Welcome to Care Coordination and Interoperable Health IT Systems Exchange of Health Information. This is lecture a. This will be an introduction to health information exchange. The learning objectives for the exchange of health information exchange unit are number one, To list the quality problems in healthcare that health information exchange is intended to remediate. Two, describe the nature of health information exchange technology assets that health information exchange is designed to interconnect. Number three, explain the motivations, capabilities and challenges of health information exchange organizations. Number four, explain the motivations, capabilities and challenges of using Meaningful Use and Direct to advance health information exchange. And number five, describe the future directions for health information exchange. What are the reasons that we need health information exchange? Health care data may be needed in a place other than where it was generated, because patients get care in multiple locations. Today, the movement of health care records is accomplished via the US mail, fax machines or having patients carry their records between providers or by other means. Now electronic health information exchange would allow the data to be available where it is needed, automatically and electronically not just where it was produced. There are several scenarios in which health information exchange could play a role in improving healthcare. One example is when a patient moves, perhaps between cities that the physician in the new city could automatically receive the patient's electronic health data from the physician who is caring for the patient in the previous city. Another example of health information exchange is a referral situation. For example, if a primary care provider refers a patient to a cardiologist, the primary care provider would automatically be able to send the relevant data to the cardiologist. In addition, the primary care provider ideally would know if this specialist has seeing the patient. And if the specialist, the cardiologist see the patient, the relevant information from that specialist visit would be available to the primary care provider. So, that is another example of how health information exchange can improve healthcare. Another example is that patients would be able to have access to their records, perhaps through patient portals or personal health records. Another example of a scenario in which health information exchange could play a role in improving healthcare is in a transitions of care scenario. For example, if a patient is discharged from the hospital to a non-acute setting like a skilled nursing facility. Ideally in those situations, the non-acute organization would know what happened in the acute setting. What actions are to be taken in the non acute setting? And who to call in the acute care setting, if there are questions about either what happened or what is supposed to be done for the patient? Another example in which health information exchange would could be valuable is that healthcare members would know who the other team members are. If a diabetic patient is being cared for by a primary care provider, an endocrinologist, a cardiologist, then each of the physicians would know who the other physicians are. Also, care team members would know if a care manager is assigned to the patient and who that care manager is and they would also know if the patient is seeing a specialist. And if so, who is that specialist? When they are scheduled to see that specialist and why? Another scenario for health information exchange is being able to send data automatically from healthcare provider organizations to public health organizations, so that surveillance can be done on health trends in the community. And another scenario in which health information exchange could play a role is if a patient comes to the emergency room, the emergency room physician could have a summary of the patients record from all the providers that the patient has been seeing. And if the patient says, I had an imagining study done at another facility some time ago, the emergency physician would be able to use health information exchange capabilities to see the results of that imaging study and fold that information into the patients care. So, these are some of the examples of the scenarios in which health information exchange could play a role in supporting healthcare processes. Why do we want health information exchange? Over the last several years, there have been increasing concerns about the quality and costs of healthcare and the potential role that health information technology could play as part of the solution to these concerns. In the year 2000, the Institute of Medicine published a report on the quality of healthcare in the United States, titled Crossing the Quality Chasm. And in that report, several problems in healthcare related to quality were identified. Some of the observations of this report were that quote, quality problems are extensive and serious that healthcare quality problems could be classified underused, overused or misused and that large numbers of Americans are harmed as a result of these problems in healthcare quality, unquote. Additional observations in the Institute of Medicine report or that, quote, current approaches to quality improvement are inadequate, unquote. One constraint to quality improvement that was identified at the time is the lack of adequate information infrastructure to support quality measurement and quality improvement. A 2003 study done by the RAND Corporation that was published by the New England Journal of Medicine about the quality of care, collected the data on 7,000 patients in 12 different metropolitan areas. This study was done via medical record review, as well as a telephone survey of the patients involved. The study looked at the quality indicators in 30 different conditions, as well as for preventive care with a total of 439 indicators of quality. The findings in that study were that patients received recommended care only 55% of the time. In other words, only in 55% of the instances did the patients actually receive recommended care. This was a measure that showed compliance with care quality guidelines happens only about only half the time. One of the observations of one of the studies's authors was that improvement of healthcare couldn't be done with the current approach, but rather a new approach to quality improvement would be needed. In addition to serious concerns about the quality of healthcare in the United States, the costs of healthcare have been increasing steadily over several decades. This graph shows that the percentage of all goods and services that are devoted to healthcare has increased from 1965 to 2013 from about 5.5% of the gross domestic product to up over 17% of the gross domestic product. So, the portion of the economy that has been devoted to healthcare is increasing steadily and rapidly at the same time that there are serious concerns about the quality of healthcare that is being delivered. As some researchers examine the possible ways to address the quality gaps in healthcare, there were several ideas promoted as being good ways to create improvements. One is that organizations need to be innovative. Meaning that they need to think of the different ways to tackle these quality problems. Number two, that there needs to be effective