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
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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
► Community
► Population
Patient)
Industry: The use of emerging
information systems and
communication systems
(Internet) to improve or enable
health and health care.
IT is an enabler, but 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 – 8th 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 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 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 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 AnalyticsSM 2004
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 (60%)
►
…has a long way to go!
Digital Hospital Technology
Element Possibilities
Evidence Of Benefits
Hospital Description
IT Initiative
Benefit Realized
350-bed, private, not-forprofit 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-forprofit 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, not-forprofit teaching hospital
serving urban, rural, and
international populations
Clinical Information system
►$2,906,000
927-bed, academic medical
center serving an urban
population
Automated billing,
admissions, discharges,
pharmacy, laboratory,
radiology, other functions
►$1,167,317
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 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 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
►$7,000,000 annual savings resulting from a reduction in unbillable tests and the
ability to bill patients directly
saved in transcription costs in one year
►28 FTEs eliminated as a result of automatic scanning, problem lists, and EMR,
saving $704,000
Source: Information Technology: Benefits for Selected Health Care Functions, U.S. General Accounting Office, October 2003
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
►
Lifestyle
►
20%
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.
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
1 9 9 6 - 2 0 0 4 In te r n e t U s e
250
M illio n s
o f
P e o p le
200
150
100
50
0
Y e a rs
1996
2002
1998
2004
2000









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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
Millions of Adult Online Users and E-Health Consumers
Online
All Online Users
140
120
100
80
60
40
20
0
E-Health Users
Personalized
Content &
eCommerce
Referral
65.4
31.1
1997
1998
1999
74.9
40.4
2000*
83.6
50.2
2001*
102.2
92.4
68.5
59.1
2002*
Source: Cyber Dialogue, Industry Brief, Year 2001, Number
2003*
1
E-Care &
Community
112.1
78.5
2004*
122.1
88.5
2005*
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
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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
►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: webVisitSM Interview
Select from 120+ Common Symptoms, 18 Chronic Conditions
webVisit Interview
SM
MD-Authored/Reviewed Interviews – Dynamic Branching
Immediate Message Delivery to Inbox
Flexible Notification – email or FAX – Immediate or Periodic
View Patient webVisitSM Interview
Summary Health Record – Concise Message Format
Reply to Patient webVisit Interview
SM
Customizable Templates, Save Time Typing, Reimbursement Key
Attach an eScript®
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
MetrikLink – 30+ devices
AirWatch
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:
•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 ®
Insulin Pumps:
D-TRON Plus
Respiratory Management
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)
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.
Government
Environment
Public
Safety
Economy
Trans-
portation
Education
Health
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
Government
Environment
Public
Safety
Economy
Trans portation
Education
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
•
•
•
Trans-theoretical
•
•
•
•
•
Awareness and
evaluation of risks
leads to action
Seeing need for change
Know which behaviors
are safe & which are not
Learn skills to change
Develop support for
implementing change
•
Precontemplation,
comtemplation,
preparation, action
maintenance
•
•
•
•
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
•
Awareness and
evaluation of risks
Planning tools
Maintenance tools
•
•
•
•
•
•
•
Implementation
Technologies
Examples
Assess community health
Communicate with peers &
leaders about choices
Assessment of individual beliefs
Indicators,
promising
practices, email,
real-time 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, real-time
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, real-time
chat groups,
subject searching,
and simulation
games
HRAs, TLP,
social support
groups,
“Brothers”
video
(modeling
behavior
shows)
Communication with peers &
leaders in an appropriate
framework
Assessment of perceived
capability to sustain change
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
•
Evolving values of
consensus
Consensualist
•
Social Conflict
•
Friere
•
Diffusion
Ideological
differences between
social units around
materialism
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
•
•
Ideological differences
between social units
around materialism
•
Knowledge,
persuasion, decision,
implementation,
confirmation
•
•
•
•
•
•
Technologies
Examples
Organization & mobilization
of grass roots groups
Discussion and debate
Email broadcast,
newsgroups, lotus
notes
Needed: large-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-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 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
Stakeholder and Community
public view
QOL Record
Indicators Tracking
Decision Support
Access to Codified Data
e.g., Immunization Registry
Behind the
scenes
Education
Government
Transportation
Natural Environment
Economy
Public Health
Records and
Public Safety
Electronic
Social Environment
Medical Records
Arts, Culture, Recreation
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
800,000
554,000
524,000
600,000
(95%)
341,000
(62%)
400,000
200,000
117,000
(21%)
0
All Docs
Online Docs
Daily Users
Source: HIMSS AnalyticsSM 2004
Professional
Users
Physicians Reported Online Needs
Search literature
databases
81%
39%
Access professional
society information
68%
21%
Search for info about
Rx drugs
66%
27%
Communicate with
colleagues
62%
38%
Search for patient
education databases
Take CME courses
Access clinical trial
info
61%
21%
45%
10%
41%
12%
Source: HIMSS AnalyticsSM 2004
Use at all
Use at least weekly
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
► Bring patients into the planning project
Consumer Trends
 Analytical skills - some college
 Disposable income - ability to choose
 Information technology - internet literacy
60%
50%
40%
30%
20%
10%
0%
1978
1988
1998
Institute for the Future
2008
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
70%
60%
50%
40%
30%
20%
10%
0%
1995 1996 1997 1998 1999 2000 2001 2002
Personalized, Convenient and Low Cost
Media/Interfaces for Electronic
Communication Applications
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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
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 HealthCare Foundation, RAND Study, May 2001
Challenge: Quality of Information
eHealth Quality Initiatives

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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 Don’t Apply to
Many Tools: MedicineOnline
Source: http://www.medicineonline.com
Challenge: Quality of Information
Stakeholders
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
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
3
2.5
2
1.5
1
0.5
0
1997
1999
2001
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
Billions
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
eHealth
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:
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.”
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
Gastritis
121,701
Allergies
1,354,895
Hearing Impaired
170,958
18,789
Hearing Impaired
170,958
Alzheimer’s Disease
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
67,157
High Cholesterol
274,942
Migraines
34,049
Motion Sickness
58,753
20,143
Bleeding Gums and Gingivitis
151,649
Osteoporosis
Blindness
107,496
Parkinson’s Disease
Diabetes
107,872
Sensitive Skin
376,225
3,903
Emphysema
19,420
Sinusitis
246,266
Epilepsy
10,017
Thinning Hair and Baldness
682,134
Frequent Headaches
209,107
Ulcer
47,451
Frequent Heartburn
242,682
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.
Penalties
The bill imposes civil money penalties and prison for certain violations.
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.
 Ensuring that consent is not coerced.
 Providing recourse if privacy protections are violated.
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
• $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
Challenge: Sustainability
Many Internet Companies Have
Shut Down
Number
Internet Company Shutdowns, Jan 2000 - Feb 2002 (n=806)
80
70
60
50
40
30
20
10
0
Ja
50 49
36
13
17 20
55
60 61 60
60
44
39 38
33
22
26
21 23 19 18
10
1 2 2 1
00
n
0
1
0
1
0
1
1
2
0
1
0
1
-0 n-0
-0 n-0
-0 y-0
-0 y-0
-0 p-0
-0 p-0
l
l
r
r
v
v
a
a
o
o
a
a
Ju Se
Ju S e
Ja
Ja
M
N
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Month
Source: Webmergers.com.http://www.webmergers.com/editorial/article.php?id=41
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 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