ATP Initiatives in Healthcare Informatics

### Background on the ATP 1999 Competition

The Advanced Technology Program announces the opening of its 1999
competition. This year ATP will not hold focused competitions but
instead is conducting one competition, which is open to proposals from
any area of technology. The subjects of the ATP research projects are
proposed by industry and not limited to a pre-defined scope associated
with focused programs.

The single competition is open to all technology areas and is structured
to capture the advantage and momentum of focused program planning. The
ATP competition encourages, but is not limited to, proposals from the
many technical teams that have identified synergy between industry needs
and ATP funding opportunities, accelerating the pursuit of critical
elements of research which were identified in focused program plans.
However, a goal of this hybrid competition is to allow industry to more
rapidly respond to common barriers and opportunities without the delay
of justifying a focused program. Instead of focused program competitions
and boards, all fiscal year 1999 proposals received will be distributed
to a technology-specific Source Evaluation Board (SEB). SEB technology
areas include advanced materials, biotechnology, electronics,
information technology and manufacturing. So, for example, many of the
funded IIH projects and many of the proposals submitted to the IIH
focused program would now fall under the purview of the Information
Technology Source Evaluation Board.

Within the healthcare area, participants are welcome to submit proposals
applicable to the previous IIH competition addressing elements of any of
the three tiers of the pyramid (see figure 1 in the full white paper on
Information Infrastructure for Healthcare at
www.atp.nist.gov/atp/focusprg.htm#Ongoing). Alternatively, companies may
want to propose innovative solutions to those technical challenges
arising from the emerging healthcare challenges of the 21^st^ century.
Still other companies might propose technological approaches that do not
fit either of these categories. All proposals submitted to ATP will be
evaluated solely for their scientific and technological merit and their
potential for broad-based economic benefits, with both parts weighted
equally. There will be no need to determine whether a proposal falls
within the scope of specific technical programs.

This year ATP invites companies to submit pre-proposals for project
ideas. Pre-proposals are optional and do not impact the outcome of
future ATP competitions. Pre-proposals are intended to provide
intermediate feedback as to whether 1) your project idea is on track
regarding information essential to developing a successful full
proposal; and 2) your project idea is appropriate for cost-shared
funding from ATP. Pre-proposals can be received at anytime throughout
the year and will be reviewed as they are received. ATP will strive to
provide written feedback generally within approximately two weeks after
receipt. Please see the November 1998 ATP Proposal Preparation Kit,
Appendix E for instructions.

## Identifying the Vision

Within this past year ATP has invited the healthcare industry to submit
ideas on their Vision of Healthcare in the 21^st^ Century. Responses
were received from individuals, corporations and consortia in the form
of full white papers, brief position papers, emails, phone calls and
visits. Significant input came from participation in informal discussion
sessions held at the Towards an Electronic Patient Record (TERP)
conference in San Antonio, May, 1998, the American Medical Informatics
Association (AMIA) Spring Congress in Philadelphia, May, 1998 and at the
ATP Information Infrastructure for Healthcare (IIH) Workshop in
Gaithersburg, July ,1998. ATP has attempted to coalesce the responses
into a robust vision of healthcare in the 21^st^ century. The paper
provided here is an amalgamation of words and ideas taken from a
multitude of industry representatives, however we would like to
especially thank the following contributors for their extensive
contributions of white papers and position papers.

Healthcare Open Systems & Trials Consortium (HOST)

444 N. Capitol Street

Washington, DC 20001

Voice: (202) 434 - 4771

Fax: (202) 434 - 4766

e-mail: <info@hostnet.org>

http:// [www.hostnet.com](http://www.hostnet.com/)

\[The HOST white paper available at their Website is a compilation of
input from over 58 individuals and 40 organizations including research
institutions, healthcare providers, universities and non-profit
organizations.\]

Global Health Initiatives, Inc.

Contact: Michael McDonald, Dr. P.H.

