Perspectives on Public- Private
Open Collaboration
Ned McCulloch, JD
Governmental Programs
Pain Points Driving Legislation
Quality and Cost
Stagnant Quality
Rising Costs
Medicare Spending (billions)
Billions
800
600
400
200
2014
2012
2010
2008
2006
2004
2002
2000
1998
1996
1990
1980
1970
0
Year
The National Quality Report found that
half of the 98 measures with trend data
show modest change, and 30
deteriorated.
Medicare spending is projected to
grow from $345 B in 2005 to $742B in
2014
2
2
Privacy
President Bush April 27, 2004
“...there's a lot of people in America who say, good,
I want there to be good information technology
in the health care field, I just don't want
somebody looking at my records unless I give
them permission to do so. And I fully understand
that. And your records are private, if that's the
way you want them to be.”
3
3
IBM Healthcare premiums have been growing significantly lower
than US Health Insurance Premiums
US Health Insurance Premiums*
1999-2005
16%
13.9%
14%
12.9%
12%
10.9%
10%
10.9%
11.2%
12.0%
9.2%
Health Insurance Premiums
8.2%
IBM HC Inflation
Overall Inflation
8%
7.3%
6%
4%
6.9%
7.2%
2004
2005
Workers Earnings
5.4%
2%
0%
1999
2000
2001
2002
2003
IBM’s GWBS & HB organization has designed and
implemented a range of programs to minimize healthcare
costs
Sources: *The Kaiser Family Foundation and Health Research and Educational Trust: Employer Health Benefits 2005 Annual Survey. Marianne Defazio for IBM growth rates.
4
© 2006 IBM Corporation
Healthy Living Rebates
IBM’s injury and illness rates are consistently lower than industry
levels and on par with peer services firms
Injury/Illness Rates (US only)
8
Rate per 100 Employees Per Year
7
6
5
4
3
2
1.34
1.04
1
0
1997
1998
1999
Private Industry
5
0.78
2000
Peer Semiconductor
0.75
0.62
0.58
0.48
2001
2002
2003
2004
Peer Services
IBM Corporation
© 2006 IBM Corporation
Health Information Technology
Provisions:
• Drive adoption of open standards by the federal
government and private industry;
• Commit initial seed funding and make early
policy choices that will set the stage for growth
of health information exchange; and
• Create incentives in Medicaid and Medicare to
reward quality of care, including those that can
be measured and rationalized through the use of
health information technology (Health IT).
6
6
Detail of Legislation Affecting HIT
House
Authorizing
Senate
Companion Bills
Rep. Johnson/Deal introduce
H.R. 4157;
Rep. Porter introduces
Personal Health Record
Passed
Senate;
Pending
House
Wired for Health Care
Quality Act of 2005
(Enzi, Kennedy) (S.1418)
Authorizing
7
Effective only for one year.
Additional funding will have to be
provided in subsequent years.
Appropriations
House Committee recommended
$75M for ONCHIT
(H.R. 3010) Appropriations for
Labor/HHS/ Education and
related agencies
Conference Report
includes $61.7 million and
Standards Language
Senate Committee
recommended
providing ONCHIT
$45M
Appropriations
Once passed stays in place until
changes are passed.
Entitlement
Spending
Medicare Value-Based
Purchasing for Physicians'
Services Act (Johnson)
H.R. 3617
Companion Bills
Mandates that can have lasting market
effects but need additional funding
appropriated for new grant authority.
P4P Passed
Senate;
Dropped in
Conference;
Additional
Medicaid
Provisions
enacted
Medicare Value Purchasing
Act (Grassley, Baucus)
(S. 1356) folded into S. 1932
(Budget Reconciliation)
Entitlement
Spending
7
Passed in Appropriations:
Increased Funding for ONCHIT and AHRQ
Total funding for the Office of the National Coordinator
for Health Information Technology (ONCHIT) was
$38M in FY 2005 but will rise in ’06 to $61.7 million
• This funding has been used to staff Dr. Brailer’s office,
initiate a national outreach program, make multiple
$250K- $2M grants, and issue & evaluate RFIs and RFPs
The Agency for Healthcare Research and Quality
(AHRQ) received approximately $50M for research
into health information technology and related areas
in FY 2005 and will receive similar funding in ‘06
• This funding was used for grants, studies and on-going
research into how IT can help improve health care quality
David Brailer, MD, PhD,
Office of the National
Coordinator for Health
Information Technology
(ONCHIT)
8
Passed in Appropriations:
Standards Language
Interoperability.—The Committee commends the efforts by the
Secretary to increase interoperability within healthcare. Through
the Consolidated Health Informatics [CHI] Project, 24 electronic
standards have been identified to allow sharing of clinical information.
The Committee urges the Secretary to implement procedures
to enable the Department to accept the optional submission of data
derived from health care reporting requirements for the purposes
of quality, surveillance, epidemiology, adverse event reporting, or
research using the electronic standards identified under the CHI
project.
