Information Technology In Health Care A Tool For Effective Change Deryk Van Brunt, DrPH Associate Professor, School of Public Health, UC Berkeley Chairman,

Information Technology In Health Care A Tool For Effective Change Deryk Van Brunt, DrPH Associate Professor, School of Public Health, UC Berkeley Chairman, Healthy Communities Foundation Senior Vice President, iMetrikus 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 Clinical Telemedicine Educational Personal (or Patient) Community Population Industry: The use of emerging information systems and communication systems (Internet) to improve or enable health and health care. IT is an enabler, but its 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 Its like crashing two 747s a day. There should be more outrage. Mark Blatt, Intel 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 of patients care not follow best care practices; e.g. diabetes nearly 2/3s inappropriate care Cost Aging population, chronic care roughly 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 FedEx packages online, trading shares, file taxes, many things except their health Little loyalty to Plans US healthcare has under-invested in IT: 2% versus 3-10%

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 Implementing CPOE and DSS major goal of most hospital systems Source: HIMSS Analytics SM 2004

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

Digital Hospital Technology Element Possibilities

Evidence Of Benefits Source: Information Technology: Benefits for Selected Health Care Functions, U.S. General Accounting Office, October 2003 350-bed, private, not-for- 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, not-for- profit integrated healthcare system Electronic Medical Record system 372,000 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 Private, not-for-profit integrated healthcare delivery system serving an urban population of 440,000 members Electronic Medical Record system 76% decrease in phone calls to obtain lab results during four-year period 2,000 fewer daily chart pulls overall, eliminating 16FTEs and saving and avoiding about $5.7 million on medical record unit FTE costs 7.5% decrease in laboratory test orderingattributable to reliable and efficient access to test resultsreducing redundant tests 1,951-bed, private, not-for- profit teaching hospital serving urban, rural, and international populations Clinical Information system $2,906,000 annual savings resulting from reduction in staff needed to route paper medical records, from clinical notes technology, and from automation of correspondence $7,000,000 annual savings resulting from a reduction in unbillable tests and the ability to bill patients directly 927-bed, academic medical center serving an urban population Automated billing, admissions, discharges, pharmacy, laboratory, radiology, other functions $1,167,317 saved in transcription costs in one year 28 FTEs eliminated as a result of automatic scanning, problem lists, and EMR, saving $704,000 Hospital Description Hospital Description IT Initiative Benefit Realized

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, www.whatswrongwithme.com says its 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 Care10% Genetics20% Environment 20% Lifestyle 50% 1. U.S. Department of Health and Human Services. Healthy People 2010. 2nd 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, McGinnis JM, Foege WH. US Department of Health and Human Services, Washington, DC 20201.JAMA. 1993 Nov 10;270(18):2207-12.

Consumer Internet The New Healthcare Consumer New Science Three Market Forces Converge Three Market Forces Converge 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 2nd 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 Source: Cyber Dialogue, Industry Brief, Year 2001, Number 1 Referral Content & eCommerce Personalized 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 33 % information about a sensitive topic Source: Pew Internet And American Life Project, May 2002, 2003

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

Evidence of Personal Health Benefits 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 CHESS - 5 of 8 QOL improvements; length of medical visits decreased (David Gustafson, University of Wisconsin, 2001, 2004 Randomized trial)

Relay Health: webVisit SM Interview Select from 120+ Common Symptoms, 18 Chronic Conditions

webVisit SM Interview MD-Authored/Reviewed Interviews Dynamic Branching

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

View Patient webVisit SM Interview Summary Health Record Concise Message Format

Reply to Patient webVisit SM Interview Customizable Templates, Save Time Typing, Reimbursement Key

Attach an eScript Powerful Prescribing Wizard Interaction and Formulary Check

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

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 wouldnt 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

