Transcript Clinical Workflow Design: A Pre

eHealth Information: Federal
Activities and Implications for
State Policy
Susan M. Christensen
Senior Advisor
CSG Health Policy Forum
On Mental Health Care and Wellness
May 31, 2006
Overview
 Terminology – Getting on the Same Page
 Federal Landscape
 AHRQ
 Privacy and Trust
 Resources
 Legal Issues
 Appendix: Case Study – Legal Issues
Terminology: HIE v. HIT
 No longer just about putting electronic medical records
in hospitals
 Electric health information systems across all care
settings, as well as payers
 Linking them together – interoperability for health
information exchange (HIE)
 For HIE, communities and states (and some regions)
are developing networked systems
 To do this, it’s not just about investing in the
technology (HIT) ; we must research how to do so in a
way that
 Maximizes the value we hope to realize – clinically,
economically, and for population health
 Assures that security and privacy protections are
“baked into” HIE
HIE Policy Issues
 In addition, a new market is being created,
with all the technical and policy issues that
entails, such as
 Standards for data exchange
 Assuring consumer participation and patient
protections
 Security concerns
 New business arrangements, new relationships
 Disconnect between payment systems and new
relationships/care delivery models
What’s the situation?
Federal Leadership
President’s Executive Order 13335 (April 2004)
– federal leadership for the development of a
nationwide interoperable electronic health
information system:
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Created Office of the National Coordinator for Health
Information Technology in HHS (ONC)
ONC is required to develop a national strategic plan to support:
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Public-private collaboration to develop, adopt and implement
standards
Evaluate benefits of HIT
Address privacy and security issues
ONC serves as principal advisor to Secretary on national HIT
policy, coordinates federal activities, and coordinates publicprivate outreach and consultation
ONC Health IT Roadmap To-Date
NOW
WORKGROUPS
Community
Established
INFRASTRUCTURE
ONC
Review Workgroup
Recommendations
NHIN RFI
Summary
JUL
MAR
Health IT Policy FHA Strategic
Council Established
Plan
SEP
2005
• Recommendations Report
to the Secretary of HHS
Interoperable
Electronic
Healthcare
Records
• NHIN Architectures
• Standards Implementation
Guidance
• Ambulatory Care
Certification Criteria
Contracts
Awarded
Health IT Strategic
Framework
2004
Recommendations for:
• Biosurveillance
Make Recommendations • Consumer Empowerment
• Chronic Care
to the Community
• Electronic Healthcare Records
Workgroups
Established
COMMUNITY
2006 GOALS
OCT
JAN
FEB
MAR
• 2006 Strategic Plan
. . .
DEC
2007
2014
Four Major HHS Contracts
HHS has entered into four significant contracts:
http://www.hhs.gov/healthit/contracts.html
 Harmonize industry-wide health IT standards (ONC)
 Develop a conformance certification process for
health IT (ONC)
 Assess and develop plans to address variations
business policies and state laws related to privacy and
security (AHRQ)
 Four contracts to develop nationwide health
information network (NHIN) prototypes that can be
used to test specialized network functions, security
protections and monitoring, and demonstrate
feasibility of scalable models (ONC)
Agency for Healthcare Research
and Quality (AHRQ)
Mission
To improve the quality, safety,
efficiency, and effectiveness
of health care for all
Americans
Research at HHS:
Where Does AHRQ Fit In?
 NIH -- basic biomedical bench research and
“efficacy” clinical trials
 AHRQ -- “effectiveness” of healthcare services
and the healthcare delivery system
 CDC -- the public health system and
community-based interventions
Other federal partners – CMS (Medicare and
Medicaid), HRSA (capital and resources,
workforce), and ONC (collaboration and
coordination on health IT)
Intersection of Safety,
Quality and Health IT
Support diffusion of HIT to
•41 states
•40 million Americans
AHRQ
Improve medication safety
•CMS e-prescribing demos
Provide HIT technical
support to safety net
•Community health centers
• Critical access hospitals
• Public hospitals
Privacy and Security
Focus on Adoption of Health IT
 AHRQ’s work focuses on the
marriage of Health IT systems with
the way work is done in health care
 Need to prepare for the impact of
new Health IT systems
 Health IT is “one part technical, and two
parts culture and work process
change.”
 Opportunity to design new and better
workflows – and review work
patterns that may never really have
been examined.
State and Regional HIT
Demonstrations
 Five-year state-based contracts:
 Help states develop secure statewide networks
 Ensure privacy of health information
 Make an individuals’ health information more
available to health care providers
 FY04: Five states awarded $1M/year
 Colorado
 Indiana
 Rhode Island
 Tennessee
 Utah
 Delaware added in FY05
AHRQ National Resource Center for
Health Information Technology
 Provides technical and expert support to health IT
grantees, contractors, and selected other federal
grantees (HRSA, CMS, IHS)
 Contract award to NORC (up to $18.5M over 5 years),
in partnership with:
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Vanderbilt University
Center for IT Leadership (Partners)
Indiana University
Foundation for the eHealth Initiative
CSC
Burness Communications
healthit.ahrq.gov
Approaching the “Trust” Issue
 Why is this important to people? What
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are people thinking? What is the
“threat”?
Can we break it down? Is HIPAA
compliance enough? Why not?
How to react?
Who should be involved?
What message?
Guidance for leadership?