9
Open Standards for Agencies
Passed Senate; Pending in House in Second Session
• `(f) Coordination of Federal Spending- Not later than 1 year after the
adoption by the Federal Government of a recommendation as
provided for in subsection (e), and in compliance with chapter 113 of
title 40, United States Code, no Federal agency shall expend
Federal funds for the purchase of any form of health information
technology or health information technology system for clinical care
or for the electronic retrieval, storage, or exchange of health
information that is not consistent with applicable standards adopted
by the Federal Government under subsection (e).
• `(g) Coordination of Federal Data Collection- Not later than 3 years
after the adoption by the Federal Government of a recommendation
as provided for in subsection (e), all Federal agencies collecting
health data for the purposes of quality reporting, surveillance,
epidemiology, adverse event reporting, research, or for other
purposes determined appropriate by the Secretary, shall comply with
standards adopted under subsection (e).
10
Medicare Pay for Value: Passed Senate, but
Dropped in Budget Conference; may be acted on in ‘07
Billions
Medicare Pay for Value Funding
$16
$14
$12
$10
$8
$6
$4
$2
$0
2007
2008
2009
2010
2011
2012
2013
2014
P4Value
Funding
projected to
grow from
$4.79 B in
2007 to
$14.84 B in
2014
Year
11
Congress Moves toward PHRs
Bill would give feds e-health records
BY Nancy Ferris
Sep. 30, 2005
Rep. Jon Porter (R-Nev.) said yesterday that he plans to introduce
legislation to mandate the creation of an electronic health record
(EHR) for every person covered by the Federal Employees Health
Benefits (FEHB) Program.
Porter, who heads the House Government Reform Committee’s
Federal Workforce and Agency Organization Subcommittee, said
the program would become “the largest [health information
technology] demonstration project in the country.” The program
covers about 4 million current and retired federal employees.
12
Top Three -- Legislation for HIT in 2005
$111 million in HIT Appropriated funding in 2006
continuing to rise in subsequent years with
Medicaid
Provision to support use of Open Standards for
Reporting
Medicare Reforms Resulting in Pay for Value
Funding that will grow from $4.79 Billion in 2007
to $14.84 B in 2014
13
IBM Governmental Programs
Integrating Available Clinical Information Can Solve
Spectrum of Health Needs
Lab Tests
Diagnosis
14
14
IBM Governmental Programs
Quality Measures Provide Roadmap for Creating
Linkages to Healthcare Data
26% of Medicare
Patients with AMI and
left ventricular ejection
fraction<0.40 were not
given ACE Inhibitor
Lab
15
15
Pharmacy Diagnosis
Improving
Care for
Heart Attack
Victims can
start with
links to
three types
of data
IBM Governmental Programs
Balancing Current Patient Health Costs and Proposed
Investments in Information Technology
Cost of Gaps
in Health
Treatments
Cost of
Proposed
Health
Information
Technology
1. Pick a Health Problem (Diabetes, Heart Attacks, Cancer)
2. Calculate Total Cost of Health Problem
3. Identify Gaps in Treatment of Health Problem (errors, compliance)
4. Estimate Cost of Information Technology to Reduce Treatment Gap
(including Hardware, Software, Services, and other Costs)
5. Evaluate Efficacy of Health Technology to Reduce Gap
6. Balance Costs and Decide on Investment
16
16
IBM Governmental Programs
Health Data Anchor Tenants in Indianapolis Landscape
100
Other
Other
Other
90
% of Central Indiana market
South Bend
80
Wishard
LabCorp
70
Other
Medicaid
St. Francis
Anthem
Other
Community
United
IHN
MACL
(Quest)
60
50
St. Vincent
40
St. Francis
Care Group
St. Vincent
Corvel
CPI
M-Plan
ICM
RxHub
MMG
St. Francis
AHN
St. Vincent’s
20
10
Wishard
Community
30
Medicaid
IUMG
Clarian
Clarian
Sagamore
Anthem
0
Hospitals
% Patient Days
17
17
Laboratories
% Lab Tests
Outpatient RX
% RXs Cleared
Physician practices
% Physicians
Health insurers
% Covered Lives
IBM Governmental Programs
Connecting Data
to Missions – the
Standards Wheel
Mission
Electronic
Standard
Clinical
Information
18
18
IBM Governmental Programs
Which Pipes to Connect First – Prioritizing Pay for Use Reimbursement
Agency or other data user
CMS
Diagnosis
Type
of
Data
Drug
Laboratory
19
19
CDC
NIH
AHRQ
Physician
Discharge
High
High
Medium
High
High
Medium
16
Admitting Complaint
Medium
Low
High
Medium
Medium
High
13
Provider Notes
Medium
Low
Medium
Medium
Medium
High
12
Order
Medium
Medium
High
High
High
High
16
Dispense
Medium
Medium
Low
Medium
Medium
Low
11
Administration
High
Medium
Medium
Medium
Medium
High
14
Blood levels, titers,
and other structured
(coded) data
High
High
High
High
High
High
18
Culture reports and
other unstructured
(free text) data
Low
High
High
High
High
High
16
Genomic
Low
High
Low
High
Low
High
12
Low
High
High
High
Medium
High
Next of Kin
Low
Low
High
Medium
Low
High
11
Home Address
High
Low
High
Medium
Medium
Medium
13
24
25
30
30
26
32
Radiology
Demographic
FDA
Total
Priority*
Architectural Principles
 Protocols To Be Used for the Storage and Access of Clinical Data --Design a




20
model architecture for healthcare markets and interaction between healthcare markets that
utilizes the Integrating the Healthcare Enterprise (IHE) Cross-Enterprise Document
Sharing (XDS) profile.
