Information Technology In Health Care A Tool For

Information Technology In Health Care A Tool For Effective Change Deryk Van Brunt, Dr. PH Associate Professor, School of Public Health, UC Berkeley Chairman, Healthy Communities Foundation Senior Vice President, i. Metrikus 10 -26 -05

Outline ► ► ► ► Types Of Information Technology (IT) Status IT – Health Care Professionals and Institutions Status IT – Patients And Consumers Lessons Learned (Learning) Current Research – Remote Monitoring Current Research – Community Health Conclusion

Health Informatics ► Administrative Industry: The use of emerging information ► Clinical systems and ► Telemedicine communication systems (Internet) to improve or ► Educational enable health and health ► Personal (or Patient) IT is an care. enabler, but ► Community ► Population it’s also destabilizing; it is a catalyst for change

Driving Forces In Healthcare IT Adoption ► Institute of Medicine Report (44, 000 to 98, 000 preventable deaths per year in US – 8 th leading cause of death, more than car accidents, breast cancer, or AIDS) ► Bush call for EHRs for all Americans ► Appointment of HHS IT Co-ordinator: RHIOs ► Costs continue to rise ► Employers (including Government) applying pressure for quality measures and reducing costs ► Consumers applying pressure “It’s like crashing two 747 s a day. There should be more Mark Blatt, Intel outrage. ” Source: Institute of Medicine, “To Err is Human: Building a Safer Health System, ” 1999

The Tipping Point? ► Quality § Employers aware of vast chasm in healthcare quality (e. g. , 2003 RAND study, examined 20, 000, 12 communities, nearly ½ of patients care not follow best care practices; e. g. diabetes nearly 2/3’s inappropriate care ► Cost § Aging population, chronic care roughly ½ of all HC costs and increasing in numbers (Diabetes 18. 2 million); the key problem: systematic interventions not practiced § Employers cannot sustain increased expenditures: GM announcement $1600 cost of benefits for workers and retirees ► Demanding Consumers § Require information for decision support § Used to tracking Fed. Ex packages online, trading shares, file taxes, many things except their health § US healthcare has under-invested in IT: 2% Little loyalty to Plans

Physicians, Medical Institutions And The Internet Physicians § Approximately 95% of physicians are online (524, 000 users). § They regularly use the internet (avg. 5. 4 hours/week). § They use the internet to research literature databases, (81%) search for info about drugs (66%) and take CME (45%). § 19% report having used email with patients; 39% say they will within 18 months. Institutions § Hospitals, Medical Schools, Government and Military § 6, 000+ US Hospitals – only 5% to 10%use online clinical management systems Source: HIMSS Analytics 2004 Source: HIMSS Analytics SM SM

What Is Being Implemented in Healthcare Institutions? Technology Adoption in US Healthcare … Computerized physician order entry (20%) ► Bar coding (10 -15%) ► Picture Archiving Communication Systems (40%) ► Mobile/Wireless Computing Devices …has a long way to go! (60%) ►

Digital Hospital Technology Element Possibilities

Evidence Of Benefits Hospital Description IT Initiative Benefit Realized 350 -bed, private, notfor-profit community hospital Decision Support system ►Prevented 1, 241 wrong drugs or dosages, amounting to a $732, 909 value in prevented errors ► 50% decrease in phone calls to the pharmacy per day 437 -bed, private, notfor-profit integrated healthcare system Electronic Medical Record system ► 372, 000 Private, not-for-profit integrated healthcare delivery system serving an urban population of 440, 000 members Electronic Medical Record system ► 76% 1, 951 -bed, private, notfor-profit teaching hospital serving urban, rural, and international populations Clinical Information system ►$2, 906, 000 fewer laboratory and radiology reports printed and filed annually ►About $1, 000 in savings per year per physician due to improved formulary compliance ► 50% or greater decrease in transcription costs in some medical departments decrease in phone calls to obtain lab results during fouryear period ► 2, 000 fewer daily chart pulls overall, eliminating 16 FTEs and saving and avoiding about $5. 7 million on medical record unit FTE costs ► 7. 5% decrease in laboratory test ordering—attributable to reliable and efficient access to test results—reducing redundant tests annual savings resulting from reduction in staff needed to route paper medical records, from clinical notes technology, and from automation of correspondence ►$7, 000 annual savings resulting from a reduction in unbillable tests and the ability to bill patients directly 927 -bed, academic Automated billing, ►$1, 167, 317 saved in transcription costs in one year medical Source: Information Technology: Benefits for Selected Health Care Functions, U. S. General Accounting Office, October 2003 center serving admissions, ► 28 FTEs eliminated as a result of automatic scanning, problem an urban population discharges, lists, and EMR, saving $704, 000