Voice: (301) 299-1507

e-mail: mcdonald@ghi-inc.com

Robert A. Greenes, MD, Ph.D

Professor of Radiology and of Health Sciences and Technology

Harvard Medical School

Professor of Health Policy and Management

Harvard School of Public Health

Director, Decision Support Group

Brigham and Women's Hospital

75 Francis Street

Boston, MA 02115

Voice: (617) 732 -- 6281

Fax: (617) 732 -- 6317

e-mail: <greenes@harvard.edu>

http:// dsq.harvard.edu

Honeywell Technology Center

Honeywell, Inc.

3660 Technology Drive

Minneapolis, MN 55418

Contact: Robert Owen

Voice: (612) 951 -- 7474

Fax: (612) 951 -- 7438

e-mail: <owen_bob@htc.honeywell.com>

Centric Engineering Systems, Inc.

624 East Evelyn Ave.

Suite L

Sunnyvale, CA 94086 -- 6488

Contact: Steven Rifai

Voice: (408) 735 -- 7600

Fax: (408) 735 -- 7686

e-mail: steve.rifai@centric.com

Healthcare Challenges of the 21^st^ Century

Emerging healthcare challenges are upon us as we enter the 21^st^
century. Americans are looking for quality, cost-effectiveness, and
personal satisfaction from their healthcare providers. The healthcare
industry, responding to this highly competitive market, is reorganizing,
consolidating, and integrating to form a new healthcare delivery
structure that will enable the delivery of high quality, cost-effective
care to everyone.

However, healthcare entities find it difficult to accurately determine
costs associated with treatments. They have little or no basis for
understanding costs associated with their services or tradeoffs
associated with in-house versus contracted professional services due to
lack of consistency across practices. As a result, many healthcare
entities take on significant risk when either bidding or letting a
capitated contract. Ongoing consolidation and affiliation of healthcare
organizations increases uncertainty in cost projections and hence the
complexity associated with efficient management.

Added to the costing complexities are greater demands for healthcare
resource planning and disease management. In the United States over 14%
of GDP is related to expenses associated with the treatment of chronic
illness and acute care. Currently there are over 100 million Americans
with chronic illness, including heart disease, arthritis, diabetes,
depression, asthma, and Alzheimer's depression. Chronic illness, which
correlates to aging, accounts for at least 70% of hospital admissions
and half of all emergency room visits. The U.S. population is aging
rapidly. Today, every eight seconds a baby boomer turns fifty, totaling
11,000 fiftieth birthdays every day. Projections are that by the year
2020 17% of the American population will be over the age of 65,
significantly increasing the incidence of chronic illness and associated
healthcare costs.

Macro health challenges of the 21^st^ century must be addressed early on
to provide opportunities for bettering individual and community health.
The use of population data for disease surveillance can lead to better
prevention and control of diseases and improved coordination of
prevention efforts and medical care. An accurate definition of community
health and disease status will facilitate health policy and resource
allocation for health service delivery worldwide.

Coordination to the extent necessary to undertake the issues presented
above requires the availability of "the right data to the right people
at the right time in the right format for the right cost", made possible
through open, interoperable and secure systems. Clinical repositories
must support the efficient sharing of data, information and knowledge
across the continuum of care, including clinical, administrative, and
knowledge services. Such access to sensitive data raise privacy and
security issues, prevalent among all information technology domains, but
especially sensitive in healthcare. The risk of unauthorized access or
disclosure of patient data and the lack of integrity of the information
must be mitigated.

## The Vision

Industry has formulated a vision of the future of our nation's
healthcare delivery system to meet these challenges and has forecast
broad and sweeping changes. The dynamic environment of healthcare
delivery within the United States is driving change in the way
healthcare will be delivered, when and where it will be delivered, and
who will be providing care. Healthcare will no longer solely be the
administration of physician expertise within the confines of a doctor's
office, clinic or hospital, initiated by the onset of symptoms. Care
will be delivered to the patient at the most cost-effective location,
and frequently delivered by medical practitioners other than physicians.
Medical expertise will be acquired remotely. Diagnoses and treatments
will be based on evidence of effectiveness determined by the collection
of outcomes data and based on population and demographics information.

