Advancing Nationwide Health Information Network: Interoperability & Transformation

1. Update on the Development of the Nationwide Health Information Network – Interoperability and Transformation through the Federal Health Architecture “An EHR for Americans within Ten Years”Marc Wine, MHAProgram Analyst, Health IT CoordinationGSA, Office of Intergovernmental SolutionsJuly 19, 2005Marc.wine@gsa.gov

2. Focus of Today’s Discussion • Health IT as a National Priority • Critical Need for EHRs, lack of standards for interoperability • Office of the National Health IT Coordinator • Federal Health Architecture – Consolidated Health Informatics – FEA/DRM • Current Actions to Advance the NHIN

3. Office of the National Coordinator forHealth Information Technology (ONCHIT) • On April 27, 2004, the President issued an Executive Order creating the Office of the National Coordinator for Health Information Technology. • On May 6, 2004 Dr. David Brailer was appointed by the President as the National Coordinator • In fulfilling the requirements of the Executive Order, the NC was charged with: -- developing an industry and federal government-wide strategy for widespread adoption of health information technology -- and for translating this into substantial quality and efficiency improvements within a decade.

4. Current State of EHR Adoption • Most physicians do not currently use the technology • ~15% in Massachusetts, typical example • Large groups are rapidly adopting • Small groups are not • Market failure • Providers make investment • Payers/purchasers realize most of the benefits • Lack of data interoperability is risky for Lines of Business (LOB) economy-wide.

5. U.S. Picture: EHRs Finally Getting National Attention “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” President George W. Bush State of the Union, January 2004

6. The Business Case for Building the NHIH is in the dollars: • One recent study estimated a net savings from national implementation of fully-standardized interoperability between providers and five other types of organizations could yield $77.8 billion annually, or approximately 5 percent of the projected $1.7 trillion spent on U.S. health care in 2003 • Source: Blackford Middleton, Jan Walker et al., “The Value of Health Care Information Exchange and Interoperability,” Health Affairs, January 19, 2005.

7. Single Individual in HHS for HIT • David Brailer named to role of National Coordinator for Health IT in 2004 by HHS Secretary Thompson • Also announcement that remainder of CHI standards have been adopted • Need for more federal support

8. Consolidated Health Informatics (CHI) President’s eGov Initiative - Scope Scope of CHI is to adopt clinical vocabulary & messaging standards to enable interoperability in the federal health care enterprise • First-time federal health enterprise “at the table” • Identify target portfolio of health data domains • Deploy cross-agency teams • Communications strategy • National Committee on Vital & Health Statistics partnership • Partners’ participation in private sector work • CHI project meetings with non-federal sector • CHI Council makes enterprise-wide decisions • Adopt specific standards for government-wide implementation in federal IT architecture

9. CHI (eGov) Partners • Department of Health & Human Services • Operating & administrative divisions; e.g., CMS, CDC, FDA, NIH, NLM, IHS, AHRQ, HRSA, ACF, Office of Secretary, SAMHSA, etc.) • Department of Veterans Affairs/Veterans Health Administration • Department of Defense • SSA, NIST, GSA (represents Western Governors Association), OMB • US AID, Environmental Protection Agency • Departments of State, Education, Justice • Department of Energy/Los Alamos National Laboratories • Others partnerships developed; e.g., USDA, USDOT, Homeland Security

10. CHI Project Plan • December 2001 – May 2002: Major partners at the table; CHI Council and goals/business case v 1.0 established • August/September 2002: First public hearings at NCVHS • December 2002: Target portfolio defined • March 2003: First government-wide adoption announcement • June/August 2003: Existing standards use inventory • January 2004 & Beyond: Closing gaps, weaknesses; measures and assessments; and more…

11. CHI was Challenged with setting the stage for a revolutionary change in the health industry • Making sure all health related agencies are represented • Change Management – culture change inside/outside government • Institutionalize the federal governance and adoption processes • New standards “ever-greening” and funding strategies • Encourage clinicians to use the standards • Covering standards for all clinical and research needs • Working with Standards Development Organizations to improve standards (gaps/weaknesses) or create standards where there are none

