to the Secretary congratulating him on the reports and noting what already occurred and the Department’s role, what NCVHS currently worked on, and additional issues they felt HHS should consider. Members discussed options, once a journal accepted the report, for writing a preface, editorial overview or update.
Dr. Yasnoff clarified that the paper was produced as a group project with the organizing committee and leaders of breakout tracks. It would be submitted through whatever departmental clearance was required, which for reports of consensus conferences was minimal. There was no intention to send it to everyone for review; he did not think there would be any differentiation between those outside and in the Department. Dr. Deering said NCVHS would love to be in the loop as early as possible and those within HHS who contributed would look forward to seeing it as it went through normal internal circulation. Mr. Scanlon emphasized that this was a NHII meeting; recommendations were not federal necessarily and journal publications were usually reviewed by the generating office. All requirements would be meet.
Dr. Yasnoff noted the initial quarterly report covering the period from July 1 through September 30 was recently completed. It contained extensive background, an outline of key activities and appendix of meetings and presentations. A report covering the October 1-December 31 quarter will be prepared in January.
The October 3 stakeholder meeting brought together a group of providers supportive of NHII’s concept and goals. They expressed a strong desire not to have mandates imposed and concern about ROI for EHR systems for physicians. They believed most benefits accrued to payers and expressed concern that EHR systems interfere with and slow down their workflow, negatively impacting revenue. Another stakeholder meeting in October for payers reflected skepticism about NHII concept and goals, despite an example presented from Anthem Blue Cross. Anthem, the dominant commercial carrier in Maine with 70 percent of the market, is in the last year of a three-year experiment that provides funds for physicians to purchase IT systems and measures related quality and financial improvements. Practices are asked to work harder on care coordination as recommended for management of chronic disease. Markers (e.g., hemoglobin A1C, cholesterol levels, blood pressure levels) indicate remarkable, consistent improvements across the board. Cost increases dropped substantially and participating physicians saw a substantial ROI. Payers worried about coordination of government activities, which were seen as not necessarily coordinated or communicative, even with each other. Payers were concerned about what NHII will cost, what will happen if it fails, and the unclear relationship between NHII, HIPAA and administration transactions. Additional meetings are planned.
Dr. Cohn clarified that the interaction concern was that there was no explicit linkage or building off the country’s major investment in HIPAA and standardization of administrative and financial transactions. NHII was posited as unrelated, and everyone “looked at each other after having made million dollar investments in privacy, security and other standards that already exist.” Dr. Yasnoff acknowledged he worked hard to disassociate NHII from HIPPA regulations, establishing it as a voluntary process. Feedback led him me to think that he might have gone too far, and he said he hoped to strike a balance.
Dr. Yasnoff highlighted special projects completed. A study of organizational issues related to creating LHIIs looked at CHINs, identifying what led to failure, and the most prominent LHIIs (Santa Barbara, Indianapolis) identifying what led to success. Key issues identified in successful efforts were the need for buy-in and dealing with participating organizations’ loss of control, ownership of information, financing, and technology. Recipients funded by AHRQ for NHII demonstration projects will received the report, which will also be available on the Web site.
A study from the Center for Information Technology Leadership (CITL) at Partners Health Care and Harvard looked at NHII costs and benefits. Dividing NHII’s net benefit into inpatient, outpatient, and community health exchange, they found about $10 billion dollars a year net benefit in inpatient, $20 billion dollars a year net benefit in outpatient, and $90 billion dollars net benefit from CHIE. Dr. Yasnoff pointed out that acute care hospitals dealt with episodic care and implementing EHR in the inpatient setting did not radiate benefits across the health care system. More care and opportunities for savings from EHR occurred in the outpatient environment, but again, implementing EHR in outpatient environments only gave complete patient information within the sphere of operation, not at the site of care. Complete patient information at the site of care was achieved in two ways: with a completely closed system and all patient encounters within the system, or CHIE.
