2006 Rural HIT NOSORH

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HIT: Issues and Opportunites Tami Lichtenberg Program Manager Rural Health Resource Center Duluth, Minnesota

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Rural Health Resource Center Located in Duluth, Minnesota Private, Non-profit National scope Seven federal contracts Funding from federal ORHP

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Supply regulation 1970s 1980s 1990s 2000s Managed behavior modification Consumer-driven health care Price regulation Consumer Driven Health Care

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What’s driving consumers? CDHC driven nationally by: High cost Questionable quality More demanding consumer

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“I Can’t Get No Satisfaction…”

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CDHC Initiatives Insurance/HSAs Public Reporting P4P

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Hospital Compare Scores publicly reported – April 2005 3,839 out of 3,906 participated Reporting hospitals received full 3.3% Medicare update CAH participation limited and problematic CAH Participation ranges from 0-86% and averages 41% nationwide.

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Quality Crisis “The stunning high rates of medical errors, resulting in deaths (44,000 to 98,000 annually), permanent disability, and unnecessary suffering, are simply unacceptable in a medical system that promises first to do no harm.” William Richardson, IOM Committee Chair

Paper Kills (article): 

Paper Kills (article)

Strategic Gap: 

Strategic Gap Inefficient Processes Patient Safety HIT

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HIT Theme Strategy Map Finance As financial stakeholders, how do we intend to meet the goals and objectives in the hospital’s Mission Statement? Customers & Community Internal Processes Learning & Growth As customers of the hospital’s services, what do we want, need or expect? As members of the hospital staff, what do we need to do to meet the needs of the patients and healthcare community? As an organization, what type of culture, skills, training and technology are we going to develop to support our processes?

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Role of HIT in Reducing Medical Errors Percent who say… The coordination among the different health professionals that they see is a problem They had to wait or come back for another appointment because the provider did not have all their medical information They have seen a health care professional and noticed that they did not have all of their medical information Have you or a family member ever created your own set of medical records to ensure that you and all of your health care providers have all of your medical information? Don’t know Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).

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We need to remember: HIT needs to support strategic planning and needs to have a purpose and benefit. It needs to be part of the solution to enhanced quality and patient safety – not another barrier.

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HIT: The Big Issue Why now? Seen as a solution to some problems Quality Rising costs Long overdue One of the last major industries to take advantage of information technology

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Looking back to see the Future HIT Initiatives have been around since the 1950’s: Computers used for dental projects at the National Bureau of Standards Expert systems developed * MYCIN * INTERNEST - 1

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FAST Forward: 1990’s Health Security Card proposed by HHS National Health Information Infrastructure via Clinton Health Reform- rewritten as HIPAA HIPAA standards for transmission of billing and clinical health information IOM “To Err is Human”

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HIT in the 2000s IOM “Crossing the Quality Chasm” 9/11 Emergency Preparedness and Public Health Infrastructure Development MMA fosters electronic prescribing ONCHIT established IOM “Quality Through Collaboration”

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Rural Health in the Digital Age The IOM Quality Series: The Rural Report HIT is a key focus area Establish a Rural Quality Initiative to coordinate and accelerate efforts to measure and improve quality of personal and population health care programs in rural areas. Expand experientially based workforce training programs in rural areas to ensure that all health care professionals master the core competencies…including informatics Congress should provide appropriate direction and financial resources to assist rural providers in converting to electronic health records over the next five years.

