Why Is Universal EHR Adoption Taking So Long

1. Why Is Universal EHR Adoption Taking So Long? May 22, 2006

2. Healthcare expected to be 20% of GDP by 2015. The country that spends the next highest percentage of GDP on healthcare is Germany at 10.6%Healthcare expected to be 20% of GDP by 2015. The country that spends the next highest percentage of GDP on healthcare is Germany at 10.6%

3. Macro-economic View:Total U.S. Healthcare Expenditures Two of the most significant components of healthcare are: Ambulatory or care that does not include overnight stays Acute or care that does include overnight stays Two are about the same size with the ambulatory segment growing faster as care is shifted from more expensive inpatient facilities to lower cost outpatient facilitiesTwo of the most significant components of healthcare are: Ambulatory or care that does not include overnight stays Acute or care that does include overnight stays Two are about the same size with the ambulatory segment growing faster as care is shifted from more expensive inpatient facilities to lower cost outpatient facilities

4. Comparing EHRs to ATMs 500,000 ATMs across the United States 24/7 access to checking, savings, and credit accounts All financial institutions linked Information is numerically-based

5. A Revolution 56 Years Long Bank Employees handling checks - 1950

6. The First Banking Computer - 1959 The result of Stanford�s work was ERMA (Electronic Recording Method of Accounting computer processing system). ERMA computerized the manual processing of checks and account management and automatically updated and posted checking accounts. The first real test on existing bank accounts occurred in 1956, and 32 units (manufactured by GE) were installed at Bank of America in 1959 The result of Stanford�s work was ERMA (Electronic Recording Method of Accounting computer processing system). ERMA computerized the manual processing of checks and account management and automatically updated and posted checking accounts. The first real test on existing bank accounts occurred in 1956, and 32 units (manufactured by GE) were installed at Bank of America in 1959

7. Necessity: The Mother of Invention MICR OCR Robotic Document Sorting Stanford Research Institute also invented MICR (magnetic ink character recognition) as part of ERMA, allowing computers to track and account for transactions by reliably and consistently reading numbers at the bottom of checks. That means that the machine simply doesn�t see ink from stamps, ballpoint pens, or any other type of �visual obliteration� � but it can always read the magnetized ink. � Two other important examples developed for banking, but with wide applicability, are OCR (optical character recognition) and robotic document sorting (3,000 checks per minute). Together, these inventions paved the way for ATMs.Stanford Research Institute also invented MICR (magnetic ink character recognition) as part of ERMA, allowing computers to track and account for transactions by reliably and consistently reading numbers at the bottom of checks. That means that the machine simply doesn�t see ink from stamps, ballpoint pens, or any other type of �visual obliteration� � but it can always read the magnetized ink. � Two other important examples developed for banking, but with wide applicability, are OCR (optical character recognition) and robotic document sorting (3,000 checks per minute). Together, these inventions paved the way for ATMs.

8. Fast Forward to 1970s 1973 - First ATM Launches at Chemical Bank in New York City 1977 � Citibank �blankets New York City with ATMs� 1978 � A blizzard stops the City: New Yorkers discover the ease of ATMs In 1973, 2,000 ATMs were in operation in the United States � at an approximate cost of $30,000 each ($93,485 in 2004 dollars). By 1994, there were already more than 100,000 ATMs. Tell my story of the first time I ever heard of/saw someone use an ATMIn 1973, 2,000 ATMs were in operation in the United States � at an approximate cost of $30,000 each ($93,485 in 2004 dollars). By 1994, there were already more than 100,000 ATMs. Tell my story of the first time I ever heard of/saw someone use an ATM

9. And. . .The Years Go By 1994 � 100,000 ATMS; nearly all within a bank�s brick walls 1996 � Cirrus and PLUS lift ban on sur-charges 2006 � 500,000 ATMs in every conceivable location 46% of the 500,000 are operated by entities other than financial institutions. Thanks to the invention of wireless and the use of surcharges, today ATMs can be financially viable on less than 200 transactions per month and have been installed on moving objects like ferry boats and in remote locations of national parks 46% of the 500,000 are operated by entities other than financial institutions. Thanks to the invention of wireless and the use of surcharges, today ATMs can be financially viable on less than 200 transactions per month and have been installed on moving objects like ferry boats and in remote locations of national parks