Dr. Yasnoff noted different issues in terms of penetration of technology in each sector. Larger hospitals in the inpatient area perceived the benefit of EHR and many invested in this area. But a threshold of investment was required that was difficult for small and rural hospitals to overcome and most had not invested. EHR in outpatient environments benefited payers, not those asked to invest. A mechanism was needed to align financial incentives. The CHIE area held substantial potential savings for everyone, but savings to any particular sector were not sufficient enough to induce investment. Seed money was needed to create CHIE that, once started, drove continued operation. Dr. Yasnoff emphasized that data supporting the study was neither definitive nor complete. Whole areas of identified benefits could not currently be quantified. Actual benefits were likely to be larger.
Discussing standards activities, Dr. Yasnoff noted HL7 was engaged in developing functional standards for EHR. An international vote on some 250 functions for the record was expected in March. In the U.S. there was contention about the need for defining standard functions in specific care settings (e.g., inpatient and outpatient). HHS’s position was standards for specific care settings would stifle a developing market and were not needed. HHS will determine its own requirements for EHR functions related to specific projects.
AHRQ issued a set of RFAs for NHII demonstrations falling into: planning, implementation, and assessment of value. Several million dollars were allocated for planning 35 grants of up to $500,000 dollars each. One-to-one matching funds were required. Half the funds were earmarked for small and rural hospitals. Another request was for research in assessment of value providing for 20 grants of up to $500,000 each. Letters of intent are due in February; applications are to be received in April.
HHS implemented a set of internal NHII educational seminars to inform policy makers about NHII issues including LHII, standards development and collaboration strategy. In 2004, HHS will continue to give presentations externally and invite people into the Department to do educational seminars. HHS is enhancing its Web site. Tentative plans call for developing a written strategic plan, video briefings and brochure. HHS will expand organizational contacts and facilitating collaboration among LHII developers with conference calls and electronic collaboration. A special stakeholders meeting for employers is scheduled in January. Another will focus on health IT vendors; a third on payers and providers together. Another NHII meeting will be scheduled in June or July to review and refine the consensus agenda and hear presentations about NHII projects. HHS continues to be involved in HL7 EHR activity and will support development by HL7 of EHR interoperability standards. The Department intends to collaborate with AHRQ, continue collaboration on NHII grants and provide technical assistance. HHS plans demonstration projects with eHealth Initiative and Markle and a project to catalyze development of LHII in the D.C. area. HHS continues to look at policy options for aligning incentives and improved estimates of NHII cost and benefits.
Dr. Yasnoff quoted the recent IOM Report stating that “establishing NHII should be the highest priority for all health care stakeholders.” He clarified that HHS understood that the universe of functions relating to EHR informed efforts to develop an interoperability standard for EHRs because the standard had to support all those functions. HHS’s expectation was that some functions represented what might not yet be implemented but was on the horizon. HHS saw no value in a subset of functions identified for specific care settings, particularly if those functions were balloted and became a draft standard because care settings changed rapidly. EHR in some care settings had not been implemented to any extent and no one yet had “a good understanding” of EHR functions in those settings. Standardizing functions for anything that changed so fast and was not understood was not productive. But Dr. Yasnoff stressed it was important to develop use cases for EHR functions included in the balloted international standard of EHR functions so balloters understood them. He agreed they were heading more towards a model than a standard.
Dr. Yasnoff noted three sources of funding available for developing NHII systems: AHRQ, eHealth Initiative, and Markle. Hopefully, other private foundations could become interested in seeding development of LHIIs, he noted the Santa Barbara system was created with a $10 million dollar grant from the California Health Care Foundation, but its creators said with lessons learned one could create a similar system for only a million dollars. He said the major strategy was demonstrating benefits of LHIIs by continuing to assess costs and benefits of systems operating, building more with funds available, and again showing costs and benefits. He emphasized that physicians could be motivated to adopt EHRs if those who benefited initially footed the bill.
THE VA’S IMPLEMENTATION OF NHII ELEMENTS – Gary Christopherson, Veterans Health Administration
Mr. Christopherson said VA was a strong supporter of NHII. He characterized health care in the U.S. as still basically an episodic care based system. He said VA strove to be more person-based and coordinate care across settings. Mr. Christopherson emphasized that best practices had to be incorporated for a high-action matrix to succeed and future best practices created that brought them closer to what they heard ideal systems would be.