New models of care are being designed to address the challenges
presented, and to improve the quality of healthcare, quality of life,
and the productivity of the U.S. population, and to do this in a more
cost-effective manner.

#  Seamless Continuum of Care

Information technology will provide the means for information sharing,
knowledge representation and management required to establish a seamless
continuum of care to all segments of the population. This means that the
healthcare of local or regional populations can be addressed with a
progressive spectrum of appropriate delivery entities such as home
healthcare, ambulatory clinics, trauma centers, hospitals, or any other
resource that is geographically distributed and available to that
community. With increasing numbers of aging individuals potentially
suffering from a variety of chronic illnesses, delivery of care must
move in the direction of quality and cost-effectiveness. With the
ability to remotely access sophisticated medical expertise and
specialties when necessary, primary practice encounters will be
administered by the lowest possible level of professional appropriate
for the care being rendered. Each service will be designed, and each
practitioner will be selected to minimize costs while maximizing the
quality of care and patient satisfaction.

Information technology can provide an environment for the aging and
chronically ill that will promote individual independence, reducing
stresses on the caregiver community and demand on healthcare resources.
Development and implementation of technologies such as sensor and
actuator software technologies, communications architectures, data
collection and assessment capabilities, and analysis and response
systems will facilitate healthcare professionals in providing
cost-effective home care. Bringing care to the patient will provide both
the social and economic benefits that come from allowing people to
remain in their homes and avoid institutional living.

# Evidence-Based Healthcare

*Evidence-Based Healthcare* will play a significant role in the future
of our healthcare system. Issues such as rising costs, unexplained
variations in treatments and outcomes, inappropriate care, and uncertain
outcomes are driving the healthcare community to acquire knowledge that
will guide them in the appropriate delivery of care. The evidence-based
approach, rooted in a wealth of geographically dispersed data, uses
knowledge about the treatments and technologies that provide the best
patient outcomes under different circumstances. The methodology of
evidence-based healthcare is to provide the best and most current
scientific evidence ultimately to the point of care. The generation and
provision of such evidence will culminate in the development and support
of practice guidelines and will facilitate the standardization of care.

Data on patient treatment and outcomes are needed for clinical
functions, quality assurance, utilization review, business planning, and
administrative and public health purposes. Predicting costs associated
with services becomes a much less risky endeavor for a healthcare entity
when utilizing both internal and external outcomes data and standardized
practice guidelines. With a proven, viable set of metrics against which
to measure its performance, a healthcare organization can identify areas
of high and low operational performance, implement risk mitigation
strategies, and provide customers with informative, accurate knowledge.
"When a healthcare organization measures and reports its performance it
can more objectively allocate resources, target needed health services,
identify improvement opportunities, and provide valuable information to
purchasers and consumers."[^1] So too can local, national and global
health policy organizations, through communication of population
outcomes generated knowledge, improve the cost-effective performance of
national and international health systems supporting the health needs of
populations.

Wellness and Prevention

"Consumer education needs to be an important part of the health care
mission" according to Dr. Greenes. *Wellness and prevention* offer a
strategy for coping with the costs associated with chronic illness, as
well as with injury-related and other types of healthcare encounters. An
emerging trend in this country is to shift more resources to preventive
care and health promotion efforts. Traditionally, healthcare has focused
resources on treatment, overlooking the benefits of prevention. By
preventing incidents requiring hospitalization and the onset of
disabilities that require long-term expensive treatment, significant
reductions in the economic burden of healthcare can occur.