10. The ATM�s Job Keep record of deposits and withdrawals for each client Make current-balance info available at an instant's notice Watch for overdrafts, stop payments, and held funds Provide, on a strict schedule, periodic statements of the account along with the accumulated checks Handle all necessary arithmetic Handle the paper documents in whatever physical condition they exist after passage through many hands All machine operations must be as exact as banking accounting Be in constant step with hourly, daily, and monthly routines of the banking system

11. How the ATM Does its Job ATM Card Personal ID Number (PIN) Bank Code Country Code Branch Code Location Code Account Code

12. You Think 56 Years is Long? Care delivery is language-specific Though consuming much expense, health facilities are not well-financed No single patient identifier ROI still emerging for Healthcare IT Privacy issues stricter than for banking There is a �tower of Babel� of standards for health information. According to the Nat�l Alliance for HIT, there are more than 1,900 health information standards in use. Each of those standards can be implemented in a healthcare setting in slightly different ways � making the flow of information between groups even more challenging. Today, using the ANSI-accredited standards development process, an IT standard takes two to three years from inception to industry adoption. Rather than too few, healthcare has too many standards; or, at least, it hasn�t yet achieved the right combination of standards. There is a �tower of Babel� of standards for health information. According to the Nat�l Alliance for HIT, there are more than 1,900 health information standards in use. Each of those standards can be implemented in a healthcare setting in slightly different ways � making the flow of information between groups even more challenging. Today, using the ANSI-accredited standards development process, an IT standard takes two to three years from inception to industry adoption. Rather than too few, healthcare has too many standards; or, at least, it hasn�t yet achieved the right combination of standards.

13. Hairball #1: Vocabulary 143 listings in the �Unified� Medical Language System 13 nursing terminologies alone Plus, patients speak a different language than clinicians Acute Lateral Wall Myocardial Infarction vs a Heart Attack The granularity of the clinical description is necessary to provide appropriate care; but, patients don�t need it.Acute Lateral Wall Myocardial Infarction vs a Heart Attack The granularity of the clinical description is necessary to provide appropriate care; but, patients don�t need it.

14. Hairball #2: A Cottage Industry 567,000 practicing physicians in the US ~ 82,000 (14.5%) are solo practitioners 50% of practicing physicians are in practices of four or less That means thousands and thousands of file cabinets with paper records In 1978, Citibank invested $160M ($499M in 2004 dollars) to blanket New York City with ATMs for its customers. That was just for Citibank customers; there was no ATM access for any other bank. No private healthcare entity that delivers care in the United States has $160M (let alone $499M) to invest in IT. In 1978, Citibank invested $160M ($499M in 2004 dollars) to blanket New York City with ATMs for its customers. That was just for Citibank customers; there was no ATM access for any other bank. No private healthcare entity that delivers care in the United States has $160M (let alone $499M) to invest in IT.

15. Hairball #3: Finding the Right Records Congress stopped HHS work on the Unique Patient Identifier Will a �Record Locator Service� work? Would a �Voluntary� Identifier work?

16. Hairball #4: Authentication Banking allows for 6% fraud � healthcare doesn�t have that luxury 5,000 Maria Gonzalez�s in Los Angeles � how does a clinician know s/he found the right records? Authentication has three options: Something a person knows (password) Something a person has (ATM card) Something a person is (fingerprint) ATMs are pretty secure. When you consider the volume of transactions, 6% fraud rate isn�t that bad. That 6% is �affordable� to the banking industry. The cost of eliminating all fraud would be so high that the banking industry would not recoup the expense of creating a fool-proof system. ATMs are pretty secure. When you consider the volume of transactions, 6% fraud rate isn�t that bad. That 6% is �affordable� to the banking industry. The cost of eliminating all fraud would be so high that the banking industry would not recoup the expense of creating a fool-proof system.

