1	Primary Care and the NHII A Report to the AMIA PCIWG Alan E Zuckerman MD FAAP Georgetown University aez@georgetown.edu
2	2004 Has Been Quite a Year for HIT Where does Primary Care fit? NHII Conference July 21-23 PITAC Report NHITC Strategic Framework for HIT AAFP EHR Pilot (aka Open Source) VA VISTA Lite Open Source ASTM Continuity of Care Record Physicians EHR Coalition – 19 societies SNOMED Vocabulary NCVHS eRx Standards for Medcare MMA
3	July 21, 2004 Secretarial Summit Over 50 speakers from government, private industry, and health care From DHSS Secretary Thompson to David Brailer, NCHIT A love fest for HIT compared to Woodstock A visible change in Federal roles A change in NHII from Plans to Action Considered a “Tipping Point” for HIT Huge attendance, international attention PITAC and Framework reports
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5	President’s Information Technology Advisory Committee Revolutionizing Health Care Through Information Technology Starting with the State of the Union address, President Bush has embraced HIT and electronic medical records Created the Office of the Health Information Technology Coordinator Funding initiatives to encourage public private partnership
6	PITAC Findings & Recommendations Part I: Promoting EHR CDSS and CPOE Economic Incentives for Investment in Health IT – need a good business case Health Information Exchange Facilitating the Sharing of EHR Technologies Leveraging the Federal Health IT Investments Standardized Clinical Vocabulary The Human Machine Interface and EHRs Coordination of Federal NHII Development
7	Part II: Promoting Secure, Private, Interoperable Health Information Exchange Unambiguous Patient Identification The need for a patient identifier is inescapable even if a universal number is not politically acceptable in the US Encrypted Internet Communication Trust Hierarchy and Authentication Tracing Access Requests
8	(IOM) To Err is Human: Building a Safer Health System …the most remarkable feature of this twenty-first century medicine is that we hold it together with nineteenth century paperwork The President of the US now acknowledges that this is unacceptable and must change The EHR is finally recognized as an essential technology for health care
9	Surmounting the Barriers to Widespread Adoption of Health Information Technology Medical Errors Reducing Costs Applying Lessons Learned From Advances in Other Fields Education and Training of Health Care Professionals Privacy and Security of Electronic Health Records Networking and Information Technology Research and Development (NITRD)
10	The Decade of Health Information Technology – NCHIT Framework Delivering Consumer-centric and Information-rich Health Care A Framework for Strategic Action David J Brailer MD PhD National Coordinator for Health Information Technology 4 Goals 12 Strategies NHII Strategy 3 Goals for each Topic
11	Readiness for Change in Health Care Avoid medical errors Improve use of resources Wasted duplication from lack of communication Accelerate diffusion of knowledge Reduce variability in access to care
12	Inform clinical practice = Implement EHR Incentivize EHR adoption Low rate loans for EHR adoption Update physician anti-kickback protections Pay for use of EHR Pay for performance programs Reduce the risk of EHR investment Promote EHR diffusion in rural and underserved areas
13	Interconnect Clinicians = NHII and Interoperability Foster regional collaborations E-Health Initiative’s Connection Communities for Better Health Develop a national health information network Technically sound and robustly specified interoperability standards Coordinate federal health information systems
14	Personalize care Encourage use of Personal Health Records (PHR) Prevent duplication and medical errors Promote communication Enhance informed consumer choice Promote use of telehealth systems Responds to goal of dissemination to rural and underserved communities
15	Improve population health Unify public health surveillance architectures Part of bioterrorism response Streamline quality and health status monitoring DOQIT Pay for Performance Guideline compliance Accelerate discovery and dissemination
16	Role of the National Coordinator Provide Leadership Promote Collaboration Develop Policy Support financial management Enhance communication and outreach
17	NHII National Health Information Infrastructure
18	Stakeholders Consumers (PHR) Health Care Providers (incentives) 90% of benefits of HIT go to others Health Care Organizations (hospitals, clinics, long term care) Public health System developers (standards, certification) Medical researchers (role of NIH) Health plans, employers, payers (share cost)
19	Functions Personal Health (PHR) Governance Incentives Standards and Architecture Confidentiality, ethics, privacy, and access Measuring progress (metrics) Population health Medical Research
20	Alternative Visions of the NHII A “Physical” Infrastructure of a central data repository with all health data on all patients in a region – Indianapolis Model A “Virtual” Infrastructure of standards and interoperability between participating partner institutions and practices – Santa Barbara Model An Index of core data and pointers to where more information is stored – CCR Model Key concept – sharing data between providers, patients, public health, and research
21	AAFP EHR Pilot Study aka Open Source EHR Open source was never a big part of the project and significant development was never planned This is, and always has been, a study of EHR adoption in small practices
22	EHR Adoption in Small Practices The study is at midpoint with 6 small practices (2 solo) in 6 states Funding by vendors – MedPlexus, Siemens, HP Very limited evaluation funding from CMS came very late in study that began without funding Focus on practitioner needs in small office and vendor relations