Lessons Learned – IT Factors ► IT foundation: EMRs, PBHRs, PHRs ► IT is implemented in departments and islands, not large scale and ubiquitous ► The real challenge is interoperability (doctors, hospitals, laboratories, pharmacies, insurers, patients, public health) ► The unintended consequences - e. g. , CPOE also causes problems (22 types medication error risks identified) (JAMA CPOE University of Pennsylvania, March 9, 2005— Vol 293, No. 10) ► Lack of alignment of financial interests ► Leadership required – vision, clear goals, finances, usability

Personal Health Informatics The Lighter Side “Well, says it’s just a virus, but I came to you for a second opinion. . . ” www. whatswrongwithme. com

Problems For Consumers ► Access to good quality information and decision support is limited § Too much information without relevant filters ► Consumers are afraid to ask questions § Confidentiality is key ► Costs of health care continue to rise ► Behavior change is difficult ► Want access to their PHR, and to communicate with doctors and their care team ► Healthcare providers slow to adopt web technology

Determinants Of Health ► Medical Care 10% Genetics 20% Environment 20% ► Lifestyle ► ► 50% 1. U. S. Department of Health and Human Services. Healthy People 2010. 2 nd ed. With Understanding and Improving Health and Objectives for Improving Health. Washington, DC: U. S. Government Printing Office, November 2000; Vol. 1; pg 18. ; 2. Actual Causes of Death in the United States, Mc. Ginnis JM, Foege WH. US Department of Health and Human Services, Washington, DC 20201. JAMA. 1993 Nov 10; 270(18): 2207 -12.

Three Market Forces Converge Consumer New Science The New Healthcare Consumer Internet Source: Focus Groups, Feb. 1998 Arthur Andersen Study; Institute For The Future; Pew Internet And American Life, Dec, 2003

The Promise Of The Internet § § § § 203 million Americans online 68% American adults online 96% of American children have been online 93% have searched for health information 80% search for family and friends 58% search for specific medical condition 92% said searches were useful 68% said information impacts decisions 50% said web led them to get 2 nd phys opinion 28% web affected decision to visit a physician 90% want to communicate with their doctor online 50% would influence choice of Health Plan 83% said it is important that they can get more information online than from other sources Sources: ING Baring Furman Selz LLC Report, Pew Internet and American Life Project, Feb. 2001 and May 2004, CIA Worldfacts 2004

Personal Health IT Evolution Content & e. Commerce Personalized Referral Source: Cyber Dialogue, Industry Brief, Year 2001, Number 1 E-Care & Community

Most Accessed Topics ► 93% have looked for a particular condition or illness (heart disease, cancer, diabetes, arthritis, depression) ► 65% nutrition, exercise, weight control ► 64% prescription drug information ► 55% gathered information before seeing a physician ► 48% alternative health or experimental treatments ► 39% mental health issues Source: Pew Internet And American Life Project, May 2002, 2003

e. Health Applications for Consumers § § § Information searching Communication (peer and professional) Decision support Behavior change Risk assessment Disease management/self-care Distance education Recordkeeping (PHR) e. Commerce Transactions and services Consultations

Evidence of Personal Health Benefits ►CHESS - 5 of 8 QOL improvements; length of medical visits decreased (David Gustafson, University of Wisconsin, 2001, 2004 Randomized trial) ►Relay Health - $3. 69 savings per patient-month, patients report 50% less likely to miss work (Liederman E, et al. A New Tool for Patient-Physician Communication. J Am Med Inform Assoc. 2003; 10: 260 -270) ►Idaho Communities Project -18% reduction in ER visits (Healthwise Idaho Study; 2002) ►Mass Respiratory Hospital – 84 ER visits reduced to 1 ER visit Grace Baldwin Doherty M. D et al, The Effectiveness of an Interactive Electronic Lung Function Monitoring System in the Total Management of Refractory Asthma, Disease Management Health Outcomes, 1998