17. Hairball #5: The Economics The majority of care is delivered in ambulatory settings Those are small business owners Limited capital available for investing in technology ROI not widely disseminated; little understood

18. Influencers Know There�s a Problem JAMA study found that missing information from 1,614 charts could, 44% of the time, adversely impact patient�s well-being Institute for Safe Medication Practices found that pharmacists make over 150M calls to physicians for clarification of illegible prescriptions/year and e-prescribing can reduce follow-up calls between pharmacists and doctors by over 50% Source: H.R. 2234 �21st Century Health Information Act of 2005�

20. The Patient Safety Reality �Though substantial proportions of the public and practicing physicians report they have had personal experience with medical errors, neither group has a sense of urgency.�

21. How Can IT Impact These Stats? CITL � savings of $77.8B yearly if health information exchange existed in the U.S. CITL � savings of $44B yearly with existence of widespread CPOE RAND � estimates savings 3-5% above CITL study Thru e-prescribing, pharmacists could cut their calls to physicians by 50% Patients would have access to their records and informed input into their care Evidence-based medicine or care guidelines could improve the quality of care

22. Glimmers of Hope Evanston Northwestern Healthcare, Evanston, IL Med administration delays down by 70% Omitted administration of drugs down 20% Mammogram test results take one day, down from as long as three weeks Cardiographics reports in one day, down from as many as 10 days Spent $7.5M on training and $35M capital on hardware, software, and implementation implemented an EMR w/CPOE capability at 3 hospitals, 50 outpatient clinics and medical offices. 6,200 system users. Demonstrating return on investment (ROI) for clinical applications has been difficult because defining the metrics that manifest tangible outcomes is very difficult. The lack of standard metrics for measuring clinical effectiveness will continue to be a huge barrier to being able to effectively measure ROI. Effective metrics must be able to measure and relate data from financial (reduced cost for clinical service or reduced LOS), clinical (achieving outcome goals with fewer nursing or medication interventions), and quality parameters (patient satisfaction or reduced re-admission for failed treatment processes) for all patient care services. Most ROI metrics today are based solely on financial/cost parameters. One of the main challenges here, besides a lack of standard metrics, is the lack of replicable examples. It�s one thing to cite the experience of an Intermountain Health Care implementation of self-developed applications at LDS Hospital, or the phenomenal work done at Partners Healthcare in Boston, but those environments were not, and still aren�t, replicable in 99% of healthcare organizations. What an academic medical center is capable of doing with advanced clinical IT (and residents and other employed physicians) is not replicable in a community hospital where most of the physicians who have admitting privileges are independent business people. There are not yet enough good examples of replicable clinical IT implementations to effectively quantify the answer to �what�s the business value of IT investment in healthcare?�implemented an EMR w/CPOE capability at 3 hospitals, 50 outpatient clinics and medical offices. 6,200 system users. Demonstrating return on investment (ROI) for clinical applications has been difficult because defining the metrics that manifest tangible outcomes is very difficult. The lack of standard metrics for measuring clinical effectiveness will continue to be a huge barrier to being able to effectively measure ROI. Effective metrics must be able to measure and relate data from financial (reduced cost for clinical service or reduced LOS), clinical (achieving outcome goals with fewer nursing or medication interventions), and quality parameters (patient satisfaction or reduced re-admission for failed treatment processes) for all patient care services. Most ROI metrics today are based solely on financial/cost parameters. One of the main challenges here, besides a lack of standard metrics, is the lack of replicable examples. It�s one thing to cite the experience of an Intermountain Health Care implementation of self-developed applications at LDS Hospital, or the phenomenal work done at Partners Healthcare in Boston, but those environments were not, and still aren�t, replicable in 99% of healthcare organizations. What an academic medical center is capable of doing with advanced clinical IT (and residents and other employed physicians) is not replicable in a community hospital where most of the physicians who have admitting privileges are independent business people. There are not yet enough good examples of replicable clinical IT implementations to effectively quantify the answer to �what�s the business value of IT investment in healthcare?�

23. Improved compliance with problem lists from 67% to 97% Improved allergy documentation from 88% to 100% 95% pain assessment documentation Improved medication list documentation from 67% to 100% Glimmers of Hope Maimonides has one hospital, 32 ambulatory clinics and numerous physician offices. One school of medicine and one medical center affiliate. Plus, a site in Italy. In 2002, it had 268k outpatient visits, and 88k ER visits. The system has 983 community-based physicians. Maimonides is located in Brooklyn New York in the heart of the Hasidic (sp??) Jewish Community.Due to religious beliefs, this group of orthodox Jewish people has a very high birth rate. The AVERAGE woman has more than 8 children. Because of mutliparity (medical term for multiple children) almost all of the women are high risk for complications. Meanwhile OB-GYN docs are notorious for minimal clinical notes. As a labor is progressing the usual documentation was "within normal limits" and then something bad happens. As Maimonides described it to me�..they knew they had to do something. Their "risk" from complicated OB-GYN put the entire hospital on shaky financial footing. They found their OB-GYN software package in Israel. Mamonides (OB-GYN staff) then wrote more than 13,000 rules to govern OB practice and labor and delivery. A "rule" guides the "thinking" of the software. Rules could be; 1. At 12 weeks gestation, evaluate blood glucose. This rule could either then pop up on the computer as a reminder each time a provider sees a 12 week pregnant mother (or 13 or 14 weeks) until such time as it is ordered. That would be 1 rule. 2. A rule could also be that each time a pregnant woman is seen in clinic, a dipstick UA should be done. This potentially could be 15 or so rules depending on how many times a high risk mother is seen in clinic prior to delivery. 3. Rules then progress to include diet, education, medication for a variety of conditions etc. 4. Rules also covered the labor-delivery. The software evaluated every vital sign, lab value etc that was entered into the EHR during the labor.When certain parameters were met, the software could remind the [physician that with a blood pressure of 140/90 and a maternal heart rate of 105, coupled with a fetal heart rate of 162 it was time to do�x, and then xx, and then xxx. For every possible variable in the combination a rule was needed.Maimonides has one hospital, 32 ambulatory clinics and numerous physician offices. One school of medicine and one medical center affiliate. Plus, a site in Italy. In 2002, it had 268k outpatient visits, and 88k ER visits. The system has 983 community-based physicians. Maimonides is located in Brooklyn New York in the heart of the Hasidic (sp??) Jewish Community.Due to religious beliefs, this group of orthodox Jewish people has a very high birth rate. The AVERAGE woman has more than 8 children. Because of mutliparity (medical term for multiple children) almost all of the women are high risk for complications. Meanwhile OB-GYN docs are notorious for minimal clinical notes. As a labor is progressing the usual documentation was "within normal limits" and then something bad happens. As Maimonides described it to me�..they knew they had to do something. Their "risk" from complicated OB-GYN put the entire hospital on shaky financial footing. They found their OB-GYN software package in Israel. Mamonides (OB-GYN staff) then wrote more than 13,000 rules to govern OB practice and labor and delivery. A "rule" guides the "thinking" of the software. Rules could be; 1. At 12 weeks gestation, evaluate blood glucose. This rule could either then pop up on the computer as a reminder each time a provider sees a 12 week pregnant mother (or 13 or 14 weeks) until such time as it is ordered. That would be 1 rule. 2. A rule could also be that each time a pregnant woman is seen in clinic, a dipstick UA should be done. This potentially could be 15 or so rules depending on how many times a high risk mother is seen in clinic prior to delivery. 3. Rules then progress to include diet, education, medication for a variety of conditions etc. 4. Rules also covered the labor-delivery. The software evaluated every vital sign, lab value etc that was entered into the EHR during the labor.When certain parameters were met, the software could remind the [physician that with a blood pressure of 140/90 and a maternal heart rate of 105, coupled with a fetal heart rate of 162 it was time to do�x, and then xx, and then xxx. For every possible variable in the combination a rule was needed.

24. Between 2001 and mid-2004 (the latest date for which I have data) there has not been a successful OB/GYN malpractice claim at Maimonides. My assumption is Maimonides is practicing safer and with excellent quality, demonstrated by no successful lawsuits. There could still of course be complications from multiparity and unhealthy babies being born, but the medical staff of Maimonides has taken tremendous steps to eliminate medical error in their practice. Between 2001 and mid-2004 (the latest date for which I have data) there has not been a successful OB/GYN malpractice claim at Maimonides. My assumption is Maimonides is practicing safer and with excellent quality, demonstrated by no successful lawsuits. There could still of course be complications from multiparity and unhealthy babies being born, but the medical staff of Maimonides has taken tremendous steps to eliminate medical error in their practice.