“Trust” v. “Privacy” v. HIPAA
Clarify the issues:
 HIPAA – legal requirement
 Additional legal privacy requirements
 Federal
 State
 Contractual
 Privacy – common law, ethics, good business,
protections beyond basic HIPAA compliance
 Trust – broader public concern about security and
reliability
Privacy and Security Contract
 In September 2005, AHRQ awarded “Privacy and
Security Solutions for Interoperable Health Information
Exchange”
 Overall contract managed by RTI International in
partnership with NGA
 18-month period; $11.5 million
 RTI will subcontract with up to 40 states to:
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Identify within the state business practices that affect electronic
health information exchange
Propose solutions and implementation plans
Collaborate on regional and national meetings to develop
solutions with broader application
 Provide final report on overall project outcomes and
recommendations
Contract Purposes
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Identify variations in organization-level business privacy and security
policies and practices that affect electronic clinical health information
exchange (HIE)
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For those that are “best practices”, document and incorporate into
proposed solutions
For those with a negative impact, identify source of the policy or
practice and propose alternatives
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Preserve privacy and security protections as much as possible in a
manner consistent with interoperable electronic health information
exchange
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Incorporate state and community interests, and promote stakeholder
identification of practical solutions and implementation strategies
through an open and transparent consensus-building process
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Leave behind in states and communities a knowledge base about
privacy and security issues in electronic health information exchange
that endures to inform future HIE activities
Connecting for Health
Common Framework

A set of free resources: 16 policy guides and technical documents
designed to advance HIE in a private and secure manner.
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The Common Framework puts forth a model of HIE that:
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Technology neutral
Includes model contract language for HIE agreements
Protects patient privacy by allowing health information to remain
under local control – avoiding the need for a large, centralized
database or creation of a national patient ID
Avoids large-scale disruption and huge up-front capital investments
by making use of existing hardware and software
Supports better informed policymaking around HIE
Establishes trust among collaborating organizations by applying
well-vetted model contract language to fit their needs
Series of activities to disseminate and provide education for how
to use: AHRQ website, teleconferences, workshops
 healthit.ahrq.gov and www.connectingforhealth.org
Vanderbilt Center for Better
Health Model
 Developed workshop design to explore trust issues,
come to consensus, and make recommendations or
develop workplan for moving forward
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Goal: state/community controls the process and the outcome
Statewide: used principles in CFH model as kickoff for
discussion about privacy and trust among stakeholders in
disparate HIEs across state
Another new statewide initiative: used workshop to do
concrete planning for both technology and governance in
new HIE
 http://www.volunteer-
ehealth.org/AHRQ/12142005/index.htm
 http://www.mc.vanderbilt.edu/vcbh/ds/0606_privacy/
 Working with AHRQ to make the workshop “portable”
Differing Approaches – Legal
Issues
 Recognize that one approach, i.e., legislation,
is not appropriate for every issue
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Federal legislation and mandates
National or regional consensus
Model state laws
State innovation through demonstrations or
regulation
 Model contracts
 Private agreements
 Coordinate among initiatives; use them in
combination
Summary
 Communities can and should make their
own choices about HIE
 The decision process on policies and
implementation is as much a part of the
solution as the technology
 Call on national initiatives for what they
can offer to save money and accelerate
the process
http://healthit.ahrq.gov
For additional information:
Susan Christensen
[email protected]
Case Study – One State
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Workgroup of stakeholders assumed time frame two years
hence
Identified potential key legal, regulatory, and policy areas that
could still be of concern as regional health information
exchange implementation progresses
Stratified issues by national, regional, local or private in
nature (i.e., best resolved at what level to be most
effective?), and split them into technical and non-technical
categories
Identified proposed approach: legislation, rule-making,
consensus, private agreement, or some combination
Model legislation would be appropriate for many of the
consensus issue areas, except data and communication
standards
Technical Issues
Issue Area
National
Regional/State
Private
Data and communication
standards
Adopted at the national
level; potential public/
private collaboration for
identification; mandatory
for Medicare to drive
take-up; common
standards identified for
Medicaid
Adopted for Medicaid by
state programs
Participation in
identification and
incorporation into product
Safety standards for
items like drugs and
devices
Same
Same
Same
Standards enforcement
Enforcement by regional
exchanges as
requirement for use;
possibly mandatory for
Medicaid
Certification
Requirements and
administration/enforceme
nt at regional level;
possibly mandatory for
Medicaid
Bioterrorism/ defense
systems
Developed and funded
federally
Portions developed and
funded at state/regional
level in collaboration with
federal efforts
Non-Technical Issues
Issue Area
National
Regional/State
Private
Research on HIT policy,
standards and value
Funding, dissemination
and oversight;
demonstrations
Funding and adoption
Funding and adoption
Payment reforms
Medicare payment
reform; Medicaid reform;
FEHBP contracts
Adopt Medicaid reforms;
SCHIP and employee
coverage reforms
Pay for performance and
IT utilization
Startup funding
Tax incentives, loans,
grants, and
demonstrations
Licensure for health
professionals
Leader in developing
standardized content that
supports information
exchange
Adoption and
enforcement of licensure
rules
Professional organization
and payer support of
“model” rules
Liability protections/
accountability
Leader in developing
standardized content
Adoption and
enforcement
Underserved populations
Model legislation that
supports interoperability
Outreach, funding and
enforcement
HIE Structure
Issue Area
National
Regional/State
Governance/ structure
Leadership in developing
standardized options that
support regional health
information exchange
State option to adopt by
statute or rulemaking
Responsibility/
accountability
Leadership in developing
standardized options that
support regional health
information exchange
and interoperability
State option to adopt by
statute or rulemaking
Taxing authority
Leadership in developing
options that support
regional health
information exchange
State option to adopt by
statute
Funding authority
Leadership in developing
options that support
regional health
information exchange
State option to adopt by
statute or rulemaking
Liability
Leadership in developing
standardized content to
support interoperability
State option to adopt by
statute
Private
Private agreements can
supplement or reflect
state option, or may be
stand-alone in absence
of state action
Private agreements can
supplement or reflect
state option, or may be
stand-alone in absence
of state action