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Utilizing Information and Communications Technology: IOM Recommendations Office of the National Coordinator for Health Information Technology should include a rural focus with programmatic and financial resources Congress should ensure that rural communities are able to use the Internet for health-related applications Congress should provide appropriate direction and financial resources to assist rural providers in converting to EHR’s

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Utilizing Information and Communications Technology: IOM Recommendations cont… Agency for Healthcare Research and Quality’s (AHRQ) Health Information Technology Program should be expanded The National Library of Medicine should establish regional information and communications technology/telehealth resource centers

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Internet usage for consumers and providers Expanded reimbursement for telemedicine Development of telepharmacy, teleradiology, and tele-home health Wireless technology for dictation, charting, and paging ITV usage for continuing education and networking Pushing the Envelope Meeting 2004/ Strategies to Increased Use of Technology

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Build HIT skills in rural areas Build a close connection to schools “Grow your own” HIT experts Establish a reverse mentoring program where students mentor hospital personnel on basic HIT skills Create state HIT infrastructure to support rural – remote support Need cost sharing within communities for HIT technical support and training Rural Health in the Digital Age

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Need for an integrated strategic planning effort with HIT as a component and connect to annual budget Develop a tool to help hospitals/clinics make informed HIT decisions: HIT needs Choosing a vendor Integration of HIT Rural Health in the Digital Age

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Rural Health in the Digital Age Link rural health HIT needs to bioterrorism and access available funding for hardware, software, and training Create a resource directory of potential vendors Develop HIT technical assistance centers at state and national level Need board education on HIT as part of an overall board leadership effort

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Rural Health in the Digital Age Need to stress what states and communities can do for themselves Need state and national communication efforts to drive learning nationwide Need more rural HIT research as well as a means of communicating the research to rural providers Need more grants for HIT solutions as well as access to HIT grant writers

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Rural Health in the Digital Age Create a web-based national HIT network that would electronically connect rural providers, researchers, and technical resource people and others. The purpose would be to: Drive HIT learning Highlight models Recommend new policies or policy changes

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Rural Health in the Digital Age Access needed HIT resources from the QIOs’ in their 8th Scope of Work Coordinate conferences of Federal projects in HIT Look to university training programs for HIT help

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So Where Are We? Electronic Health Record Gap: US Vs. Others Source: "European Physicians Especially in Sweden, Netherlands, and Denmark, Lead U.S. in Use of Electronic Medical Records." Harris Interactive Health Care News 2(16).

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Rural Health in the Digital Age Important Health information technologies (HIT) issues remain: Lack of HIT in rural health settings has to be addressed Lack of support for HIT systems, programs, software, etc… is also an issue Because of isolation, small rural hospitals probably cannot design and implement HIT strategies alone; It is difficult for rural providers to make an informed decision about vendors; New national “interoptability” requirements for HIT implementation might disadvantage rural.

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Rural Health in the Digital Age HIT issue con’t: Lack of HIT in rural health settings has to be addressed

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health Rural Challenges Size and limited infrastructure mean that rural providers face unique HIT challenges

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health Rural HIT Is there an adoption gap? For hospitals, yes AHA survey and Flex survey For other rural providers?

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health AHA survey Rural hospitals less likely to be investing

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health AHA survey, continued Urbans using IT more than rurals

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health AHA survey, continued System hospitals doing more

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health 2006 Flex Survey Majority of CAHs have more than 20 computers in the facility More than 1/3 of CAH clinicians use PDAs All have internet access with 98 percent using high-speed Source: Flex Monitoring Team Briefing Paper No. 11, The Current Status of Health Information Technology Use in CAHs, May 2006

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health Flex survey, continued Half of clinicians have electronic access to clinical guidelines 1/5 have some form of an EHR Source: Flex Monitoring Team Briefing Paper No. 11, The Current Status of Health Information Technology Use in CAHs, May 2006

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health Flex survey, continued About ¼ use computerized prescription order entry Almost half use computerized screening for allergies and drug interactions Almost ¼ use telepharmacy Source: Flex Monitoring Team Briefing Paper No. 11, The Current Status of Health Information Technology Use in CAHs, May 2006

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health Flex survey, continued Almost half use computerized clinical lab ordering Almost half can order and review radiographs More than 2/3 use teleradiology Source: Flex Monitoring Team Briefing Paper No. 11, The Current Status of Health Information Technology Use in CAHs, May 2006