23	AAFP Future of Family Medicine Report Central role of Information Technology in defining the specialty Use of IT to improve quality, boost patient confidence, implement guidelines, and disseminate knowledge to the point of care Essential role of EHR in residency training programs
24	VA Open Vista Lite A True Open Source Venture Part of the goal of leveraging federal investment in HIT Involvement of physicians and professional societies in functional specifications Targeted to small office practice Still built on MUMPS / Cache architecture but with some open source options A real opportunity for Informatics community Need for vendor support involvement
25	ASTM Continuity of Care Record CCR
26	History of the CCR Inspired by a paper patient safety document from the Massachusetts Medical Society Builds upon a history of “Face Sheet” and “Discharge Summary” projects Developed under ASTM through a partnership of Maintenance Organizations Professional Societies MMS, AAFP, AAP, AMA, PSI Vendors HIMSS Standards ASTM Passed on First Ballot April 6, 2004 Provisional Implementation guide for TEPR 2004 First implementation guide ballot expected in Sept, 2004 AAFP Center for Health Information Technology Partners for Patients Program (Doctors and Vendors will use it)
27	Goals of the CCR Improve Patient Safety and Healthcare quality Prevent redundant data entry Reduce healthcare cost by improving efficiency and effectiveness of care Improve continuity of care Provide a pathway to increased use of Health Information Technology Share information between different organizations and vendor systems Be usable by physicians who do not have EHR systems in their offices Potential to serve as a report card to monitor compliance with chronic disease management guidelines
28	Key Features of the CCR A one time messaging document providing a snapshot in time of information needed to support clinical decisions Value to both patient and provider Use of XML to enable both human readable and machine readable documents You never know when you will need a CCR so you should produce one for every visit Can be given to patient, sent to the next provider, or stored in data repository Not an EHR – no HPI, ROS, or PE
29	Clinical Scenarios for Using a CCR Change of Primary Care Provider Hospital Discharge and return to Primary Care Emergency Room visit with primary care follow-up Referral to a Specialist with return to primary care Routine visits to a new physician in the same group practice Auditing outcomes, guideline compliance, and quality of care
30	Overview of the Structure of the CCR Document Date (creation, transmission) Patient – most of the details stored in the Actors section From To Purpose – constrained by an enumerated list Body – 14 sections of clinical information Comment – on the CCR as a whole References – Actors and Links Signatures – Format not yet fixed
31	Sections of the CCR Body Insurance Advance Directives Problems Family History Social History Alerts Medications Immunizations Vital Signs Results Procedures Encounters Plan Of Care Practitioners
32	Overview of the Structure of Each Section in the CCR Body Code (for the Title of the section) Optional and better done using XSL Line Items specific to each section Every section is optional, but if included must have at least one line item Reference – an Actor or a Link Comment The Source tag is now a Reference to an Actor
33	Common Element Group Repeats for each instance of a line item Status Participant An Actor with a specific role Reference The Source is a reference to an Actor Links to line items in the same or other sections Comment Multiple comments from different Actors are permitted
34	SNOMED–CT Now that we have it, how do we get people to use it?
35	SNOMED-CT What is it and how do we get it? A comprehensive clinical vocabulary Supports the richness of coding required by primary care Multi axial coding – precision by combining multiple terms and atributes A nomenclature or vocabulary of terms, not a classification like ICHPPC that is useful for research Potential to unify coding for billing and patient care Translation to ICD-9 available – will it work
36	SNOMED-CT Codes much more than Diseases attribute body structure context-dependent categories diseases environments and geographic locations events findings observable entities organisms pharmaceutical / biologic agent physical force physical objects procedures qualifer value social context special concepts specimens staging and scales substances
37	Has the world of HIT eclipsed the Informatics Community? What is the purpose of AMIA and the PCIWG in a society that has embraced HIT and change?
38	Dramatic changes in who is involved in HIT now that it has big stakes Professional societies (AMA, AAFP, AAP, ACP) are responding to member needs and reimbursement issues Physicians EHR Coalition PEHRC formed by 19 medical societies Main role may be with vendors Primary care is not at the center Consolidated Health Informatics CHI increases the power of Standards Organizations Vendors are Where is AMIA, PCIWG, and NAPCI?
39	Future Roles for AMIA PCIWG Focus on Education and Research Shift from educating about informatics to using informatics in training Vocabularies and coding User interfaces (templates) Continutiy of Care Defining Interoperabilty Security Lessons from the International community
40	Building a Core Curriculum in Security Security should not be defined only by HIPAA compliance and patient privacy Authentication Access Control Access Logging Secure transmission Encryption (secure storage) Digital Signature Backup and disaster recovery Physical protections and equipment disposal
41	The World Around us is Changing Rapidly We must decide how to evolve and adapt