25. Safety and Quality Opportunities Healthy States Pre & Perinatal Acutely Ill Chronic Conditions Stable Disability Near Death End Organ Failure Frail Demise Specific HIT/Quality Opportunities: .Healthy - e-reminders, e-scheduling, e-visits, access to individualized information Pre and Perinatal � home monitoring, interoperable systems for transfer of care between hospitals Acutely Ill � system wide (hospital, ambulatory, post acute) decision supported certified EHR systems Chronic conditions � PHRs, shared careplans, home monitoring, e-visits 5. Stable disability � PHRs linked to EHRs, interoperability across multiple settings, focus on home based services 6. Near death � access to documented life closure information, immediate communications. .End Organ failure � home monitoring, shared decision support, careplans, advanced planning Frail Demise � home based monitoring, virtual careplans, life closure plans and documentationSpecific HIT/Quality Opportunities: .Healthy - e-reminders, e-scheduling, e-visits, access to individualized information Pre and Perinatal � home monitoring, interoperable systems for transfer of care between hospitals Acutely Ill � system wide (hospital, ambulatory, post acute) decision supported certified EHR systems Chronic conditions � PHRs, shared careplans, home monitoring, e-visits 5. Stable disability � PHRs linked to EHRs, interoperability across multiple settings, focus on home based services 6. Near death � access to documented life closure information, immediate communications. .End Organ failure � home monitoring, shared decision support, careplans, advanced planning Frail Demise � home based monitoring, virtual careplans, life closure plans and documentation

26. The CCR & Patient Safety � What�s In It? * Core data set of the most relevant and timely facts about a patient�s healthcare * Organized and transportable * Prepared by a practitioner at the conclusion of a healthcare encounter * To enable the next practitioner to readily access such information * May be prepared, displayed, and transmitted on paper or electronically The CCR & Patient Safety � What�s In It? * Core data set of the most relevant and timely facts about a patient�s healthcare * Organized and transportable * Prepared by a practitioner at the conclusion of a healthcare encounter * To enable the next practitioner to readily access such information * May be prepared, displayed, and transmitted on paper or electronically

27. Problem & Solution = Complexity �You�re writing a contract for a product that�s impossible to describe, that will change over time, will need to be renegotiated, that will make you dependent upon the provider and for which termination is not an option.� Paul Roy, Partner Mayer, Brown, Rowe, & Maw LLP Don�t assume the vendor understands healthcare and your workflow. Conversely, Don�t assume you DON�T understand healthcare and your workflowDon�t assume the vendor understands healthcare and your workflow. Conversely, Don�t assume you DON�T understand healthcare and your workflow

28. U.S. Healthcare IT Investment However, investment in technology is very different In the ambulatory sector, technology investment is equal to less than 1% of gross revenues while in the acute care sector the level of technology investment is about 5% of revenues�overall healthcare is spending about 2.5% of revenues on IT compared to nearly 4% across all industries. However, investment in technology is very different In the ambulatory sector, technology investment is equal to less than 1% of gross revenues while in the acute care sector the level of technology investment is about 5% of revenues�overall healthcare is spending about 2.5% of revenues on IT compared to nearly 4% across all industries.

29. State of EMR Adoption As a result, you have a situation where virtually all small physician offices using paper health records (a very inefficient form of record keeping). Even in hospitals, about half still use paper records and very few operating in a fully automated environmentAs a result, you have a situation where virtually all small physician offices using paper health records (a very inefficient form of record keeping). Even in hospitals, about half still use paper records and very few operating in a fully automated environment

30. President Bush�s Goal �Medicine ought to be using modern technologies in order to better share information, in order to reduce medical errors, in order to reduce cost to our health care system by billions of dollars...Within ten years, every American must have a personal electronic medical record. The federal government has got to take the lead in order to make this happen by developing what's called technical standards.� April 26, 2004

31. Goal Reaffirmed in 2005 �. . .most Americans to have electronic health records within ten years. The President�s vision would create a personal health record that patients, doctors and other health care providers could securely access through the Internet no matter where a patient is seeking medical care.� June 6, 2005 HHS Press Release

32. And, again in 2006 �We will make wider use of electronic records and other health information technology, to help control costs and reduce dangerous medical errors.� Source: President Bush�s State of the Union Address, January 31, 2006

