Transcript NHII Brief 5.1-2003

Addressing the Healthcare Needs of
our Aging Population with
Technology
6-4-04
Jennie Harvell
Office of the National Coordinator on
Health Information Technology
Department of Health and Human Services
Challenges Facing U.S.
Healthcare

Health care spending rising faster than inflation.

Despite spending $1.6 trillion on health care:
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medical errors abound; and
medical information is not communicated
across providers.
Challenges (cont’d)
3

The population is aging

Population surviving until 65:
- 1900 - 41%
- 2004 - over 80%

2000: 35 million Americans are 65+

2050: increases to 82 million

Biggest expected increase: those 85+
Life Expectancy
(Older Americans 2000: Key Indicators of
Well-Being. Federal Interagency Forum on Aging Related Statistics)
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Chronic Illnesses
Approximately 40% of Americans have a chronic
condition
Prevalence of chronic conditions is increasing
(RAND):
2000- 125 million
2010 – 141 million
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Chronic Conditions
(Older Americans 2000: Key Indicators of
Well-Being. Federal Interagency Forum on Aging Related Statistics)
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Multiple Chronic Illnesses
As people age, the number suffering from chronic
illnesses increase. Those reporting 2+ chronic
conditions:
ages 45-64 = 35%
ages 65+ = 62%
Approximately half of those with a chronic illness
have multiple chronic illnesses.
Prevalence of multiple chronic conditions is
increasing (RAND):
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2000- 60 million
2010 –70 million
LTC Users Today
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
12.2% of Americans reported LTC needs
in 1995

55% over 65 (3% are children)

25% community based LTC users are
severely disabled

Older Americans with severe disabilities
will more than double by 2050
Health Care Spending

Health care spending (in 1998) for those
without a chronic illness: $680

Health care spending (in 1998) for those
with chronic illness and ADLs.
# of chronic conditions
and presence of ADL
Limitation
1 chronic illness - $1,500
$3,830
2 chronic illnesses - $2,550
$5,650
3 chronic illnesses - $4,060
$7,800
4 chronic illnesses - $5,650
$11,890
5 chronic illnesses - $7,560
$12,420
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(Chronic Conditions: Making the Case for Ongoing Care; JHU, 12/02)
Challenges in the Current
Health Care System

Physicians treating patients with chronic
conditions report poor outcomes related to:
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receipt of contradictory information
from multiple physicians
adverse drug interactions
unnecessary hospitalizations
(Chronic Conditions: Making the Case for Ongoing Care; JHU,
12/02)
Summary:
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
Persons with chronic illnesses and/or
disabilities have:
- more frequent contacts with health
providers; and
- higher health care costs.

Persons with chronic illnesses and
disabilities are at higher risk of inefficient
practice and medical errors.
Health Information Technology

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“By computerizing health records, we can avoid
dangerous medical mistakes, reduce costs, and
improve care.”
--President George W. Bush, State of the Union
Address, January 20, 2004
“All these problems – high costs, uncertain
value, medical errors, variable quality,
administrative inefficiencies, and poor
coordination – are closely connected to our
failure to use health information technology
as an integral part of medical care.”
--President George W. Bush, April 27, 2004
Policy Goals:


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Assure that most Americans have
electronic health records within the next 10
years by:
coordinating public and private sector
efforts that will accelerate adoption of HIT;
doubling funding (to $100 Million) for
demonstration projects on HIT;
using the Government to foster the
adoption of HIT (creating incentives); and
creating a new, sub-cabinet level position of
National Coordinator of Health Information
Technology in HHS.
Executive Order 4/27/04
1.
2.
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Establish the position of National Coordinator of
Health Information Technology (NCHIT).
The NCHIT shall work to:
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ensure that appropriate information is available to
guide medical decisions;
-
improve quality,reduce errors, advance evidencebased care;
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reduce costs, errors, inappropriate care, incomplete
information, and increase efficiency; and
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increase effective market place, competition, and
available accurate information on costs, quality,
and outcomes.
Executive Order (cont’d)
Responsibilities- NCHIT shall develop, maintain, and
direct a strategic plan to guide national
implementation of interoperable HIT which shall:
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advance implementation of IT standards;
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ensure technical, scientific, and other issues
are addressed;
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address privacy and security issue of
interoperable HIT; and
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include measurable outcomes.
Executive Order (cont’d)
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
Reports:
-
incentives report to promote interoperable
HIT;
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OPM report on FEHB on incentives to
promote interoperable HIT; and
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VA/DoD report on working with the private
sector to extend the HIT in rural and
underserved areas.
EHRs: A Key to Improving
Quality and Improving Efficiency
Standardized Electronic Health Records
(EHRs) are one of the essential building
blocks for the evolution of a national health
information infrastructure (NHII).
The NCVHS stated that “implementation of
the NHII will have a dramatic impact on the
effectiveness, efficiency and overall quality
of health and health care in the United
States.”
NCVHS, 2001: pg 2
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Why are standards needed for
EHRs?
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
The promise of an NHII is based in part on
the ability of EHRs to exchange and reuse
health information.