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health What does that mean for rural? Networking with other providers is key Models are out there Vendor interest in the rural sector growing but challenges remain Challenges remain in ensuring a rural voice in the larger policy discussions

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health The current environment Private sector leading Government playing a supporting role Setting the context to allow the technology to diffuse A realization that the total adoption cost is large Not enough grant $$ to do more than create some models here and there

Slide42: 

What Everyone is Going Through: Some Planning Considerations Governance Principles & Key Objectives Stakeholder Perspectives Establishing a Business Case Needs Assessment Legal & Regulatory Challenges Defining Interoperable Architectures Evaluation Methodologies * Courtesy of Health Tech Strategies, LLC

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Some Additional Rural & Practice Challenges Small rurals may have no IT support let alone an IT Department Hard to find M.D. or Adm. leaders / change agents Other business priorities i.e. “surviving” No business case for connectivity / linkages to other institutions (stand-alone EHRs?) No aggregate buying power (hence pooled vendor selection processes) Need to address critical referral pattern issues, disruptions, patient flows, etc… Rural health care organizations will need special legislative consideration * Courtesy of Health Tech Strategies, LLC

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Technical Assistance and Services Center (TASC) HIT Supplement Working with the AHRQ National Resource Center (NRC): Compile a list of expertise needed to assist rural hospitals with HIT Build expertise within the organization or retain consultants Develop tools and resources Customize a rural HIT portal for the NRC web site Develop a compendium of HIT consultants and technical experts for rural health providers

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“Efforts to develop local and national health information technology infrastructures should focus specific attention on rural communities” Further, the benefits of HIT “may be even more substantial in rural communities” (“Quality Through Collaboration: The Future of Rural Health Care”, Institute of Medicine, November 2004.) Focusing Attention On Rural Communities * Courtesy of Health Tech Strategies, LLC

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Reimbursement & Capital Costs Aligning Financial Incentives Driving Cost-Effectiveness (i.e. Chronic Care & Disease Mgmt) Start-up Costs Capital Investment Standards (Clinical & Communications) Quality & Safety Infrastructure Issues Network Infrastructure / Access / Interoperability Human Dimension Issues Practitioner and Patient Acceptance Licensure, Accreditation, Certification Legal (Stark Law, Liability, FDA, HIPAA) Policy Considerations * Courtesy of Health Tech Strategies, LLC

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Pending HIT Legislation HR 4157 (Reps. Johnson and Deal) Codifies ONC Standard-setting committee Push toward interoperability Anti-Kickback exception S. 1418 (Sens. Enzi, Frist, Kennedy and Clinton) S. 1501

Policy Updates: 

Policy Updates

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Infrastructure Issues $400 B Needed to Build NHIN Over 5 Years (Commonwealth Fund Study) Rural Broadband Access Continue to Lag Behind (California HealthCare Foundation) Yet, deployment of fiber and wireless in rural areas has accelerated sharply in the past year. (Verizon Foundation) Infrastructure support, limited technical investment, ongoing support – Top Listed Barrier in Surveys (First Consulting) * Courtesy of Health Tech Strategies, LLC

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Financial Incentives targeted toward physicians and providers Reimbursement for implementation of EHRs and other incremental applications Access to capital for EHR purchases Matching grants, clinical IT purchasing contracts EHRs as a Tax Credit rather than Business Expense Reduce liability insurance premiums for HIT users Reimbursement & Capital Costs * Courtesy of Health Tech Strategies, LLC

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Numerous Players Federal Government Congress Agencies (HHS, DoC, Ag, DoD, VA, IHS, NASA) States Statewide Initiatives (Governors, Legislatures, Regional Networks) Private Sector Coalitions/Consortia (ATA, HIMSS, eHI, AHIMA, AMIA, NAHIT, CCHIT) Capital Hill Steering Committee on Telehealth and Healthcare Informatics) Standard Groups Foundations (Markle, RWJ, Commonwealth, eHI) * Courtesy of Health Tech Strategies, LLC