Relay Health: web. Visit. SM Interview Select from 120+ Common Symptoms, 18 Chronic Conditions

web. Visit. SM Interview MD-Authored/Reviewed Interviews – Dynamic Branching

Immediate Message Delivery to Inbox Flexible Notification – email or FAX – Immediate or Periodic

View Patient web. Visit. SM Interview Summary Health Record – Concise Message Format

Reply to Patient web. Visit Interview SM Customizable Templates, Save Time Typing, Reimbursement Key

Attach an e. Script® Powerful Prescribing “Wizard” – Interaction and Formulary Check

Lessons Learned – Challenges Tremendous Demand for Information ► Quality of Information ► Privacy and Confidentiality ► Sustainability ► Standards and Limited Benefit w/o integration with healthcare delivery

Transformative Technology Examples – Chronic Care and Remote Monitoring “If we could fully monitor patients in a way that is safe, a lot of reasons people get admitted to hospitals wouldn’t happen. We would just monitor them at home and have them come back if something happens. ” Dr. David Brailer, National Coordinator for Health Information Technology in US HHS Healthcare takes place outside of hospitals considerably more than inside them …

Member Dashboard PHR

Member Dashboard Information Flow Claims Data File Rx Encounters Lab Results Claims Abstract Sent via Web Service PHR Electronic Data Uploads Metrik. Link – 30+ devices Air. Watch Via PHR Platform, patients receive: Self-Care Tools Alerts, Reminders and Secure Messaging Member-Direct Guides Uploaded Biometric Data CDHP Cash Account Manager

Problem: Chronic Care & Biometrics. Cardiac Management Diabetes Management Blood Glucose Monitors: Insulin Pumps: • Accu-Chek ™ Active D-TRON Plus • Accu-Chek™ Advantage • Accu-Chek ™ Compact • Accu-Chek ™ Complete • Ascensia® Breeze™ • Ascensia® Contour™ • Ascensia Elite XL® • Bayer Glucometer ® DEX 2 • Bayer Glucometer ® Elite XL • BD Logic ™ • BD Paradigm Link ™ • In Duo ™ • One Touch® Basic • One Touch ® II Respiratory Management • One Touch ® Profile Digital Spirometry: • One Touch ® Ultra Air. Watch • One Touch ® Ultra. Smart • One Touch ® Sure Step • Precision Q-I-D ® • Precision XTRA™ • Prestige Smart System™ • True. Track Smart System ™ • Thera. Sense Free. Style ® Blood Pressure Cuffs: A&D Life. Source UA-767 PC (Arm) OMRON HEM-637 (Wrist) OMRON HEM-757 (Arm) Digital Scales: A&D Life. Source UC-321 H* Lipid Testing: Cardio. Chek PA* (cholesterol, triglycerides, glucose, & ketones)

Challenge – Biometric Data Silos Multi Devices to Single DB Multiple Devices to Multi DBs • ` Connectivity Functionality Relationship Transparency Disease Registry (Practice, National, etc. ) Knowledge Silos Aggregate Knowledge

Integrating Biometrics - Components Device Adapters Physical Adapter Transmission Handler Protocol Interpreter Data Feeds Diabetes Asthma EMR COPD HTN PHR Fitness Obesity HIV Other Apps

Patient and Professional Level Reports

Transformative Technology Example – Community Health Moving Upstream

The Need For Transparency Problem ► Most information about a community lives in organizational silos; is reported to a limited audience; is often only on paper. ► No single system shows status of all variables related to quality of life in a community, nor how to use that information to effect change. G o vern men t E n vi ro n men t Public S a fe ty E co n o my T ran s- p o r ta ti o n E d u c a ti o n H e a l th

The Need For Transparency Solution One portal which provides all stakeholders in a community with a “dashboard” view of the quality of life in their community, an understanding of the activities and programs that have worked in other communities (in such areas as childhood obesity, smoking cessation, water quality, traffic congestion, education, etc), and the ability to make informed decisions and positive change based on consistently good quality data – all to improve the determinants of health. User Healthy Communities Network G o vern men E n vi ro n men t Environment Public S a fe ty E co n o m Econom y y T ran s p o r ta ti o n E d u c a ti o n H e a l th Health