He explained that VISTA, the health information system created by VA, was one of the largest, most comprehensive systems in the world and had been around a long time, was not as flexible as it needed to be or designed for what future health care might be. VA nearly dismantled it three years ago, then decided, though they would use commercial products in some key places, to build upon VISTA, to develop the future generation also as public domain software. VA could now track and provide clinical information among any of their clinical sites across the country. Mr. Christopherson said VA was migrating through the technologies toward the repository model, building an enterprise person- and data-centric approach, health data repositories, and a more modularized standards-based system designed to exchange information with the outside world. One of the first products of the new system, care management, enabled VA to look at any cut of patients and manage across them, moving VA from an episodic to a person- and, ultimately, population-based system. Data standardization, the repository, and reengineering of the clinical front end are targeted for completion in 2005. New pharmacy and scheduling systems will add functionality.
VA believed that doing good documentation they would break even on the initial entry of data. Subsequently they expect to save “massive quantities of time” from ease of use and having much data already there.
Mr. Christopherson considered EHR the foundational piece. VA encouraged private vendors to have better products, worked with provider communities to adopt them, and aimed to ensure that the public version of VISTA, Healthy People, was available. He added that PHR systems were the tool that enabled people to get more involved: more than a record, PHRs were services, information and the ability to link with others to share information. He noted community-level exchange was important, and emphasized that they would not succeed if they “didn’t figure out how to communicate and exchange information at the local level.” Noting learning experiences could be applied across communities and providers, he said anyone who wanted to exchange information at any point in time ought to be able to do so.
VA’s PHR, My Healthy Vet, went live on Veteran’s Day 2004. By the end of 2004 VA intends to have access to the medical record and enable people to put their personal information in the system. To date, federal health information exchange with DOD is one-way with data flowing to VA. The future version will be two-way and extend the relationship and create a partnership with these large systems. VA also worked with other parties (e.g., state veteran’s homes, Indian Health Service, affiliated medical schools, AAMC, local and state governments) providing tools or helping develop areas. VA utilized PHR and home tele-health care to help communities define new ways to provide care outside institutions and reach out to people where they work and live. VA was conducting a joint effort with CDC on sharing data between their systems and talked with several countries that tried to move forward with EHR systems. Mr. Christopherson said DOD and VA committed to three key points that became the devices enabling two-way exchange: a good EHR, adopting standards so they could exchange at that level, and a repository.
VA estimated that no more then $50 to $70 billion dollars a year would be spent in IT to produce the $120 billion dollars in benefits. One would get at least a two-to-one ratio of benefits to cost.
Dr. Ortiz noted VA “had been wonderful” in implementing IT systems nationally, but a criticism heard was that VA spent so much money implementing and little evaluating. Much that drove IT implementation (e.g., Medicare, ePrescribing) occurred because systems were evaluated over 20-or-30 years, laying the foundation. VA had a “great system across the board and was doing neat things.” Evaluation would: indicate if things were working as intended, improving quality, and show VA could counter doctors’ concerns about cost, effectiveness and, access to care. Mr. Christopherson clarified there ”wasn’t a prohibition” against using IT dollars for evaluating research, but an issue about how many dollars VA had to spend and how they prioritized. VA was convinced in the value of an EHR system and trying to restructure and revamp VA. Over five years they had worked to change outcomes and how care was delivered. VA, Kaiser and others had to sit down together and think about documenting their experiences to move the rest of the community along. However he noted VA “didn’t have a control and, in a sense, was tricky.” He favored potential partnership with AHRQ.