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

Problem: Chronic Care & Biometrics Blood Glucose Monitors: Accu-Chek Active Accu-Chek Advantage Accu-Chek Compact Accu-Chek Complete Ascensia Breeze Ascensia Contour Ascensia Elite XL Bayer Glucometer DEX Bayer Glucometer DEX2 Bayer Glucometer Elite XL BD Logic BD Paradigm Link In Duo One Touch Basic One Touch II One Touch Profile One Touch Ultra One Touch UltraSmart One Touch Sure Step Precision Q-I-D Precision XTRA Prestige Smart System TrueTrack Smart System TheraSense FreeStyle Diabetes Management Cardiac Management Respiratory Management Insulin Pumps: D-TRON Plus Blood Pressure Cuffs: A&D LifeSource UA-767PC (Arm) OMRON HEM-637 (Wrist) OMRON HEM-757 (Arm) Digital Scales: A&D LifeSource UC-321H* Digital Spirometry: AirWatch Lipid Testing: CardioChek PA* ( cholesterol, triglycerides, glucose, & ketones)

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

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

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. Trans- portation Education Public Safety Economy Environment HealthGovernment

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. Public Safety Environment Environment Health Health Government Education Trans - portation Economy Economy Healthy Communities Network User

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

Design of Personal and Community Health Information Networks Based On Change Theories Theory Change Process Implied Feature ImplementationTechnologiesExamples Consensualist Evolving values of consensus Evolving values of consensus Taking person initiative for societal change Deconstructing and reconstructing explicit norms Organization & mobilization of grass roots groups Organization & mobilization of grass roots groups Discussion and debate Discussion and debate Email broadcast, newsgroups, lotus notes Needed: large-scale decision making groupware Political action based on values Social Conflict Ideological differences between social units around materialism Ideological differences between social units around materialism Making information publicly available (re: economic powers and population needs) Making information publicly available (re: economic powers and population needs) Expanded access to electronic democratic forums, electronic town halls Expanded access to electronic democratic forums, electronic town halls Freedom of Information Act Freedom of Information Act Email broadcast, newsgroups, lotus notes Needed: large-scale decision making groupware Political action based on materialism (via Internet) Friere Ideological differences between social units around materialism Ideological differences between social units around materialism Group health education Group health education Social activism Social activism Electronic: disclosure & role-playing groups Electronic: disclosure & role-playing groups Organization & mobilization of grass roots groups Organization & mobilization of grass roots groups Needed: software framework and method of engaging users Political action for community (via Internet) Diffusion Knowledge, persuasion, decision, implementation, confirmation Knowledge, persuasion, decision, implementation, confirmation Societal adoption and popularization of innovations Societal adoption and popularization of innovations Compatibility of CHINs Compatibility of CHINs Engage critical mass of users 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 community decision-making process A dashboard of quality of life indicators Database of best and promising practices Facilitate communication, collaboration and change Key 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 Putting A Face On The Quality Of Life Of Communities Community QOL Record Community QOL Record Education Government Transportation Natural Environment Economy Public Safety Social Environment Arts, Culture, Recreation Public Health Records and Electronic Medical Records Access to Codified Data Access to Codified Data e.g., Immunization Registry Stakeholder and public view Behind the scenes Indicators Tracking Decision Support

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

Physicians Reported Online Needs Source: HIMSS Analytics SM 2004

CPOE Adoption

Bar Coding Planned Use Up Significantly

Wireless Has Legs in Healthcare

PACS Installation Summary

Lessons Learned - Leadership 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 Bring patients into the planning project IT is a catalyst for change But it does not manage the needed transformation it causes.