Design of Personal and Community Health Information Networks Based On Change Theories Theory Health Belief Model Change Process Perceptions of: susceptibility, severity, benefits, and barriers to health actions • • Social Learning Theory • Expectancies Incentives Self-efficacy Implied Feature • • Theory of Reasoned Action • • Seeing need for change Know which behaviors are safe & which are not Learn skills to change Develop support for implementing change • • Implementation Awareness and evaluation of risks leads to action • Evaluating beliefs about how events are connected Consequences Ability to change Reinforcement • Role of intention and perceived normative expectation in behavior “Choice” heavily influenced by social norms • • Technologies Examples Assess community health Communicate with peers & leaders about choices Assessment of individual beliefs Indicators, promising practices, email, realtime chat groups, and subject searching Indicators, HRAs, Therapeutic Learning Program (TLP) Communication with peers & leaders in an appropriate framework Assessment of perceived capability to sustain change Contextual counseling Email, realtime chat groups, and subject searching Indicators, PP’s, HRAs, TLP, social support groups Communication with peers & leaders in an appropriate framework Assessment of perceived capability to sustain change Role-playing and simulation Email, realtime chat groups, subject searching, and simulation games HRAs, TLP, social support groups, “Brothers” video (modeling behavior shows)

Design of Personal and Community Health Information Networks Based On Change Theories Theory Change Process • Evolving values of consensus Consensualist • Social Conflict Ideological differences between social units around materialism • Ideological differences between social units around materialism Friere • Diffusion Knowledge, persuasion, decision, implementation, confirmation Implied Feature Implementation Taking person initiative for societal change Deconstructing and reconstructing explicit norms • Making information publicly available (re: economic powers and population needs) • Group health education Social activism • Societal adoption and popularization of innovations • • • Technologies Examples Organization & mobilization of grass roots groups Discussion and debate Email broadcast, newsgroups, lotus notes Needed: large. Needed: scale decision making groupware Political action based on values Expanded access to electronic democratic forums, electronic “town halls” Freedom of Information Act Email broadcast, newsgroups, lotus notes Needed: large. Needed: scale decision making groupware Political action based on materialism (via Internet) Electronic: disclosure & role-playing groups Organization & mobilization of grass roots groups Needed: software framework and method of engaging users Political action for community (via Internet) Compatibility of CHINs Engage critical mass of users Networked technologies and standardization Internet

Change Meta-Model Deryk Van Brunt, March 1997 Personal and Community Health: • Reference information • Profiles/risk assessment • Structured forms of communication • Decision support • Operationalizing decisions • Records

Grant - Design Community Health System ► Useful § § to community stakeholders Policy makers and program managers Providers of services General public Researchers ►Catalyze § § § A “dashboard” of quality of life indicators Database of best and promising practices Facilitate communication, collaboration and change ► Key § § community decision-making proc Attributes Maintain in one place, provide low cost template to thousands of communities Provide local view for each community; local governance

“Putting A Face” On The Quality Of Life Of Communities Stakeholder and Community public view QOL Record Indicators Tracking Decision Support Access to Codified Data e. g. , Immunization Registry Behind the Education scenes Government Transportation Natural Environment Economy Public Health Records and Public Safety Electronic Social Environment Medical Records Arts, Culture,

Community Health

Conclusion ► Tipping Point? Tremendous use and activity of clinical and personal health IT ► Benefits: Evidence is building ► Institutional Challenges: Interoperable widespread systems, resulting workflow changes, economic alignment of interests ► Personal Health Challenges: Quality, privacy, connectivity & standards ► Key to Success: Strong leadership to guide change ► Future trends: Seamless e-care, bio sensors and genomics, community health information systems

Discussion

Department Applications Summary of Installation

Physicians Online Source: HIMSS Analytics. SM 2004 Source: HIMSS Analytics SM

Physicians Reported Online Needs Source: HIMSS Analytics. SM 2004 Source: HIMSS Analytics SM

CPOE Adoption

Bar Coding – Planned Use Up Significantly

Wireless Has Legs in Healthcare

PACS Installation Summary

Lessons Learned - Leadership IT is a catalyst for change … But it does not manage the needed transformation it causes. ► Clear vision for IT project ► Senior management attention needed to ensure collaboration ► Board buy in - for cost overruns ► Medical staff support to avoid user refusal (e. g. create new positions or financial incentives) ► Management leadership to fill the gap from top to users (support development of new skills and training) ► Vendor products not as robust as they think they are (islands) – maintain good hospital and vendor relationships ► Work processes need to change