Dr. Yasnoff clarified that the $120 billion dollar benefit was a net number. There was a $140 billion dollar gross benefit less a $20 billion dollar estimated cost after investment. He agreed that EHR saved time, remarking that doctors who actually had used an EHR never gave it up. He expressed concern that VA was one of the few health care organizations in Santa Barbara not participating in a successful LHII. Mr. Christopherson said VA was very interested in sharing data at the local level, but had resource limitations. Many communities approached them to do the exchange and VA tried to determine the best ways to do that, both at the local and national level: whether it required changes to the core VISTA system or was just a matter of working out a business relationship. VA had worked with Santa Barbara a long time. The “bump” was that Santa Barbara had a set of legal agreements allowing a form of one-time signing that caused participants to follow state laws, something federal agencies could not do. VA still sought a way to get through that single legal issue. Santa Barbara, Indianapolis, PSI and others all made significant contributions to community health kinds of exchange operations and VA learned from their efforts. But no one had quite “got it all together;” everyone waited for the next model.
Mr. Christopherson noted there was a vehicle in VA to do direct research and a health services research group had begun opening that up. He said they would do a collaborative venture that allowed more latitude
He described a search for a common mechanism enabling any two providers at any given point in time to share information and the realization that the tools basically existed and the solution was assembling the pieces and making them work. About 30 organizations including VA, Kaiser, Microsoft, Hewlett Packard, CMS, IOM and NHII were forming a public/private collaboration. The collaboration will begin to look at the experiences of Santa Barbara, Indianapolis, PSI and others at a January 9 meeting. He emphasized the intent was not to create policy but to execute.
Noting the Workgroup already made a significant contribution by putting the NHII agenda on the table, Mr. Christopherson suggested next steps for moving the concept forward were nudging people toward financial incentives, standardization where appropriate, and a functional model for EHR systems. He encouraged the Workgroup to do whatever they could, whether in “payoffs” or timeframe, to break through to those skeptical about NHII. He noted that every year tens of thousands of doctors were trained on the VISTA system and walked “on to the next place.” VA was still at an infancy stage about where to go with PHR and welcomed anything the Workgroup could do to help define where the consumer came into play and how to enable involvement. On the exchange level, he called for reinforcing community exchange efforts and funding to get that work done both at the demonstration phase and proliferation. He noted CHI and others had not yet put together a model into which all the standards fit. They “hadn’t yet touched” some areas of standards and had to think through the roadmap laying out where they were going with standards, the model, how it fit together, its potential scope, and who would do it.
STATUS OF HIMSS NHII SURVEY — Steven J. Steindel, Ph.D., CDC
Dr. Steindel presented first results from HIMSS NHII Task Force’s initial survey on how NHII was perceived. He noted the group, balanced between providers, vendors, and government representatives, was the first HIMSS task group to report directly to the board of directors, an approach reflecting NHII’s importance to HIMSS. It was charged with creating demonstration projects and doing a status survey of NHII implementation for HIMSS members. For their initial input on NHII, HIMSS utilized a quick, Web-based, limited question/publicity survey mechanism designed for HIMSS to get information monthly from members on issues of importance. HIMSS posted five questions in September and had 196 respondents. Dr. Steindel noted they had no information on what respondents represented. Given the response rate, results were not representative. He pointed out that it was a NHII-aware population. Only a third indicated no familiarity with the project.
Resource constraints within institutions and a lack of defined ROI were the most significant barriers to forming local or national health information infrastructure. Only four percent considered governmental intervention a barrier; ten percent, privacy and security issues from HIPAA; 12 percent, issues of standards and lack of interoperability. Fourteen percent were unwilling to exchange information with competitors.
Respondents did much electronically. Laboratory results were the function health care institutions processed most electronically (about 83 percent). Clinician access to patient results from outside the facility was about 80 percent; pharmacy orders and prescriptions, 60 percent; tele-health, 40 percent. Patient access to results was about 15 percent.
National standards used for electronic communication were tabulated and indicated the penetration of standards recommended by NCVHS for PMRI messaging standards implemented in institutions. Some 46 percent said they did not exchange information with public health organizations at this time; 25 percent said they would send information electronically if public health could receive it. Dr. Steindel said he was encouraged that 15 percent reported they received alert information from public health agencies, but he felt the 14 percent indicating full exchange of information was unrealistic. Dr. Lumpkin suggested they probably did not share anything, but what they did was done electronically.