33. HHS Secretary Mike Leavitt: �When I wake up each morning, I think three things: HIT, HIT, HIT.� President George W. Bush Executive Order 13,355 HIT mentioned in State of the Union � Three Years Running Funded $50M via reprogramming for FY05; $67.1M for FY06; and requesting $116M for FY07 Federal Landscape: David Brailer, PhD, MD named Nat�l Coordinator for Health IT Secretary of Health and Human Services -- Big HIT Proponent Agencies Meeting Executive Order Requirements President George W. Bush Executive Order 13,355 HIT mentioned in State of the Union � Three Years Running Funded $50M via reprogramming for FY05; $67.1M for FY06; and requesting $116M for FY07 Federal Landscape: David Brailer, PhD, MD named Nat�l Coordinator for Health IT Secretary of Health and Human Services -- Big HIT Proponent Agencies Meeting Executive Order Requirements

34. What�s Driving Legislation & Administration Activity? Quality Safety Costs Bio-preparedness Change Unmeasured costs to Excess Costs � can we find another quote? Remember Hillary Clinton � excess Costs HIPAA was also a response to these excess costs � part of the simplification � take costs out Because using computers provide for privacy and security � This was a necessary preamble. Change Unmeasured costs to Excess Costs � can we find another quote? Remember Hillary Clinton � excess Costs HIPAA was also a response to these excess costs � part of the simplification � take costs out Because using computers provide for privacy and security � This was a necessary preamble.

35. HHS Health IT Strategy HHS is focused on the consumer & the clinician. About 90% of activities going into the delivery of care center around information and information exchange. The consumer is the central object within this Information System. Therefore, clinically-derived �Consumer-Centric, Information-Rich� EHRs will become the common nexus of information for all players in the 21st century health system. In the past two years, the Department of Health & Human Services has: 1. Created Office for Nat�l Coordinator of HIT 2. Established four sequential goals: Inform Clinicians, Interconnect Clinicians, Personalize Care, & Improve Population Health 3. Awarded four contracts to achieve goals 4. Requested Funding - $125M in FY06 and $156M for FY07 5. Launched American Health Info Community HHS is focused on the consumer & the clinician. About 90% of activities going into the delivery of care center around information and information exchange. The consumer is the central object within this Information System. Therefore, clinically-derived �Consumer-Centric, Information-Rich� EHRs will become the common nexus of information for all players in the 21st century health system. In the past two years, the Department of Health & Human Services has: 1. Created Office for Nat�l Coordinator of HIT 2. Established four sequential goals: Inform Clinicians, Interconnect Clinicians, Personalize Care, & Improve Population Health 3. Awarded four contracts to achieve goals 4. Requested Funding - $125M in FY06 and $156M for FY07 5. Launched American Health Info Community

36. Proposed Rule Changes Proposed Changes to Physician Self Referral and Anti Kickback Act Regulations: CMS Changes to Physician Self Referral (Stark) OIG Changes to Anti Kickback Act Safe Harbors Many common provisions; seeking industry on donation caps, fraud avoidance measures, and best practices for ensuring interoperability. CMS Changes to Physician Self Referral (Stark) Proposed Stark Exception for E-Prescribing (MMA Requirement) Proposed Stark Exception for �Pre� and �Post� Interoperable EHRs (Administrative Action) OIG Changes to Anti Kickback Act Safe Harbors Proposed safe harbor for E-Prescribing (MMA Requirement) Proposed safe harbor for �Pre� and �Post� Interoperable EHRs (Administrative Action) Many common provisions; seeking industry on donation caps, fraud avoidance measures, and best practices for ensuring interoperability. Responses were due December 12, 2005 CMS Changes to Physician Self Referral (Stark) Proposed Stark Exception for E-Prescribing (MMA Requirement) Proposed Stark Exception for �Pre� and �Post� Interoperable EHRs (Administrative Action) OIG Changes to Anti Kickback Act Safe Harbors Proposed safe harbor for E-Prescribing (MMA Requirement) Proposed safe harbor for �Pre� and �Post� Interoperable EHRs (Administrative Action) Many common provisions; seeking industry on donation caps, fraud avoidance measures, and best practices for ensuring interoperability. Responses were due December 12, 2005