Consumer Trends § § § Analytical skills - some college Disposable income - ability to choose Information technology - internet literacy

Consumer Trends ► Customers are taking charge ► Choice redefined--from choice of physician to choice of treatment ► Information--the central tool of empowerment ► Treat me with respect (partner) Source: Focus Groups, Feb. 1998 Arthur Andersen Study; Pew Internet And American Life, May, 2002

The “New Science” Evidence-Based Medicine ► Randomized clinical trials ► 120, 000 articles (half in the past 6 years) ► “Avalanche of rigorous data”

Forces Changing The Industry The Internet Personalized, Convenient and Low Cost

Media/Interfaces for Electronic Communication Applications § § § § Direct Mail (generic and tailored) Print (generic and tailored) Phone (wired and wireless) (live person, IVR, Internet-enabled) Radio TV (broadcast and interactive) Fax Video tape CD-ROM/DVD PDAs Web site (PC) Kiosks Beepers Video game consoles Standalone portable devices (watches, gadgets) Internet-enabled appliances

Challenge: Quality of Information Quality Of Health Information Online ► Coverage Of Information § 67% breast cancer, 43% childhood asthma § 53% depression, 40% obesity ► Accuracy Of Information § 91% breast cancer, 84% childhood asthma § 75% depression, 86% obesity ► Generalizations § Search engines 20% likely to lead to quality site § Information is incomplete, but fairly accurate § Spanish sites less accurate, less up-to-date Source: California Health. Care Foundation, RAND Study, May 2001

Challenge: Quality of Information e. Health Quality Initiatives § § § § American Medical Association (AMA): Guidelines for Medical and Health Information Sites on the Internet: Principles Governing Web Sites British Healthcare Internet Association (BHIA): Quality Standards for Medical Publishing on the Web DISCERN EC (European Community) Quality Criteria for Health-related Websites e. Health Code of Ethics Health Internet Ethics (Hi-Ethics) Health on the Net Foundation Code (HON Code) Information on the Net (Med. CERTAIN) International Federation of Pharmaceutical Manufacturers Associations (IFPMA) Code of Marketing Med. PICS Certification and Rating of Trustworthy and Assessed Health TNO Organizing Medical Networked Information (OMNI) Quality Medical Information and Communication (QMIC) The Health Summit Working Group-Criteria for Assessing the Quality of Health Information on the Internet: IQ Tool (HSWG IQ Tool) URAC Health Web Site Accreditation Program Source: Risk A, Dzenowagis J. Review of Internet Health Information Quality Initiatives. Journal of Medical Internet Research 2001; 3(4): e 28. http: //www. jmir. org/2001/4/e 28/

Quality Initiatives Don’t Apply to Many Tools: Medicine. Online Challenge: Quality of Information Source: http: //www. medicineonline. com

Challenge: Quality of Information Stakeholders § § § § Government agencies Academia Pharmaceutical and device manufacturers Health insurance and delivery Providers Employers Start-ups: personal health, genomics, communications Population health companies

Challenge: Quality of Information Driving Economics U. S. Online Advertising ► Direct to Consumer (DTC) advertising grew from $1 B in ‘ 97 to over $3 B in ’ 03 ► Pharmaceutical & biotech companies continue to add to the number of therapeutic compounds ► High untreated populations in many disease markets ► Low compliance rates Source: ING Baring Furman Selz LLC Report, Oct. ‘ 98 Pharmaceutical Executive, Feb. ’ 01; IMS Health 9/2003

Challenge: Quality of Information Driving Economics Why DTC Is Attractive To Pharmaceutical Companies § 27% of consumers that see a DTC ad request the advertised drug § 73% of physicians prescribe medication requested by patient § 80% operating margins for prescriptions attributed to DTC ads Source: ING Baring Furman Selz LLC Report, Oct. ‘ 98

Challenge: Privacy and Security Health Data Sources Providers • Outpatient • Inpatient Clinical Labs Payors • Enrollment • Transactions/Claims • Prescriptions Third Parties • Affiliate companies • Purchases (stores) Transaction Intermediaries Sensors • Internal • Wearable • Environmental Govt. Agencies • Surveillance • Service utilization e. Health Companies Individual User Generated • Online HRAs • Chat, email • Surveys • Usage logs