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

Source: Focus Groups, Feb. 1998 Arthur Andersen Study; Pew Internet And American Life, May, 2002 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) Consumer Trends

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 Wearable/implanted devices

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 HealthCare Foundation, RAND Study, May 2001 Challenge: Quality of Information

eHealth 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 eHealth Code of Ethics Health Internet Ethics (Hi-Ethics) Health on the Net Foundation Code (HON Code) Information on the Net (MedCERTAIN) International Federation of Pharmaceutical Manufacturers Associations (IFPMA) Code of Marketing MedPICS 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):e28. http://www.jmir.org/2001/4/e28/ Challenge: Quality of Information

Quality Initiatives Dont Apply to Many Tools: MedicineOnline 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 Pharmaceutical Executive, Feb. 01; IMS Health 9/2003 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: Quality of Information

Sensors Internal Internal Wearable Wearable Environmental Environmental Providers Outpatient Outpatient Inpatient Inpatient Third Parties Affiliate companies Affiliate companies Purchases (stores) Purchases (stores) User Generated Online HRAs Online HRAs Chat, email Chat, email Surveys Surveys Usage logs Usage logs Clinical Labs Govt. Agencies Surveillance Surveillance Service utilization Service utilization eHealthCompanies Transaction Intermediaries Individual Payors Enrollment Enrollment Transactions/Claims Transactions/Claims Prescriptions Prescriptions Health Data Sources 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 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 nations 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 doctors 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. Im scared, says Ed Mierzwinski, consumer program chief at U.S. Public Interest Research Group. You wont know about a privacy invasion until its 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 patients 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: 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, youre giving the information to hundreds or thousands of people. In Jacksonville, Fla., the 13 year old daughter of a hospital clerk used her mothers 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 fathers gun to kill herself but was stopped by family. The 13 year old, traced by one of the victims 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 Allergies1,354,895 Alzheimers Disease 18,789 Angina113,947 Arthritis and Rheumatism 113,429 Asthma56,580 Back Pain 129,713 Bladder Control and Incontinence 67,157 Bleeding Gums and Gingivitis 151,649 Blindness107,496 Diabetes107,872 Emphysema19,420 Epilepsy10,017 Frequent Headaches 209,107 Frequent Heartburn 242,682 Gastritis121,701 Hearing Impaired 170,958 170,958 Heart Disease 44,780 High Blood Pressure 44,983 High Cholesterol 274,942 Migraines34,049 Motion Sickness 58,753 Osteoporosis20,143 Parkinsons Disease 3,903 Sensitive Skin 376,225 Sinusitis246,266 Thinning Hair and Baldness 682,134 Ulcer47,451 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 States ability to require health plan reporting or audits. Penalties The bill imposes civil money penalties and prison for certain violations. Challenge: Privacy and Security

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. Ensuring that consent is not coerced. Providing recourse if privacy protections are violated. Protecting The Privacy Of Patients Health Information - Summary of the Final Regulation Challenge: Privacy and Security

Protecting The Privacy Of Patients Health Information - Summary of the Final Regulation 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 per person, per year, per standard. Federal Criminal Penalties $50,000 and 1 year in prison for obtaining or disclosing protected health information$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$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 information with the intent to sell, transfer or use it for commercial advantage, personal gain or malicious harm$250,000 and up to 10 years in prison for obtaining or disclosing protected health information with the intent to sell, transfer or use it for commercial advantage, personal gain or malicious harm Challenge: Privacy and Security

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

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 doesnt want you to succeed? Challenge: Sustainability

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 Challenge: Standards and Limited Benefit w/o integration

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

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

Community Health

Healthy Communities Network Stakeholders Examples Of Target Stakeholders 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 : Underserved; Seniors; Childhood/Youth Health; Native Americans; Rural Health; HIV/AIDS; Chronic Diseases; Urban Planning; Smoking Cessation; Domestic Violence; Mental Health; Disaster Preparedness; Others Underserved; Seniors; Childhood/Youth Health; Native Americans; Rural Health; HIV/AIDS; Chronic Diseases; Urban Planning; Smoking Cessation; Domestic Violence; Mental Health; Disaster Preparedness; Others 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 Examples Of Uses

Information Technology In Health Care A Tool For Effective Change Deryk Van Brunt, DrPH Associate Professor, School of Public Health, UC Berkeley Chairman,

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