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Major HIT Funding Efforts AHRQ THQIT $139 M DHHS effort, over 100 Grants to Communities, Hospitals, Providers, Systems for planning, implementation, RHIOs eHealth Initiative – “Connecting Communities for Better Health” $6.9 M RWJ – “Health e-Technologies Initiative” $10.3 M Markle – “Connecting For Health” collaboration of 100 partners * Courtesy of Health Tech Strategies, LLC

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Complementary Private Sector Efforts Working to address the Issues: eHealth Initiative “Connecting Communities for Better Health” $6.9 M Robert Wood Johnson “Health e-Technologies Initiatives” $10.3 M Markle Foundation “Connecting for Health” – 100 partners Commonwealth Fund * Courtesy of Health Tech Strategies, LLC

Slide54: 

Rural Health Resource Center Facilitating Planning Committee for National Rural HIT Conference in September ’06 Creating HIT Assessment tool for rural hospitals Gathering rural health HIT tools and resources, best practices Rural HIT Web Portal

Slide55: 

Technical Assistance and Services Center (TASC) HIT Supplement Working with the AHRQ National Resource Center (NRC): Compile a list of expertise needed to assist rural hospitals with HIT Build expertise within the organization or retain consultants Develop tools and resources Customize a rural HIT portal for the NRC web site Develop a compendium of HIT consultants and technical experts for rural health providers

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health Current General Barriers and Challenges Privacy Incentives for data sharing in a competitive environment Experience level with HIT Cost/Rapid change in technology offerings Legacy systems Organizational change

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health National Coordinator for Health Information Technology Agency for Health Research and Quality Health Resources & Services Administration Other Departments Federal Agencies and Departments involved in HIT U.S. Dept. of Health and Human Services

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health The Office of the National Coordinator on Health Information Technology Established in response to Executive Order 13335, April 27, 2004 Responsible for realizing the President’s vision of Healthcare IT: Widespread adoption of interoperable EHR within 10 years Medical information follows the consumer Clinicians have complete, computerized patient information Quality initiatives measure performance and drive quality-based competition Public health and bioterrorism surveillance are seamlessly integrated into care www.hhs.gov/healthit

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health The Office of the National Coordinator on HIT Focus on strategic investments to support that the health IT market place evolves appropriately Standards (i.e. interoperability) Certification (to ensure protection for buyers) Privacy and Security Nationwide Health Information Network (i.e., setting the framework, health exchange) American Health Information Community (a key driver for these processes). www.hhs.gov/healthit

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health The Agency for Health Research and Quality Health Information Technology Program 122 projects in 41 States Six State and Regional HIT Demonstrations National Resource Center

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AHRQ’s Grantees

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AHRQ’s HIT Website: http:healthit.ahrq.gov

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health Medicare and the Quality Improvement Organizations 8th Scope of Work focuses on “Transformational Change” with a strong emphasis on HIT DOQ-IT Program: Work with 5% of physician offices in each State to increase HIT adoption 80 percent will be small and medium sized practices

National HIT Policy and Funding for Rural Health: 

National HIT Policy and Funding for Rural Health Back to the “Rural Adoption Gap” Reality is not so clear cut There are gaps but there are also rural successes Systems do better than “stand-alones” Networks do better than solo providers All of which begs a question How to create a floor and who creates it …

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Rural HIT: A Roadmap to Quality Largest Rural-Specific HIT Meeting Ever Focus on Small Providers in the Early Stages of Planning or Implementation Sept. 21-23rd; Downtown Marriott Kansas City http://www.securemcking.com/hrsa/rural/ HIT And Strategic Planning Meeting

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Tami Lichtenberg Program Manager, Rural Health Resource Center 600 E. Superior St., Suite 404 Duluth, MN 55802 218-727-9390, ext. 230 tlichten@ruralcenter.org