Dr. Steindel reported the HIMSS Task Group planned a budgeted, well publicized Web-based survey for March 2004 with about 16 of 48 core questions that differed based on the target group. Respondents will be identified. The task group planned to have yearly repeats of this survey and worked with those surveying EHR vendors and the user community to introduce NHII-like questions. The group worked with EHR to introduce external communications into their systems. Dr. Steindel noted HIMSS, as an institution-and-vendor-based organization, was inherently biased and was investigating ways to increase their penetration into the ambulatory care community. Public and personal health dimensions also were missing from their population. While the HIMSS population could answer how the group provided information it did not necessarily indicate how information was used. HIMSS looked for ways to augment that.
Dr. Cohn commented that they tended to under appreciate public health data (e.g., immunization registries fed by electronic data sources, many lab results) that came from private entities. Dr. Steindel pointed out that they took advantage of this target of opportunity for the March survey and refined the question accordingly.
Asked how their efforts to look at metrics would be integrated, Dr. Steindel said they had not discussed formal integration but members of Dr. Yasnoff’s staff had the questions and he hoped they would comment. Dr. Yasnoff said someone on the staff would participate directly in the work group. He said input through HIMSS was premature, but would be valuable once there was an established set of metrics. Dr. Steindel said they considered two types of survey questions: penetration metrics and characteristics. Questions were geared from HIMSS’s perspective of characteristics. Only their membership was surveyed and it was difficult to make presumptions about national penetration of a NHII metric.
The ePrescribing demonstration planned by HIMSS was still in the formative stages, pending funding. They were considering using an ePrescribing RX hub, a national clearinghouse for prescription information. Cleveland Clinic and VA would be involved. Other institutions were being recruited. They intended to introduce a full ePrescribing system between these institutions with funding from eHealth. Implementation would begin in the spring, running 12-to-18 months.
Dr. Lumpkin noted that December 18 the Commonwealth Fund released their view of the ten most significant health care policy events in 2003. The major Medicare prescription drug legislation was first, eighth was clinical IT standards gaining traction due to government effort, number nine was advances made by quality improvement efforts.
Dr. Steindel said activities could go in three directions, none mutually exclusive. They could define other dimensions of NHII or go into depth on circles already there. They were beginning to look in depth at the personal health dimension, focus of the Connecting for Health Initiative funded by Markle. EHR activities, electronics, the Standards Committee and CHI were involved in another circle, the health care provider dimension. A second alternative involved the third dimension, population health. NCVHS already had hearings on PHIN and work was underway with the National Electronic Disease Surveillance system (NEDS). A third alternative was to focus on interfaces between the circles, movement of data from the personal health dimension and between the health care provider dimension and the interface with population health and the other dimensions. The other alternative was focusing on accomplishing higher-level issues.
DISCUSSION OF WORKGROUP PRIORITIES AND PLANS – Workgroup
Dr. Yasnoff pointed out that senior policy makers in the Administration and on the Hill did not have the understanding of NHII or belief in financial benefits outlined in the NCVHS report. He stressed that neither OMB nor CBO was convinced of a business case. He emphasized making that case and communicating a vision that defined NHII.
Noting architecture implied technology, Mr. Blair advocated defining the subgroup broader. He emphasized putting flesh on NHII’s bones and suggested a sense of what NHII should be in seven to ten years as Mr. Christopherson’s model. Mr. Blair noted that could derive from an expansion of their report: functional, technology, standards, financial and legal models as well as a policy model comprised of NCVHS’s values and ethical components. He stressed that there was a sense of urgency.