Challenge: Privacy and Security USA Today March 22, 1995 Online Medical Records Raise Privacy Fears Technology To Collect ‘Voluminous Amount’ of Information Outpaces Laws By Robert Davis Warning: What you tell your doctor could hurt you. Just ask the California man who tearfully admitted to his doctor that he had smoked marijuana as a youth. His medical record went into a computer system where an insurance company later used drug abuse as one of the reasons to deny him benefits. As the nation’s largest credit report company takes its first steps towards linking millions of medical records in a computerized database, chances are growing that private diagnoses, patient histories, even offhand remarks made in a doctor’s office could show up on a computer anywhere. Critics say plans announced last week by Atlanta-based Equifax – to join AT&T in connecting the computers of doctors, hospitals, labs, pharmacies, nursing homes and insurance companies – threatens the privacy of millions. “I’m scared, ” says Ed Mierzwinski, consumer program chief at U. S. Public Interest Research Group. “You won’t know about a privacy invasion until it’s already happened. ” Electronic medical records have clear benefits: Specialists can review the notes of a general practitioner, doctors can instantly send a prescription to the pharmacy and, in an emergency, doctors could even open a patient’s file from another star in the middle of the night. But like other forays onto the information highway, easy access to medical records by hospitals, doctors groups and insurance companies also is opening a new range of problems: 8 In Boston, one doctor who became a patient was alarmed to learn her colleagues had read her medical file on computers to see how she and her newborn baby were doing. “Putting this information in a database is publishing it, ” says Beverly Woodward, a sociology researcher at Brandeis University. “Even if a hacker doesn't break in, you’re giving the information to hundreds or thousands of people. ” 8 In Jacksonville, Fla. , the 13 year old daughter of a hospital clerk used her mother’s computer access to hospital files to cull a list of emergency room patients. She called seven people to say they had tested positive for the virus that causes AIDS. One teen victim of the prank, told she was pregnant and had HIV, tried to get her father’s gun to kill herself but was stopped by family. The 13 year old, traced by one of the victim’s caller ID phones, was charged with taking confidential information from computers and making threats. A Louis Harris survey, commissioned by Equifax in 1993, shows public worries on the rise: 80% believed consumers have lost control over information about themselves; and 34% of medical professionals said information is given to unauthorized people “somewhat often. ”

Challenge: Privacy and Security Contact Information for Sale ACT ONE Mailing List Services, Inc. QUANTITY: 4, 936, 091 Allergies Alzheimer’s Disease Gastritis 121, 701 1, 354, 895 Hearing Impaired 170, 958 18, 789 Hearing Impaired 170, 958 Angina 113, 947 Heart Disease 44, 780 Arthritis and Rheumatism 113, 429 High Blood Pressure 44, 983 Asthma Back Pain Bladder Control and Incontinence 56, 580 129, 713 High Cholesterol 274, 942 Bleeding Gums and Gingivitis 151, 649 Blindness 107, 496 Diabetes 107, 872 Emphysema 19, 420 Epilepsy 10, 017 Frequent Headaches 209, 107 Frequent Heartburn 242, 682 34, 049 Motion Sickness 58, 753 Osteoporosis 67, 157 Migraines 20, 143 Parkinson’s Disease 3, 903 Sensitive Skin 376, 225 Sinusitis 246, 266 Thinning Hair and Baldness 682, 134 Ulcer 47, 451 Yeast Infection 77, 528

Challenge: Privacy and Security HIPAA Summary of Administrative Simplification Provisions Standards for electronic health information transactions Within 18 months of enactment, the Secretary of HHS is required to adopt standards from among those already approved by private standards developing organizations for certain electronic health transactions, including claims, enrollment, eligibility, payment, and coordination of benefits. These standards also must address the security of electronic health information systems. Mandate on providers and health plans, and timetable Providers and health plans are required to use the standards for the specified electronic transactions 24 months after they are adopted. Plans and providers may comply directly, or may use a health care clearinghouse. Certain health plans, in particular workers compensation, are not covered. Privacy The Secretary is required to recommend privacy standards for health information to Congress 12 months after enactment. If Congress does not enact privacy legislation within 3 years of enactment, the Secretary shall promulgate privacy regulations for individually identifiable electronic health information. Pre-emption of State Law The bill supersedes state laws, except where the Secretary determines that the State law is necessary to prevent fraud and abuse, to ensure appropriate state regulation of insurance or health plans, addresses controlled substances, or for other purposes. If the Secretary promulgates privacy regulations, those regulations do not pre-empt state laws that impose more stringent requirements. These provisions do not limit a State’s ability to require health plan reporting or audits.