Interoperable health information requires:
- clear, unambiguous data
- data that can be encoded
- ability of computers to send and receive
electronic information (i.e., messaging)
What standards are needed?
For interoperable exchange of information across
clinicians, institutions, payers, and vendor
products standards are needed for:
- terminology (content)
- messaging standardized formats for the
exchange of specific findings and electronic
documents
- definition of EHR functions
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What does this mean for PostAcute and Long-Term Care?
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
In 2001, Congress was concerned about
the noncomparable data in Medicare,
particularly in post-acute care.

Required HHS to submit a report 1/05 on
the development of standard instruments
for the assessment of health and
functional status of patients for whom an
array of Medicare services are provided
(BIPA Section 545).
BIPA Section 545
Requires that the Secretary design
standard health and functional
assessment instruments so that:
1. elements that are common may be readily
comparable and statistically compatible;
and
2. only elements necessary to meet program
objectives are collected.
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Framing the BIPA Mandate
ASPE sponsored and partnered with CMS to develop
a framework for this mandate.
Issues that emerged included:
- a common data dictionary for functional status
measurement is needed;
- federally required assessments should be more
clinically useful while balancing provider burden;
- real-time exchange of comparable data across
settings would promote continuity and
coordination of care; and
- HIT is needed to promote comparability of data
across the continuum.
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Federal Efforts to Encourage EHRs,
Particularly in Post-Acute and LongTerm Care (PAC/LTC)
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Mayo Study
SNOMED-CT license
Consolidated Health Informatics (CHI) Initiative
Council for the Application of Health Information
Technology (CAHIT)
HL7 EHR Functional Model and Standard
Study on the status of EHR implementation in
PAC/LTC
Apelon Study
Modify patient assessment content and conform
with CHI standards
upcoming NHII conference
Mayo Study
ASPE funded Mayo Clinic to examine:
1. Whether leading terminology and classification
systems provide content coverage to support
clinical decision-making and quality oversight in
nursing homes in three domains (pressure
ulcers, chronic pain, and urinary incontinence).
2.Whether MDS v.2 content provides
information needed to understand quality.
the
3. Whether MDS v.2 content is captured by selected
terminology/ classification systems (SNOMEDCT, ICF, and ICNP).
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Mayo Study Findings –
Coverage Provided by Terminologies
and Classifications

SNOMED CT provides relatively complete
coverage of terms suggested by the experts and
the literature as needed to understand quality in
the domains of pressure ulcers, pain, and
incontinence (77% - 95% match rates).

ICF and ICNP provided less than 20% complete
match rates of the terms suggested by experts
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MDS Findings

MDS provides limited coverage of terms needed
to understand nursing home quality in the
domains of incontinence and pain; better
coverage for the domain of pressure ulcers.

Most MDS data is not captured by SNOMED CT,
ICF, or ICNP:
- SNOMED CT provided a complete match for
46% of the MDS terms; and
- ICF and ICNP were found to provide a complete
match for terms in the MDS 2% and 12% of the
time, respectively.
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SNOMED-CT
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
HHS acquired a licensed with the College of
American Pathologists (CAP) to make SNOMEDCT freely available to U.S. health care entities.

SNOMED-CT is recognized as the world’s most
comprehensive clinical terminology database
(350,000+ terms).

SNOMED-CT is available via the Unified Medical
Language System (UMLS) at the NLM/HHS.
Consolidated Health
Informatics Initiative
President’s e-Gov initiative includes the CHI
Initiative.

Goal: Working in sync with the health industry,
adopt standards that enable inter-operability in
federal health care enterprise.

