# Presentation: 235462

##  Overview of The National Health Information Infrastructure (NHII)v.2003

- 			Don E. Detmer, MD, MA
-    Dennis Gillings Professor of Health Management 			University of Cambridge
- 	Professor of Medical Education,University of Virginia
- 				June 30, 2003
- 			        Washington, DC

## The Past & Future of Care: Defining Attributes

- _Health as a Social Good_
- Acute, Episodic
- Patient passive
- Great deference to health professionals
- Personal memory-based
- No systems awareness

- _Health as Economic Good_
- Chronic,Acute,Preventive
- Patient active
- Accountable/effective, safe, efficient, timely, equitable
- Knowledge Managed; Protocol/process support
- Team-based with System IT
- Personal &
-     Population

## A National Health Integrating ‘Infostructure’ is Healthcare’s Moon shot

- Apollo Program advantage
- With both feet still firmly on the ground, you could see a clear target overhead.
- My personal goal for this meeting
- 			Sharpen Our Focus

## The First Wealth is Health.

- - Ralph Waldo Emerson

## A Vision for Health Communications

- NHII is ...‘the set of values, systems, standards, applications, technologies, & laws that support **all** facets of **individual health, health care, and public health**.’
- NCVHS 2000

## An International Health Development

**Comprehensive Visions**:
- 	Australia, Canada (*Info*structure), England (I*f*H), Hong Kong, Malaysia, New Zealand (*WAVE* – Working to Add Value through E-Information), Singapore, U.S.A.(*NHII- ‘Paperless’ Healthcare*)
- 	_______________
**Smart Cards for authentication **
**	****(unique personal identifiers)**:
- 	England, France, Germany, Italy, Spain

## The Vision’s Goal

- The broad goal of the NHII is to **deliver information** to individuals – consumers, patients, and professionals – when and where they need it, so they can use this information **to make** **informed decisions** about health and healthcare.
- NCVHS 2000

## ‘Supporting All Facets of Individual Health, Healthcare, & Public Health’ (includes Research & Evaluation)

**Values & Systems**
- Standards
- Applications
- Technologies
- Laws

## When Health is absent, Wisdom cannot reveal itself, Art cannot become manifest, Strength cannot be exerted, Wealth is useless & Reason powerless. 

- - Herophiles, 300 B.C.

## An Integrating Information Infrastructure

- There must be a renewed national commitment to building an information infrastructure to support **health care delivery, consumer health, quality measurement & improvement, public accountability, clinical & health services research, & clinical education**.
-  - IOM Report,  “Crossing the Quality
- Chasm”  2001 (see www.nap.edu)

##        The Chasm 

-        The Chasm

- Healthcare in  year 2000.

- Healthcare with ‘paperless Healthcare’   in 2010 -

## Chasm Edge 2000 (left side)

- 90 % of annual 30 billion health           transactions done by phone, fax or mail.
- Fewer than 5% of prescriptions from US physicians are managed electronically.
- Most healthcare organizations spend 1-4 % on IT vs. 8.5% in relevant
-    industries.

- Connecting for Health: Facts and Stats. June 2003

## Health Care Systems are in Need of Fundamental Change. 

- Dx: Unsafe, costly, inefficient ....
- The current care systems cannot do the job.  Trying harder will not work.  Changing systems of care will.
- - IOM: Crossing the Quality Chasm

## Values & Systems Healthy Individuals & Healthy Communities 

- Support personal & community health decisions using the best available knowledge & support.

- Chaotic

- Simple

**Complex**

**Health Care Systems are Complex**

##        The Chasm 

-        The Chasm

- The  year 2000.

- ‘Paperless Healthcare’ in the  year 2010 -

- Self-organization within Complex Adaptive Systems: the only way across

## Achieving Goals in Complex Systems

- In Command & Control models, Newton’s laws of motion can calculate how to do so
- Works well for inanimate materials like a rock.
- It fails if you throw a bird!
- A bird is a complex adaptive system.
- True despite both being subject to the same laws of physics
- adapted from Jake Chapman
**Solution:** Coordination & Integration

## Leading Change in Complex Adaptive Systems

- Set simple rules & minimum specifications
- Create conditions for system to evolve 	over time
- Create space for creativity & local actions 	within the system
- This is “Self-organisation.”

## Complex Adaptive Systems:Birds, Herds, Schools

- Observe 3 simple rules:
- Move to the center of the group.
- Keep up with the group.
- Don’t hit anyone.