Mr. Blair said he’d begun a list of possibly 60 initiatives including legislative, CHI, eHealth and standards that came from different perspectives, which many considered part of NHII. He expressed concern that these initiatives would proceed for years and those investing now would be hurt as everyone was pulled into a cohesive single NHII. He cautioned that the model had to be produced as quickly as possible; Dr. Yasnoff, AHRQ and other HHS agencies were about to fund demonstration projects that were extensions of what people did today and each was shaped from a different perspective. Mr. Blair emphasized: building national consensus about what NHII would be in ten years; measuring demonstration projects against whether “they’re getting us there;” and a roadmap from the initiatives, laws, demonstration projects and standards to that model, noting impediments, gaps and milestones so they ensured convergence. He expressed concern that those involved in technology and standards had too big a role in defining NHII and other areas where this model needed “weight” (e.g., principles, ethics, support for wellness and PHRs) lacked as strong a voice as interoperability and connectivity.
Responding to Dr. Yasnoff’s comments about the need to get the budget people’s attention, Dr. Steindel expressed concern that CHI was basically an OMB initiative. He emphasized that the roadmap was importance if OMB was aware of the need for interconnectivity in the federal health systems but not tuned to the need for NHII and how to there. Dr. Huff agreed with communicating the vision, putting flesh on the bones, and creating the model Dr. Yasnoff and Mr. Blair described. He said describing the vision state and how it would look to a patient- or physician-user (e.g., how it changed how one accessed health care or practiced medicine) led to what had to be in place in terms of privacy, confidentiality, infrastructure, standards and business cases. Asked what was envisioned as the vision case extending beyond NCVHS’s first document, members replied update, enhance, re-communicate, and then draw out from the vision, specifically stating what was required.
Reflecting that they kept talking about metrics and that people with opposite views embraced the vision as their view, Dr. Cohn said “to tighten” it a bit. He cautioned that, without reflecting on financing mechanisms for NHII and health care, they could not talk about the business case.
Dr. Lumpkin commented that looking at the business case also involved considering non-financial things. A second order of business case saved money by improving quality. Noting the CITL study indicated cost savings accrued to those who had not implemented, members emphasized the need to ensure providers shared in the benefits and for financial models leading to incentives for implementation.
Dr. Steindel noted the cost/benefit analysis identified benefits targeted to the large circles and the $90 billion accrued where circles overlapped. Members discussed fleshing out overlap areas and an emphasis on where the provider/payer view and HIPPA fit within them. Dr. Lumpkin suggested NHII‘s financial dimension was really the overlap; payers and purchasers weren’t in their model. Dr. Zubeldia noted the state of Utah was considering building a repository for lab, radiology and prescription information. Payers said they would increase reimbursement if providers improved quality by looking into the repository rather then ordering extra x-rays or prescribing. Everything overlapped; the provider had financial incentive to use the repository.
Dr. Cohn noted the need to look at the payer/purchase dimension and financial value in persuading OMB and CBO. Dr. Steindel recalled they had discussing an administrative or payer/provider dimension but left it out partly because they “didn’t know enough…to put it in.” Noting the NHII model and HIPAA gave a clearer sense of how finances interacted with the care area, he suggested reinvestigating that dimension. Asked if the financial dimension might be a circle overlaying the others, as privacy might, Dr. Yasnoff suggested the implementation strategies, enablers and management recommendations from the NHII meeting could inform putting this together. He noted he had added another circle, research/public policy, to his own presentations. Those areas would not drive NHII, but would be valuable in the long run.
Dr. Ortiz emphasized substantial, tangible achievements that could occur. He clarified that the AHRQ $50 million dollar portfolio was not a NHII but a Congressionally mandated patient- safety portfolio on how to use IT to improve patient safety/quality of care. As much as possible, they tried to facilitate interconnectivity, use of standards and improving quality through IT to support the vision
While AHRQ’s view was that the $50 million dollars was patient safety, Dr. Yasnoff noted the money was written by ASPE as an NHII Initiative and Congressional language declared it should be used to show NHII. He said this was illustrative of how different views might be reconciled and participating organizations could coordinate and work together. Dr. Lumpkin remarked that the positions were complementary.