37. The Congressional Policy Process starts the same as most IT projects but often seems a little different when viewed from outside the hallowed halls of Washington DC. We start with describing a vision � for example wouldn�t it be nice if physicians and nurses could see clinical data from a visit to an earlier provider. Next Congress starts to show its skill and expertise. Committees get busy with hearings and markups to craft the legislation necessary to drive the vision. Sometimes this stage goes on for a long time. Successful legislation emerges to move from Committee to the full House or Senate where additional Members can make thoughtful amendments. Finally, we get to see the final product. A bill that sometimes doesn�t exactly track the vision or requirements but is a step forward. The Congressional Policy Process starts the same as most IT projects but often seems a little different when viewed from outside the hallowed halls of Washington DC. We start with describing a vision � for example wouldn�t it be nice if physicians and nurses could see clinical data from a visit to an earlier provider. Next Congress starts to show its skill and expertise. Committees get busy with hearings and markups to craft the legislation necessary to drive the vision. Sometimes this stage goes on for a long time. Successful legislation emerges to move from Committee to the full House or Senate where additional Members can make thoughtful amendments. Finally, we get to see the final product. A bill that sometimes doesn�t exactly track the vision or requirements but is a step forward.

38. Health-related Bills Incorporating HIT Introduced and/or Signed into Law between 1776 - 1996

39. Health-related Bills Incorporating HIT Signed into Law between 1997 - 2005 Two: Medicare Modernization Act & Patient Safety Act

40. Current Federal Legislation - HOUSE National Health Information Incentive Act of 2005 (H.R. 747) Murphy/Kennedy: 21st Century Health Information Act of 2005 (H.R. 2234) Preserving Patient Access to Physicians Act of 2005 (H.R. 2356) Medicare Value-Based Purchasing for Physicians' Act of 2005 (H.R. 3617) Murphy: Medicaid Transaction Grant Act of 2005 (H.R. 4142) Johnson: Health Information Technology Promotion Act of 2005 (H.R. 4157) Gingrey: Assisting Doctors to Obtain Proficient and Transmissible Health Information Technology (ADOPT HIT) Act (H.R. 4641) Wired for Health Care Quality Act (H.R. 4642) Porter: Federal Family HIT Act (H.R. 4859) HIMSS Endorsed House � Jon Porter (R-NV) Senate � Tom Carper (D-DE) Use Federal Employee Health Benefits Program (FEHBP) as a model to create EHRs or PHRs for 9 million beneficiaries House � Jon Porter (R-NV) Senate � Tom Carper (D-DE) Use Federal Employee Health Benefits Program (FEHBP) as a model to create EHRs or PHRs for 9 million beneficiaries

41. Affordable Health Care Act (S.16) Jeffords: Patient Safety and Quality Improvement Act of 2005 (S. 544) - PASSED Preserving Patient Access to Physicians Act of 2005 (S. 1081) Information Technology for Health Care Quality Act (S. 1223) Stabenow/Snowe: The Health IT Act (S. 1227) Health Technology to Enhance Quality Act of 2005 (S. 1262) Medicare Value Purchasing Act of 2005 (S. 1356) Enzi/Kennedy/Frist/Clinton: Wired for Healthcare Quality Act (S. 1418) Healthy America Act of 2005 (S. 1503) National Medical Error Disclosure and Compensation (MEDiC) Act of 2005 (S. 1784) Critical Access to Health Information Technology Act of 2005 (S. 1952) Current Federal Legislation - SENATE

42. Changes in Federal Regulations Significant State level activities Privacy issues could derail it all 2006 National Health IT Week in Washington, D.C. What�s on the Horizon? Federal Regulations focused on e-Prescribing and Personal Health Record Initiatives To learn more about privacy issues, read California Health Foundation�s Nov 2005 Privacy Study (www.chcf.org) To learn more about Nat�l Health IT Week (June 4-9, 2006), visit www.healthitweek.orgFederal Regulations focused on e-Prescribing and Personal Health Record Initiatives To learn more about privacy issues, read California Health Foundation�s Nov 2005 Privacy Study (www.chcf.org) To learn more about Nat�l Health IT Week (June 4-9, 2006), visit www.healthitweek.org

43. How can you learn more? www.himss.org Legislative Action Center State Legislative Tracker Davies Award program Integrating the Healthcare Enterprise

44. Thank You!