-  - Reynolds 1987

## Six Rules for theHealth Care Delivery System

- Safe
- Effective
- Person/Patient-Centered
- Timely
- Efficient
- Equitable
*- IOM:Crossing the Quality Chasm*, 2001

## Connections for Healthcare Delivery

- Patient to Other Patients (P2P)
- Patients to For-profit & Non-profit Organizations (P2B) (P2O)
- Patients with Doctors (P2D)
- Doctors with Health Care Organizations (D2B)
- Doctors with Other Doctors (D2D)
- Healthcare Organizations with Other Healthcare Organizations (B2B)
- D. Blumenthal, 2002

##  Timely Valid Communications (plus a Record of Key Information) is undervalued today.

- People more often need to be reminded than informed.
- 			- Samuel Johnson
- (Even simple reminder systems help.)

- PATIENT Record –
*Clinic & Hospital Records*

- PERSONAL
- Record – *Consumer & e-health records*

- PUBLIC HEALTH/
- POPULATION
- Record –
*    **Community Records*
*Data Banks *
*         **Repositories*

- Interlocking computer-based health records (C3PRs)
- supported by knowledge & IT infrastructure

- First-class
- Health Care

- ‘Infostructure’
*Knowledge *
*& IT*

## Goal: Computer-based Health Communications & Records (C3PRs)

- Personal - Health Communications & Records for own uses
- Patient – Care System’s Communications & Records
- Community/Population - without personal identifiers, records for planning & management
- - NCVHS 2000

## Relevant Knowledge & Decision-supportfor all with a need & right to know...so they make better decisions.

## Value & Systems: Workforce & Research Issues

- Core Competencies* for 2010-
- Patient-centered & multidisciplinary
- Evidence-based practice
- Quality Improvement Approaches
- Informatics
- We need ‘Human Genome II’ ** Action & Research  Plan for Health Systems Informatics
- *IOM: Health Professions Education: Bridge to Quality http://www.nap.edu
- **Human Genome Project II: http://www.genome.gov

## ‘Supporting All Facets of Individual Health, Healthcare, & Public Health’

- Values
- Systems
**Standards**
- Applications
- Technologies
- Laws

## Aim for NHII Standards

- Easy Secure Data Exchange among all key players
- Connected
- Compatible
- Interoperable

## Tension: Reconciling Proprietary Innovation & Systems Compatibility

- Genomics
- Intellectual Property (patents/licenses) v. Common Domain
- IT/ Telecommunications
- Proprietary Systems v. IT (including Health) Commons Domain
- Standards become “etiquettes”
- Ken Krechmer

## ‘Supporting All Facets of Individual Health, Healthcare, & Public Health’

- Values
- Systems
- Standards
**Applications**
- Technologies
- Laws

## “I think I know the problem, please help me manage it*.”

- ‘Just-in-time’
- knowledge service
- with strong decision support

- me* = patient, non-professional caregiver, health professional, informaticists, policy wonk, payer,        business leader, etc.

## Assured Process Improves Outcomes & Reduces Costs

- Prevention is preferred to detection
- The patient is central
- Focus on the system & not the individual
- Variation in clinical practices is endemic
- Quality can be constantly improved
- 			 - Reed Gardner, 1995

## Evidence-based Adaptive Decision-support Systems

- Evidence-based
- Locally generated & from literature
- Decision-support systems/templates with ‘just-in-time’ knowledge service at ‘point of care’
- Adaptive – continuously studied & improved against care delivered & patient’s outcomes
- Sim, Gorman, Greenes et al, JAMIA 2001
- Examples:  IHC Utah
- No. New England CV Group
- Others

## Evidence-Based Adaptive Decision-Support Systems: Clinical

- Alert – high or low lab values
- Assist – tailoring antibiotic choices
- Calculate & Suggest – adjusting mechanical ventilator
- Critique – rejecting an order
- Diagnose – dx in clinical practice
- Interpret – ECG
- Predict – risk of mortality with severity score
- Remind – give jab
- Structure thinking
- Randolph et al: JAMA 1999, from
- Pryor, 1990

## End-to-end Process Redesign: “Industrial Strength Applets”

- For Citizens, Patients & their Caregivers
- For Patient Care Professionals
- For Public Health Professionals

## e-Patient Examples(Clicks & Mortar)

- Cleveland Clinic – C. Martin Harris
- My Chart, My Consult, My Monitoring
- CareGroup Health System – John Halamka
- PatientSite
- Palo Alto Clinic – Paul Tang
- PersonalPath.com – David Levy
- Others