Mr. Hungate proposed demonstrations of better results because of information shared through the ePrescribing initiative. Noting the Medicare Prescription Drug Improvement Modernization Act included demonstration projects for ePrescribing that follow the selection of the standards, Mr. Blair said probably they could come up with 12 initiatives underway to “pull into” this vision. He said they needed both the projects and sense of where they wanted to be because they had to give guidance to the funding of projects to ensure they converged on that vision. Members agreed it was time for NCHVS to encourage and pull together more demonstration projects, fitting them within context.
Dr. Deering suggested envisioning ways outside groups could play a more direct role in the creation of the statement. She noted there were different levels of problems and issues on the table. Those linked to financing might lend themselves to a targeted study, papers might have to be commissioned for in-depth issues.
Dr. Lumpkin noted foundations interested in different pieces of the health care picture might fund similar but connected studies. He heard consensus about fleshing out the bones of the first report and developing a roadmap for seven-to-ten years, including a model with multiple dimensions: legal, policy (values and ethics), standards, architecture, and financial (financial models and the business case). Candidates for expanding the scope include the payer/ purchaser and research/public policy dimensions. He emphasized encouraging development of metrics, in order to concretely measure going forward, and considering how all the pieces fit together in developing the model.
Dr. Cohn noted many entities were empowered to help create this. They had to ensure they were not too restrictive and identify, wherever possible, the potential to do things different ways and how all this could fit together “in this grand vision.”
Mr. Blair emphasized the urgency and need for consensus. Members discussed putting together an initial NHII model and a straw person of the models the group could review at the next NHII meeting and extend to broader sets. Members discussed an effort coordinating Dr. Yasnoff’s activity and the mid-2004 NHII conference to further discussion about both the model and path leading to it. Dr. Yasnoff asked the Workgroup to review and advise on the conference, but cautioned that there was a timeline and intensive work in the first months of 2004. He said the group was ready to bring the model of how NHII could be built to the Workgroup and would welcome NCVHS’s ideas and efforts to solicit additional input. Members suggested thinking about financial models and groups working together to refine straw-person documents for the conference. Participants discussed the importance of unique contributions beyond what had already been heard the first time that could come from the June 2004 conference and push the field forward: the straw-person documents, critiquing a roadmap, and identifying the proper gaps and anything left out.
Dr. Lumpkin said in looking at this dimension and the financial models it was important that CMS play a “fairly big” role in thinking through and developing the straw-person document. Noting Stu Gutterman, head of RDI, was thinking about financial models to stimulate the clinical effectiveness of care, Dr. Ferrer pointed out that the Medicare reform bill provided an opportunity to look at the financial impact of clinical modifications of IT. Dr. Lumpkin noted a broad spectrum at the conference could provide input on the financial pieces. Mr. Scanlon pointed out that there were many market incentives. He noted they had to leave open a fair amount of flexibility; Departmental leadership would have other ideas and facets to pursue.
Dr. Deering cautioned that, drawing up straw-person documents internally, they would lose the opportunity to open up the planning and development process by giving certain stakeholders responsibility for taking a lead in the initial drafting, thus providing feedback and ensure their buy-in from the beginning. She suggested that research and public policy had to be split apart because those working on the bioinformatics and research grids would not see the linkages. Dr. Lumpkin said they could open up the process by preparing several documents. NCVHS, working with federal partners, could take input from the conference and craft a single document. Members noted work to be done over the next three or four months with groups that intensively developed straw persons. Dr. Steindel’s staff will pull together, review with NCVHS, and refine them. Straw models and roadmaps will be presented at the 2004 meeting and stakeholders’ critiques and suggestions collected.
ASPE will take the lead with the financial model, working with CMS to develop a straw document about financial modeling and alternatives. American Association of Health Plans and others might be asked to put together a similar document from their perspective. Conference attendees and subgroups will compare the soundness of various approaches, enabling NCVHS to put together a synthesis that gave the Secretary alternative choices for reaching this end.
Dr. Steindel said he would like to see the tracks set up so that they collectively gained advantages of experts with both specific and broad talents and afterwards synthesized ideas from all the groups; “stove piping” could be done at more targeted meetings and hearings. Dr. Lumpkin noted that they were considering this meeting as a vehicle to enable assembling a follow-up report on NHII that described a model, roadmap, began to delve into financial models, and fleshed out other dimensions and metrics.