professional training and continuing education to ensure that quality care is being delivered. Number three, the evidence-based in healthcare needs to be increased. Meaning that we need to understand better what constitutes and what will lead to high quality care. Number four, we need to ensure that when evidence is present that it is being applied consistently and that we're following best practices. Number five, there should be alignment of reimbursement with quality goals. And lastly, we should be implementing appropriate information technology including electronic health records to support the quality goals. One observation of this is that information systems and electronic health records are part of the solution to improving quality, but they're not the entire solution. They're part of a broader program, as we try to improve health care quality. In November 2001, the National Center for Vital and Health Statistics produced a report titled a strategy for building the national health information infrastructure. The report looked at healthcare from three dimensions or perspectives. They looked at the perspective of healthcare providers. They looked at it from the perspective of patients and consumers of healthcare, and they also looked at it from the population or public health perspective, and what would be needed to improve care along each of those dimensions. What the National Center for Vital and Health Statistics recommended was that there was to be a comprehensive system that provides information, so that providers, patients and public health workers are all able to make sound decisions about health, healthcare and healthcare policy. This electronic information infrastructure should be developed with leadership from the United States Department of Health and Human Services. Additionally, in the mid-2000s, the idea that there needed to be interconnected health information infrastructure begin to get broad support across public settings, private settings and governmental settings. In particular, then President George W Bush in his State of the Union address in 2004 remarked that quote, by computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care, unquote. This really lifted the general principle of an electronic health information infrastructure to a national policy level. At the same time in 2004 on President George W Bush's website, it was indicated that he quote, outlined a plan that would ensure that most Americans would have electronic health records within the next ten years, unquote. In the mid-2000s, data were assembled to understand what would be required to create an electronic health information infrastructure in the United States. The data showed that there were approximately 5,000 hospitals, about 500,000 office-based physicians, 15,000 nursing homes and 12,000 home health agencies, 250,000 labs and 5,700 imaging centers. About 67,000 pharmacies, about half of which were in large chain pharmacies and healthcare payers and insurance companies. About 75% of hospitals had basic information technology capabilities, such as electronic laboratory result to lookup in place. About 10% of office-based physicians had some kind of an electronic health record in place at that time. There were about 15,000 nursing homes and 12,000 home health agencies. All of which had very low rates of adoption of information technology. There were 250,000 labs and 5,700 imaging centers. These generally had information technology in place, but those systems were not connected to other systems of care or broader information networks. There were about 67,000 pharmacies, about half of which were in large chain pharmacies. The chain pharmacies were automated, but their information systems were not connected to broader networks. Smaller pharmacies were not yet automated. Healthcare payers and insurances companies were automated, but not connected to broader information networks. An expert panel was convened to estimate the size of the financial investment that would be necessary to create, a model of an achievable national health information network was created. The relevant providers, functionalities, interoperability needs, goals, current state, gaps between current state and an ideal status and the necessary funding to address the gaps all were identified. The result of that analysis was that quote, to achieve a national health information network would cost $156 billion in capital investment over a five-year period and $48 billion in annual operating costs, unquote. This seemed like a large amount of money and it certainly is a large amount of money. But in the discussion section of the study, the authors noted that quote, $156 billion is equivalent to only 2% of annual healthcare spending for five years, unquote. So compared to the total cost of healthcare, this may not be exorbitant as it first seems. Moving forward from the mid-2000s, there were two different approaches that were taken to achieve interconnected infrastructure. One was activities to interconnect hospitals or other large provider organizations. The reason for focusing on these kinds of organizations is that these large providers take care of hundreds of thousands of patients and they hold many data types, such as laboratory tests, radiology reports, medication data, etc. By connecting a small number of these large providers, there could be substantial progress made in creating an interconnected health information infrastructure. The other approach to advancing an interconnected information infrastructure for healthcare was to try to increase the prevalence of electronic health records in physicians's offices. The observation here was that quality and cost could be improved if physicians had and used electronic health records, but there really was no motivation for physicians to do so and there were costs involved. This gap would need to be addressed and this strategy started in 2009. Why were there these two different approaches? The strategy for interconnecting hospitals and large providers which really began in 2005 aimed to make the most of what was already in place. These large healthcare providers which had some information system capabilities and that by interconnecting those, there would be advancement of an interconnected infrastructure. The idea here was to give responsibilities to states and other regions rather than the federal government taking a lead role. This was more a distributed approach and this would help to address local variability across regions, and states. In terms of getting electronic health records into physician owned offices, the strategy began in 2009 and was really part of the American Recovery and Reinvestment Act known as ARRA. And within ARRA, there was $30 billion set aside to create incentives for providers to adopt electronic health records. This concludes lecture a of health information exchange. The summary of this lecture is that number one, we need health information exchange, because patients get care in multiple locations. Number two, there are many scenarios in which health information exchange may be helpful. Number three, there are quality problems in healthcare that health information exchange can help to address. Number four, there are many different kinds of health information systems that need to be connected. And number five, in the mid-2000s, there were two strategies that emerged to advance health information exchange.