## Informed Patient 

-  including
- Nonprofessional Caregivers

## Evidence suggests:

**Better informed patients are:**
- Less anxious
- Treatment starts earlier
- More satisfied & litigate less
- Follow advice better
- Lower risk interventions are selected
- Healthcare costs drop through more self-management & a more efficient use of resources
- 		- Detmer et al:
- 	 “The Informed Patient” Study - 2003

**Notes:**
A review of the literature provides evidence that better informed patients are:
Less anxious
Treatment starts earlier
More satisfied & litigate less
Follow advice better 
Lower risk interventions are selected
Healthcare costs drop through more self-management & a more efficient use of resources

## ‘Supporting All Facets of Individual Health, Healthcare, & Public Health’ including Related Research

- Values
- Systems
- Standards
- Applications
- Technologies
- Laws

## Bioconvergence: Health & Devices

- Miniaturization
- Genomics - “Personalized” Medicine
- Nanotechnology
- Monitoring Devices
- ‘Sniff’ Technology

## The Challenge of Knowledge Management

- Evaluating & Integrating Emerging Technologies
- Growth of Knowledge Base
- Management of Data Bases
- Identifying the Truly Useful
- Removing Outdated Practices

## ‘Supporting All Facets of Individual Health, Healthcare, & Public Health’

- Values
- Systems
- Standards
- Applications
- Technologies
**Laws**

## Coordination vs. Control: A Balancing Act

- Coordination & Integration is key.
- Control gets messy in a Democracy.
-  Who Calls the Shots?
- Patient
- Doctor
- Government
- Commercial Interests
- Others
- Ex:
- Patient: Why can’t I waive my HIPAA
- privacy ‘rights’ if I want to gain quicker
- access to care & use e-health as I wish?

## NHII: 2002-03 Scorecard

**All Time High:**
- Leadership, Awareness & Collaboration
- Movement on some Standards
**Some Progress but much more needed**
- Public: Private Partnerships
- Consumer & Population Care Standards
**Definitely needing help**
- Financial Incentives
- Clarity on Role of Government
- Rapid Advancement Projects
- Specific High Priority Items

**Notes:**
More folks working together
Connecting for Health, IOM, eHealth Initiative, Rapid Demonstration Projects, federal Consolidated Health Informatics’ eGov initiative, NCVHS, SNOMED/NLM, Congress, CMS, etc, etc, etc...
International HL7, others

## Financial Incentives Really Matter

- Everybody loves money. That’s why they call it ‘money’.
- Movie  ‘The Heist’

## Role of Government

- “Rules of the Road”
- Data Standards, Laws & Regulations
- “Building the highway”
- Public – private partnership for secure data exchange
- “Use of the highway”
- Private sector with government
-   help for access to capital
- -NHII Financial Incentives Draft Document 2003

## Rapid Advancement Projects for 2010

**Support for Data Exchange Platforms** for 40 “communities” - 18 months
- Public-Private Partnerships
**“****Paperless Healthcare” ICT Infrastructures** in 8-10 communities – 5 year
**Pilot Projects** – 12 months
- Consumer Applications
- Chronic Care Management
- Public Health Surveillance
- - At http:www.nap.edu

## D   Top Five 2003-4 Priorities

**I.  Financial Incentives**
**	**Implement Loan Program
- 	Fast Track CPOE: Hospital & Ambulatory
**II. Standards**
**	****Current Work Agenda**
**	****Add: **Informed Patient & Population Care
- 	Initiatives
**	**
**	**

- 2

## Top 2003-4 Priorities (3-5)

**III. National Smart Card initiative for Personal Authenication**
**IV. Showcase for Implementation the Top Innovation in each of the 8 Priority Areas**
**V. NHII Action Plan (2003-5) with Annual Targets & Performance Review**
**	**
**	**

##        The Way 	Across The 	Chasm 

-        The Way 	Across The 	Chasm

- The  year 2000

- Self-organization in Complex Adaptive Systems with ‘Paperless’ Healthcare:

- 2010 -

**Notes:**
Healthier & more productive lives
Less waste in Healthcare
Better chances of national security
Better control of risks to public health

Happy healthy people going 
      about their affairs.

## John Shaw Billings - 1913Creator of what became the U.S. National Library of Medicine

- There is nothing really difficult if you only begin -- some people contemplate a task till it looms so big, it seems impossible, but I just begin and it gets done somehow.  There would be no coral islands if the first bug sat down and began to wonder how the job was to be done.