The Role of Health Care Related IT Advances In Advancing Public Health Surveillance

1. The Role of Health Care Related IT Advances In Advancing Public Health Surveillance John Lumpkin, M.D., M.P.H., Senior Vice President and Director-Health Care Group The Robert Wood Johnson Foundation

2. EDI CLEARING HOUSE HEALTH DEPT PAYER 1 PAYER 2

3. More than 15% Above Average (36) 0 - 15% Above Average (68) 0 - 15% Below Average (112) More than 15% Below Average (90) Not Populated Medicare Reimbursements (Part A and B) in Relation to the National Average (2000) Jack Wennberg Dartmouth Atlas of Health Care

4. 2.0 1.66 1.6 1.38 1.18 1.2 1.04 1.03 0.98 1.00 1.00 1.00 1.00 0.99 0.97 Ratio to Lowest Spending Region 0.8 0.4 0.0 Medicare Reimbursements Effective Care Preference-Sensitive Care (Discretionary Surgery) What does Greater Per Capita Spending BUY?not more effective or preference sensitive care More than 15% Below Average Jack Wennberg Dartmouth Atlas of Health Care 0-15% Below Average 0-15% Above Average More than 15% Above Average

5. Asthma: Outpatient Follow-upAfter Acute Episodes • Core concept: Outpatient follow-up after either ER visit or admission • Children 5-17 years old • Standard based on national expert panel guidelines

6. Quality of Health Care in US?? • Overall Care 54.9% • Preventive 54.9% • Acute 53.4% • Chronic 56.1% • History 43.4% • Counseling or Ed 18.3% • Immunization 65.7% Elizabeth McGlynn, et al NEJM June 26, 2003 348:26

7. The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system To Err is Human - Institute of Medicine

9. Current practice depends upon the clinical decision-making capacity and reliability of autonomous individual practitioners, for classes of problems that routinely exceeds the bounds of unaided human cognition Daniel R. Masys, M.D. 2001 IOM Annual Meeting

12. “We have wonderful technology, but some grocery stores have better technology than our hospitals and clinics.” Secretary Tommy Thompson Chicago Medical School Commencement June 7, 2002

13. Vision of the NHII • The set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health. • NOT a centralized database. • Connects distributed health information in the framework of a secure network with strict confidentiality protections.

14. NHII Healthcare Provider Personal Health Population Health (Preparedness) Health Infospace

15. Comparability Interoperability Data Quality Framework for PMRI (Patient Medical Record Information) Standards

16. Inflamed Objectives of PMRI Standards • More easily & accurately exchange PMRI between systems • Better understand PMRI across systems Ear ? Rx

17. Comparability Interoperability Data Quality Overview of PMRI Dimensions

19. HIPAA

20. Radiology Laboratories Patient HL7 & Registration/ Payers DICOM HL7 & ASTM Admissions Hospital NCPDP & HL7 Pharmacy ASC ASC X12N Billing HL7 X12N & Pharmacy Knowledge NCPDP HL7 HL7 Benefits Mgrs Clinical bases & PMRI PMRI content ASTM NCPDP & ASTM Physiological X12N & HL7 HL7 monitors IEEE Community Pharmacies Orders Medical IEEE Bedside & devices computer results Interoperability Status

21. Comparability Interoperability Data Quality Overview of PMRI Dimensions

22. Terminology Vocabulary Set of highly granular, specialized terms Classification Organization of related terms Code representation of term Comparability Issues • Comparability requires that the meaning of data is consistent when shared among different parties

23. Message Specific Codes Nursing Codes • DICOM Other Codes • NCPDP • HHCC* • IEEE • Health Language Center • NANDA* • HL7* • UMDNS (ECRI)* • NIC* • X12N • DEEDS • NMMDS • UPN (HIBCC)/UPC (UCC) • NOC* • OMAHA* Convergence • PCDS* SNOMED RT/ • PNDS Diagnoses & Procedure Codes NLM - UMLS • Alternative Link* • CDT-2* • CPT-4* Clinically Specific Codes • HCPCS* Drug Codes • ICD-9-CM/ICD-9-V3* • DSM* • • ICD-10-CM* • Gabrieli • * • ICD-10- PCS • LOINC* • • ICIDH-2 • MEDCIN • MedDRA • SNOMED V3* • NHS Clinical Terms* Comparability Status

24. Financial & Administrative Comparability Privacy & Security Interoperability Data Quality The Health Informatics Pipeline Foundation HIPAA Standards

25. Other Standards • HL-7 EMR • CHI

26. Standards Announced March 2003 • LOINC: Laboratory Result Names • HL7 Messaging Standards: Includes scheduling, medical record/image management, patient administration, observation reporting, financial management, patient care • NCPDP: Includes retail pharmacy transactions • IEEE 1073 Messaging Standards: Connectivity • DICOM Messaging Standards: Includes Image Information to Workstations

27. May 6, 2004

28. AHRQ ASIRM ASPE CDC CMS Data Council FDA HRSA NCHS NIH NLM OCR OPHS HHS Agencies with NHII Responsibilities

29. I always knew that Data was a four letter word, I just never knew it was spelled T-U-R-F Phil Lee, MD

30. Issues for the Development of the NHII • Government Role • HIPPA Approach • CHI • 800 pound Gorilla • New IT Czar

31. Architecture Issues • Options for structure • Repository based structure • Directory based structure • National Databank • Napster • Systems of Systems • Free floating peer to peer

34. PUBLIC HEALTH AND MEDICAL PRACTICE BOTH USE THE SAME DATA, WE JUST LOOK AT IT DIFFERENTLY - CHRISTINE GEBBIE

35. Recommendations* to the Secretary of HHS and DHHS agencies • Recommendation 1. Appoint a national commission to develop a framework for state public health law reform. • Recommendation 5. Initiate a broad-based national dialogue, led by a national commission convened by the Secretary of HHS, to explore perspectives on workforce credentialing, and to outline next steps based on decisions reached. • Recommendation 7. Facilitate the development and implementation of the National Health Information Infrastructure (NHII). Committee on Assuring the Health of the Public in the 21st Century - 2002

36. Radiology Laboratories Patient HL7 & Registration/ Payers DICOM HL7 & ASTM Admissions Hospital NCPDP & HL7 Pharmacy ASC ASC X12N Billing HL7 X12N & Pharmacy Knowledge NCPDP HL7 HL7 Benefits Mgrs Clinical bases & PMRI PMRI content ASTM NCPDP & ASTM Physiological X12N & HL7 HL7 monitors Community Pharmacies Orders Medical IEEE Bedside & devices computer results Interoperability Status IEEE

37. Issues for Health Care • HIPAA • Cost of Reporting • Time is money • Hassle factor • What’s in it for me? • Reporting as a Quality Measure?

38. Arthur C. Clarke Laws Third Law: "Any sufficiently advanced technology is indistinguishable from magic."

39. First Wave of Public Health System Development • State based Systems • Metabolic Disease • Federal Systems for State Usage • HIV/AIDS Registry 1987 • In the beginning we saw that it was good...

42. Second Wave of Public Health Information System Development • State Developed Systems • Integrated • Cornerstone – 1993- Illinois • WIC • Immunization • Case Management • Well Child • Stand alone • Immunization registries

43. Third Wave of Public Health Information System Development • Federal Centric • State developed prototype • Installed in many states • State Centric • System Development by Consortium of States • Web enabled Immunization Registry • Reuse Model • ASP Model

44. An Enterprise View,Defined Collaboratively,to build organizational capability and data interoperability:A Case Study