Challenge: Privacy and Security Protecting The Privacy Of Patients’ Health Information - Summary of the Final Regulation Covered Entities § Final regulation covers health plans, health care clearing houses, and those health care providers who conduct certain financial and administrative transactions (e. g. , electronic billing and funds transfers) electronically. Information Protected § All medical records and other individually identifiable health information held or disclosed by a covered entity in any form, whether communicated electronically, on paper, or orally, is covered by the final regulation. Consumer Control Over Health Information § Patient education on privacy protections. Providers and health plans are required to give patients a clear written explanation of how they can use, keep, and disclose their health information. § Ensuring patient access to their medical records. Patients must be able to see and get copies of their records, and request amendments. § Receiving patient consent before information is released.

Protecting The Privacy Of Patients’ Health Information - Summary of the Final Regulation Challenge: Privacy and Security Boundries On Medical Record Use And Release § Ensuring that health information is not used for non-health purposes – such as use by employers to make personnel decisions. § Providing the minimum amount of information necessary. Ensure The Security Of Personal Health Information § Adopt written privacy procedures. § Train employees and designate a privacy officer. § Establish grievance processes. Establish Accountability For Medical Records Use And Release § Civil penalties. $100 per incident, up to $25, 000 person, per year, per standard. § Federal Criminal Penalties • $50, 000 and 1 year in prison for obtaining or disclosing protected health information • $100, 000 & up to 5 yrs. in prison for obtaining protected health information under “false pretenses” • $250, 000 and up to 10 years in prison for obtaining or disclosing protected health

Challenge: Sustainability Many Internet Companies Have Shut Down Internet Company Shutdowns, Jan 2000 - Feb 2002 (n=806) Source: Webmergers. com. http: //www. webmergers. com/editorial/article. php? id=41

Challenge: Sustainability: Lessons from the Dot. com Era Boom And Bust § § § § Race for users, over-investment Customer acquisition cost too high Selling products at little or negative gross profit Value proposition – what is the ROI? Who will pay, how much? Reliance on huge marketing spending Power of the status quo – who doesn’t want you to succeed?

Challenge: Standards and Limited Benefit w/o integration Connection to Care Team and Standards § § § Limited value to patients without access to health records and communication with health care team SNOMed ICD CPT HL-7

Clinic Before and After … Before After Solving workflow issues for healthcare professionals

Biometric Data And Chronic Care Management Home and Point-of-Care Access Diabetes Asthma Clinicians / Educators COPD Hypertension Fitness PHR Obesity Patients / Families Data Repository Information Exchange HIV phone jack, PC, wireless Analysis Payers / Public Health

Community Health

Community Health

Community Health

Healthy Communities Network Stakeholders Examples Of Target Stakeholders Examples Of Uses ►Mayor/Town Council/County Board ►Health Department/ Healthcare Delivery ►Economic Development ►Foundations ►Community Service Coalitions and Councils ►Public Safety and Environment ►Education ►Transportation ►Chamber of Commerce ►Volunteer Organizations ►Fund Raising Organizations ►Arts and Recreation ►General Public ►Organizations with a domain focus: ►View QOL, focus on problems ►Monitor/benchmark progress ►Compare with other communities ►Attract new businesses and people ►Find best practices, e. g. , reduce infant mortality by changing bus routes ►Advance research, e. g. , recycling ►Run surveys ►Increase awareness of services, e. g. , after school, health education, domestic violence, etc. ►Engage community, e. g. , help people find specific volunteer opportunities, or give funds ►Alert community to urgent issues, e. g. , infectious disease outbreak, immunization shortage, crime wave Underserved; Seniors; Childhood/Youth Health; Native Americans; Rural Health; HIV/AIDS; Chronic Diseases; Urban Planning; Smoking Cessation; Domestic Violence; Mental Health; Disaster Preparedness; Others