The public will be expected to share in the responsibility of
maintaining their health. From personalized health risk profiles,
*health risk assessments* will be developed. From this information,
individual intervention programs can be developed to prevent onset of
disease. Through personal health information systems, *health education*
information and decision-support will be directly accessible to the
public over the Internet, through newsletters, and through Telemedicine.
A strong patient-centered lifetime wellness strategy combined with a
robust patient education program could have a major impact on
lifestyle-related chronic illness.

*Disease Management* is another important aspect of the Wellness and
Prevention paradigm. Disease management is a prospective
disease-specific approach to delivering health care, that spans all
encounter sites including inpatient treatment, emergency services,
outpatient care and home care. It is a new model of care that requires
proactive intervention in illnesses at all disease stages, with the
emphasis on preventing acute episodes and complications in order to
avoid expensive and unpleasant hospitalizations. Common features of
disease management are physicians guidelines, monitoring (drug and other
treatment interventions), patient education, and behavior modification
interventions.

# Privacy and Security

The healthcare industry has established a need to make systems and data
more accessible external to the organization where the system and data
reside. This need arises out of new business relationships among various
healthcare players established to respond to the new paradigm shifts in
healthcare delivery, and from the need to deliver information directly
to the patient to encourage and make possible patient involvement in
his/her own healthcare decisions.

Open exchange of healthcare data and information mandates due diligence
be practiced to mitigate the risk of unauthorized access or disclosure
of information, or a lack of integrity of information. Systems must
distinguish between clinical and personal information and each of these
types of data must be handled differently. Clinical data is the
proprietary property of the physician who collects and assimilates it,
and who can then share this data as he/she determines. Personal data
belongs to the individual patient who can specify access. Technically,
solutions must come about that both allow for linking of clinical data
to personal data, and preventing that same linking. Systems must be able
to provide security against unauthorized access, maintain the integrity
of the data, and confirm the originators and requesters of the data.
Existing systems will not scale to meet these types of demands.

#### The Challenge

Information technology will enable the healthcare industry to implement
these paradigm shifts in the delivery of healthcare that will allow for
a more cost-effective and efficient, quality healthcare system. *Process
reengineering and automation of current manual transactions and
processes* are necessary technological accomplishments that will enable
the implementation of a Seamless Continuum of Care, Evidence-Based
Healthcare and Wellness and Prevention. One of the key problems to be
solved is providing a means for practitioners to enter data they develop
during patient encounters without imposing on the encounter process or
the practitioner's natural, individual workflow. Such *Unobtrusive Data
Capture* will allow for the development of resources such as the
longitudinal patient record, knowledge services and clinical
repositories that are necessary to address the healthcare challenges of
the 21^st^ Century. Be mindful however that providing information alone
will not serve to improve quality of healthcare delivery. *Intelligent,
Context-Based Presentation of Information* must be provided. Information
must be intelligently presented to the practitioner in a fashion
synergistic to his/her manner of practicing medicine.

Enabling technologies will allow for a seamless, evidence-based
continuum of care to be delivered to the patient when and where it is
desired, and that will allow the healthcare community to work
collaboratively on integrated disease-treatment regimens. Healthcare
delivery in the 21^st^ century will have moved from fee-for-service to
managed care, and from managed care to virtual health management. Each
shift brings with it increased complexities in *knowledge acquisition,
knowledge management methodologies, life cycle management issues and
knowledge distribution issues*. Through enhanced user interfaces the
real needs of the healthcare providers will be met, improving the
results in all areas of healthcare ranging from acute to chronic care,
from prediction to prevention, from inpatient to home care.

ATP encourages industry to address these and other healthcare challenges
and invites those companies with innovative technical solution
approaches to submit proposals to the ATP 1999 Open Competition.

[^1]: "Medical Management -- Performance Measurement" the tenth article
    in the Medical Management "\
    Signature Series" by Managed Care Resources, Inc. -- articles on
    topics in managed care written by experts in the field. The author
    of this article is Roberta L. Carefoote, a Vice President of Managed
    care Resources, is an RN with 20 years of managed care QM
    leadership.