12. CHI Standards for Interoperability – Adopted 2003-2004 Progress to Date -- • Government-wide health IT governance council established Portfolio of 24 target domains for data and messaging standards identified • Partnered with 23 federal agencies/departments who use health data for agreements to build adopted standards into their health IT architecture • Messaging and terminology standards adopted for 20 domains, yielding 11 sets of standards to be used in federal IT architectures • Domains that did not have standards ready or mature enough to adopt produced follow-up recommendations • Regular meetings with industry to prevent major incompatibilities in partnership with the National Committee on Vital and Health Statistics

13. CHI Standards Progress, cont. Standards Announced on March 21, 2003 • On March 21, 2003, the Departments of Health and Human Services, Defense, and Veterans Affairs announced the first set of uniform standards for the electronic exchange of clinical health information to be adopted across the federal government.

14. CHI Standards Progress, cont. The standards all federal agencies adopted 2003: • Health Level 7 (HL7) messaging standards to ensure that each federal agency can share information that will improve coordinated care for patients such as entries of orders, scheduling appointments and tests and better coordination of the admittance, discharge and transfer of patients. • National Council on Prescription Drug Programs (NCDCP) standards for ordering drugs from retail pharmacies to standardize information between health care providers and the pharmacies. These standards already have been adopted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and ensures that parts of the three federal departments that aren’t covered by HIPAA will also use the same standards. • The Institute of Electrical and Electronics Engineers 1073 (IEEE1073) series of standards that allow for health care providers to plug medical devices into information and computer systems that allow health care providers to monitor information from an ICU or through telehealth services on Indian reservations, and in other circumstances. • Digital Imaging Communications in Medicine (DICOM) standards that enable images and associated diagnostic information to be retrieved and transferred from various manufacturers’ devices as well as medical staff workstations. • Laboratory Logical Observation Identifier name Codes (LOINC) to standardize the electronic exchange of clinical laboratory results

15. CHI Standards Progress, cont. Standards Announced on May 6, 2004: • On May 6, 2004, the Departments of Health and Human Services, Defense, and Veterans Affairs announced the adoption of 15 additional standards agreed to by the CHI initiative to allow for electronic exchange of clinical information across the federal government.

16. CHI Standards Progress, cont. The specific new standards 2004 are: • Health Level 7 (HL7) vocabulary standards for demographic information, units of measure, immunizations, and clinical encounters, and HL7’s Clinical Document Architecture standard for text based reports. (Five standards) • The College of American Pathologists Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) for laboratory result contents, non-laboratory interventions and procedures, anatomy, diagnosis and problems, and nursing. HHS is making SNOMED-CT available for use in the U.S. at no charge to users. (Five standards) • Laboratory Logical Observation Identifier Name Codes (LOINC) to standardize the electronic exchange of laboratory test orders and drug label section headers. (One standard.)

17. CHI Standards Progress, cont. Specific new standards 2004: • The Health Insurance Portability and Accountability Act (HIPAA) transactions and code sets for electronic exchange of health related information to perform billing or administrative functions. These are the same standards now required under HIPAA for health plans, health care clearinghouses and those health care providers who engage in certain electronic transactions. (One standard.) • A set of federal terminologies related to medications, including the Food and Drug Administration’s names and codes for ingredients, manufactured dosage forms, drug products and medication packages, the National Library of Medicine’s RxNORM for describing clinical drugs, and the Veterans Administration’s National Drug File Reference Terminology (NDF-RT) for specific drug classifications. (One standard.) • The Human Gene Nomenclature (HUGN) for exchanging information regarding the role of genes in biomedical research in the federal health sector. (One standard.) • The Environmental Protection Agency’s Substance Registry System for non-medicinal chemicals of importance to health care. (One standard.)

18. Some CHI standards are yet ready to be adopted. CHI reports contain recommend follow-up work on these domains: • Disability • History and Physical • Medical Devices and Supplies • Multimedia • Population Health

19. CHI Standards – Next Steps • Create implementation guides for adopted standards. • Implement adopted standards in new opportunities for HIT investments. • Identify appropriate pilots, demonstrations, and deployments. • Require standards for interoperability throughout federal health enterprise and facilitate them across the private sector healthcare industry.

20. Federal Health Architecture (FHA) FHA and the ONCHIT • ONCHIT's Framework for Strategic Action and the Federal Health Architecture (FHA) are irrevocably linked in the effort to address critical health care needs. The FHA is under the leadership of the ONCHIT and will provide the structure or "architecture" for collaboration and interoperability among federal health efforts that the Framework for Strategic Action urges.