Mr. Hungate emphasized simplicity and easily identified structures that worked when dealing with chaotic situations; Dr. Lumpkin suggested holding onto that reservation while fleshing out the first straw model enough that it had adequate coverage. Noting their list covered the three most troublesome areas for penetration, he suggested describing through their lens what NHII was and could do, while maintaining in that description the core model of patients, health care providers, and population health. Dr. Yasnoff suggested considering two categories might help them visualize how to organize, not only the conference, but also activities promoting the vision and moving it forward. One was the roadmap or management piece for building this central, unified, information space. The other included specific issues, concerns and views of various stakeholder groups.
Members agreed that potential vehicles included: the conference, specific stakeholder group meetings, hearings on financial models and each dimension. While emphasizing the highest value of the stakeholder group meeting was increasing the commonalty of views while defining the single information space, Dr. Yasnoff cautioned about ending up with divergent recommendations from each group rather then a unified vision of one system benefiting everyone.
Dr. Lumpkin noted the theme was to build a central info space where many stakeholders had needs and views that was neither a single system nor database. NCVHS will flesh out the bones of the first report, focusing on a model that describes what NHII should look like in seven-to-ten years, a roadmap and metrics for measuring progress. It will include: financial models and incentives needed to continue in that direction, and “views” of this info space held by interest groups’ that need to be brought into the fold.
Dr. Ferrer cautioned not to just abstractly look at the financial model itself, but to think that and the clinical model would lead to incentives for using IT to evaluate clinical and financial effectiveness of care. Dr. Lumpkin noted current financial models impeded progress towards quality and development of NHII because those doing quality interventions did not necessarily benefit from quality occurring.
Members noted interfaces between payers, purchaser, providers and researchers had to be managed in the system design and soliciting individual perceptions required paying attention to communication methods and interfaces between those dimensions. Dr. Yasnoff noted all the metrics of progress could not be defined and suggested iterative prototyping and gradually specifying details as they “approached where they were trying to go.” A realistic work plan could either declare there was more than could be done and focus on one thing or it could touch all areas, outlining to the level understood and explicitly leave space for filling in details as they became clear. Dr. Lumpkin concurred. A first report in mid-2005 might identify gaps but the plan being defined would extend into 2006 in an iterative fashion with the initial draft, updates and refinements.
Ms. Williamson suggested a model for education that addressed how NHII worked and how education had to be a component outlining what needed to be done within hospitals, in health departments, medical training, and for consumers. Dr. Lumpkin agreed that addressing how to convince providers, hospitals, and consumers to engage was a metric of the model. Providing proper training in informatics was a recommendation and implementation strategy.
Dr. Lumpkin said models should be designed to both resist and drive change in the health care system; he emphasized embodying principles that had to be in place to drive targeted changes. The Workgroup will assist in the planning, work on strategy and what the conference will and can not accomplish, map out a series of hearings for 2004 based on that assessment, and write January through May. The synthesis would draw from both conferences and the hearings. The 2004 conference will inform writing a report, starting early in 2005. A synopsis or draft would be presented to the conference; the final version would be submitted to the Committee for approval in September 2005.
The Workgroup will finalize the plan at a short meeting on January 29. Members will flesh out and finalize the NHII conference plans at a meeting in February. A timeline for activities besides the conference will be developed at March meeting. Dr. Yasnoff will email documents to be discussed at the February meeting (i.e., drafts of the straw man papers, roadmap, metrics, and financial incentives) to members at least a week before the meeting. Major planning for the NHII meeting must be completed by April 30. Members will ballot for a meeting in either the second or third week of February. Noting they had a plan, concept, meetings in January, February and March and will start working on an April meeting and hearings later in the year, Dr. Lumpkin adjourned the meeting.
I hereby certify that, to the best of my knowledge, the foregoing Summary of minutes is accurate and complete.
John R. Lumpkin 09/24/2004