Involved agencies include: HHS, VA, DoD

Process: For specified domains, workgroups
identified and made recommendations for
standards that meet federal health information
needs.
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CHI Standards Adopted
Adopted March 2003
1. Laboratory Results Names: LOINC® adopted
2. Messaging Standards: Includes scheduling,
medical record/image management, patient
administration, observation reporting,
financial management, patient care: HL7®
adopted
3. Messaging Standards: Includes retail
pharmacy transactions NCPDP SCRIPT®
adopted
4. Messaging Standards: Connectivity: IEEE™
1073 adopted
5. Messaging Standards: Includes Image
Information to Workstations: DICOM®
adopted
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CHI Standards Adopted May
2004
Demographics (HL7®)
Lab Result Contents (SNOMED CT®)
Units (HL7®)
Immunizations (HL7®)
Medications (Federal Drug Terminologies, FDA
Standards, RxNorm, VA’s National Drug File
Reference Terminology)
Interventions/Procedures: Lab Test Order
Names (LOINC®)
Interventions/Procedures: Non-Lab
(SNOMED-CT®)
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CHI Standards Adopted May
2004
Anatomy (SNOMED CT® and NCI Thesaurus)
Diagnosis/Problem Lists (SNOMED CT®)
Nursing (SNOMED CT®)
Financial/Payment (HIPAA Transactions and
Code Sets)
Genes and Proteins (Human Genome
Nomenclature – HUGN)
Clinical Encounters (HL7®)
Text-Based Reports (HL7® – Clinical
Document Architecture)
Chemicals (EPA’s Substance Registry
System)
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CHI Domains with No Standard
Physiology
Medical Devices and Supplies
History and Physical
Disability
Multimedia
Population Health
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CHI - Disability Domain
Workgroup lead by ASPE and comprised of
representatives from: CMS, NCHS, VA, SSA

Extended content coverage analyses of SNOMED-CT,
ICF, and other sources in the UMLS Metathesaurus for
terms sampled from:
- NH MDS
- HH OASIS
- FIM (used by the VA and included in the Medicare
Rehab Hospital patient assessment instrument)
- Social Security Administration
- National Center for Health Statistics
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Disability Workgroup (cont’d)
Findings:

neither SNOMED CT nor ICF adequately address the
disability data or scaling needs of involved federal
agencies.

The CHI Council recommended that:
work proceed to refine an existing granular
terminology;
34
-
consider whether and how incorporation into
LOINC of disability questions could contribute to
future standardization of disability questions; and
-
enhance LOINC coverage of disability questions
used by the Federal government.
Council for the Application of
Health Information Technology
The Secretary of HHS created CAHIT in 6/03 to
promote a timely exchange of information about
and across relevant HHS activities and
opportunities.
CAHIT establishes the Department’s position on
health information technology issues after
considering opinions and perspectives from HHS
agencies and offices.
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CAHIT Coordination Role –
Example:
- Coordinated efforts to modify the MDS to
support implementation of EHRs.
- CMS is funding work to enhance the clinical
content of the MDS.
- CMS and ASPE will fund work to embed CHI
standards in the MDS to maximally support EHR
implementation.
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Study on Electronic Health
Information in Post-Acute and
Long-Term Care

ASPE funded UCHSC to study the current status of
implementation of interoperable electronic health
information systems (EHIS) in nursing homes, home
health agencies, and rehabilitation facilities.

A written report will be available 7/04 summarizing
findings and recommendations the public and
private sectors could pursue to accelerate the
adoption of EHRs in post-acute and long-term
care.
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Study on Content and Messaging
Standards and the MDS
ASPE is funding Apelon to examine the
applicability of terminology and messaging
standards for selected MDS items. Specifically, we
have asked Apelon to:

- Examine, for selected MDS v.2 and v. 3 items, the
ability to encode MDS questions and answers in
LOINC and standardized terminologies (e.g.,
SNOMED and CHI-endorsed standards); and
- advance options for how an MDS redesign could
use terminology and messaging standards.
Study to be complete in July 2004.
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Technology Website
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ASPE funded "Technology for Long Term
Care" to develop a website to on
information on technologies that can help
improve quality of life and care for the
elderly and the disabled in LTC
residential settings.
www.TechForLTC.org
provides information for professionals in
NHs, ALFs, board and care facilities, ADC
facilities, and CCRC.
Upcoming NHII Conference
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
Participation is important

NHII Website: http://aspe.hhs.gov/sp/nhii
Jennie Harvell
Office of the National Coordinator on
Health Information Technology/ HHS
[email protected]
202/690-6443
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http://aspe.hhs.gov/daltcp/home.shtml