21. FHA – Supports a Strategy for Action on HIT • Framework for Strategic Action and the Federal Health Architecture (FHA) are irrevocably linked in the effort to address critical health care needs. The FHA is under the leadership of the ONCHIT and will provide the business rules, or architecture” for collaboration and interoperability among federal health efforts that the Framework for Strategic Action urges.

22. FHA Accomplishments to Date: In the past year • Established a vision and goals; produced initial Governance and Program Management Plans • Defined architecture development methodology and developing standard templates to capture information • Assimilated the Consolidated Health Informatics (CHI) initiative into the FHA • Defined and provided revisions to the Federal Enterprise Architecture (FEA) Health Lines of Business sub-functions • Established four work groups and began to review architecture efforts of the participating agencies through these groups • Developed and distributed a survey to evaluate federal agencies that deal with EHR and the HL7 Functional Model

23. FHA Development & Implementation Approach FHA will strive to achieve: • Improving coordination and collaboration on National Health IT goals, and • Improving efficiency, standardization, reliability and availability of comprehensive health information solutions - Within a Framework for Strategic Action for Health IT…

24. Framework for Strategic Action – Has Four Goals • Incentivizing EHR adoption, reducing risk of HER investment, and promoting EHR diffusion in rural and underserved areas; • Interconnecting clinicians by fostering regional collaboration, developing the NHIN, and coordinating federal health information systems; • Personalizing care by encouraging the use of the personal health records, enhancing informed consumer choice, and promoting use of telehealth systems; • Improving population health by unifying public health surveillance architectures, streamlining quality and health status monitoring, and accelerating research.

25. FHA Review Process • FHA Program Management Office (PMO) has two groups that will evaluate and recommend architectural products from the FHA. • These groups are the FHA Partner Council and the FHA Architectural Peer Review Group (APRG), The FHA Council consists of members from all the participating federal agencies; and APRG consists of the chief architects from DoD, VHA, EPA, HHS agencies, and OMB FEA PMO,

26. FHA- Aligning with the Federal Enterprise Architecture (FEA) & Data Reference Model (DRM) By aligning the FHA with the FEA DRM - the business value of healthcare data and information will improve for individuals and the economy as a whole by providing assess to timely, quality information without geographic boundaries, by: • Providing a structure that drives consistency in standards of data exchange; • Addressing the need for semantic understanding of government information; • Providing a classification of government data that allows citizens to locate information with ease; and • Enabling the collaborative development of information exchange, defining policies for development, storage and use through government.

27. ONCHIT Request for Information (RFI) • June 3, 2005 HHS Released Report on Nationwide Health Information Exchange Largest Compilation of Private-Sector Comments on Nationwide Interoperable Health Information Exchange to Date “We asked the health care and IT sectors to tell us what we need to know to plan a health information exchange system that will work -- delivering health care records when and where they're needed, and strictly protecting their privacy and confidentiality," said HHS Secretary Mike Leavitt. "

28. American Health Information Community (AHIC)will provide the political will to change the way health care is delivered through information technology… Action • On June 6, 2005, Health and Human Services (HHS) Secretary Mike Leavitt announced the formation of a national collaboration, the American Health Information Community (AHIC), that will advance efforts to reach President Bush’s call for most Americans to have electronic health records within ten years.

29. AHIC’s Role in Achieving NHIN • The AHIC will help nationwide transition to electronic health records – including common standards and interoperability – in a smooth, market-led way. The AHIC, which will be formed under the auspices of the Federal Advisory Committee Act, will provide input and recommendations to HHS on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected.

30. Dr. Brailer Announces Actions to Advance the NHIN, 4 RFPs: June 6, 2005 1) Harmonize industry-wide health IT standards development, maintenance and refinements over time. 2) Develop a certification process for health IT, including the infrastructure or network components through which health IT systems interoperate.

31. 4 RFPs to Advance NHIN: 3) Assess state laws that affect privacy and security practices, including those related to HIPAA, which may pose challenges to interoperable health information exchange. 4) Develop, and create prototypes for, and evaluate a nationwide health information network (NHIN) architecture for widespread health information exchange.