The Physical Location of the Clinical Data -- Designate a “home” healthcare
market for each patient, and locate all clinical documents for that patient there. A subset of
health information, known as the “critical clinical information,” will be kept in a single
document repository within the healthcare market infrastructure so that it is readily
available when needed while other, less critical information, will be maintained within the
source systems and accessed when needed.
Modify Existing Healthcare Markets vs. Build an Adapter -- Build StandardsBased “Adapters” for existing healthcare markets that already have an information sharing
capability within the community itself but would like to extend this capability to include
participation within the NHIN ecosystem.
National Patient Registry vs. Federated Registry -- No national patient registry,
but within each healthcare market utilize a patient registry/cross-reference service that is
based upon the IHE PIX (Patient Identifier Cross Reference) profile. Also, create a national
Public Health Events Registry to track specific events that are related to public health.
Data Security --Personally identifiable information deserves the highest level of security
protection. Encrypt data during message transfers; investigate the feasibility of encrypting
data while at rest (in databases).
© 2006 IBM Corporation
Conceptual Architecture that Addresses Privacy
Concerns from IT Vendors
National Health Information Network (NHIN) Hub
NHIN Conceptual Architecture
 Some demographic data
should be stored either
regionally, nationally, or at
HISPs to reduce complexity,
improve performance, and
allow for future
development of valueadded services
 Limited critical clinical
information will likely need
to be aggregated and
stored regionally for the
same reasons
 Actual patient records will
remain in source systems
controlled by patients or
their care providers
NHIN
NHIN
Cross
Cross Ref
Ref
Locator
Locator
Patient
Patient
Event
Event
Pointers
Pointers
NHIN
NHIN
Provider
Provider
Directory
Directory
NHIN
NHIN BUS
BUS Core
Core Services
Services
Marketplace 1:
Clinical Information Exchange
Prov.
Prov.
Dir.
Dir.
CIE
CIE
MPIs
MPIs
Patient
Patient
Access
Access
Profiles
Profiles
Critical
Critical
Clinical
Clinical
Info.
Info.
Marketplace 2:
Clinical Information Exchange
Secure Data Transfer
HISP
HISP BUS
BUS Core
Core Services
Services
Electronic
Health
Records
Patient
Patient
Access
Access
Profiles
Profiles
Prov.
Prov.
Dir.
Dir.
CIE
CIE
MPIs
MPIs
HISP
HISP BUS
BUS Core
Core Services
Services
Home Clinical Care
Setting
Local
Local
MPIs
MPIs
Critical
Critical
Clinical
Clinical
Info.
Info.
Remote Clinical Care
Setting
Lab
Tests
Emergency
Room
Primary Care
Physician
Local
Local
MPIs
MPIs
Hospital
Visits
Specialist
Referrals
Electronic
Health
Records
Patient
Centric Care
21
© 2006 IBM Corporation
IBM Initiative Advances Open Software Standards In Healthcare
and Education
ARMONK, N.Y. - 24 Oct 2005: IBM's healthcare and education practices
today announced a major initiative to improve interoperability and
information-access through the development of open software standards.
Under this initiative, IBM is pledging royalty-free access to its patent portfolio
for the development and implementation of selected open healthcare and
education software standards built around web services, electronic forms and
open document formats.
22
© 2006 IBM Corporation
IBM Provides Its U.S. Workers With Digital Medical Records
IBM is giving its 150,000 US employees and
their dependents access to online tools,
including electronic health records, to help
them better manage their personal health.
InformationWeek Oct 19, 2005 06:00 PM
23
© 2006 IBM Corporation
IBM is Funding RHIOs in Employee-Dense Geographies
Taconic Health Information Network & Community – A Multistakeholder community-wide medical data exchange among Hudson
Valley physicians, hospitals, reference laboratories and health insurers
Participants: Benedictine Hospital, Kingston Hospital, Vassar Brothers
Medical Center, LabCorp, MVP HealthCare
64,000 IBM covered lives
2004: Physicians’ portal
2005-6: e-Prescribing (eRx)
2006: Electronic health records
IBM engagement
Chair payers’ subcommittee; consensus is building on pay-for-adoption and
pay-for-performance incentives
Rollout of e-Prescribing began July 1; target: 100 PCP’s in Ulster &
Dutchess Counties in 2006; ROI 3:1 – 6:1
IBM pays $0.50 PMPM incentive for eRx technology adoption and use
24
© 2006 IBM Corporation
IBM Governmental Programs
Reporting Hasn’t Changed Much Over the Years
Report to Temple
2350 BC, Sumeria
25
25
Report to Federal Agency
2005 AD, USA