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Health IT Strategic FrameworkReadiness for Change in Health CareStakeholders involved in the delivery of health care in the U.S. recognize the critical role of HIT in making health care safer and more efficient by enabling complete, accurate, and timely information at the point of care for both clinicians and consumers. Each of these groups understands that HIT is critical to delivering safe, affordable, and consumer-oriented health care, as well as helping to mitigate public health and bioterror threats. This consensus results from the convergence of a variety of issues that shape the reality of health care today. Arising from this is a new paradigm for care that is built upon seven critical needs:
Each of these needs is summarized in the sections below. Avoid medical errorsThe IOM has estimated that 44,000 to 98,000 deaths occur each year as a result of preventable medical errors in hospitals. Additional research has shown that over 770,000 people are injured or die each year in hospitals from adverse drug events (Classen 1997, Cullen 1997, Cullen 1995). Consumers are vulnerable to errors when they receive care from multiple sites, so the lack of timely exchange of information has been a longstanding safety and quality concern among clinicians. Many new efforts are under way to evaluate and address medical errors, including the use of HIT, but new techniques and strategies are needed. There is growing evidence that the use of HIT improves consumer safety, quality, and continuity of care. There is consistent evidence that errors can be reduced by the appropriate use of computerized provider order entry (CPOE) and decision support systems (DSS), particularly in the case of drug prescribing, dispensing, and administration. For example, at LDS Hospital in Salt Lake City, a CPOE system reduced adverse drug events by 75% (Evans et al., 1998). Also, at the Regenstrief Institute for Health Care in Indianapolis, researchers demonstrated that automated computerized reminders increased orders for recommended interventions from 22% to 46% (Overage et al., 1997). A 1998 systematic review of the literature assessing the effects of 68 computer-based clinical DSS demonstrated a beneficial impact on physician performance in 43 of 65 studies, and a beneficial effect on patient outcomes in 6 of 14 studies (Hunt et al., 1998). A new pharmacy software system implemented by DoD in 2001 that integrates and reviews information from all sources prior to prescriptions being filled has eliminated over 100,000 adverse drug interactions. Improve use of resourcesThe United States spent an estimated $1.7 trillion on health care in 2003, and increases in health care spending continue to surpass increases in the rate of inflation. As new treatments and diagnostic tools are developed, the population ages, and demand increases for more specialized and intensive services, America will need innovative cost-containment tools. Studies have shown that nearly 30% of health care spending, or up to $300 billion each year, is for treatments that may not improve health status, may be redundant, or may be inappropriate for the patient's condition (Wennberg et al., 2002, Wennberg et al., 2004; Fisher et al., 2003, Fisher et al., 2003). Some studies estimate that HIT has the potential to reduce inefficient use of resources. These studies demonstrate that use of EHRs can reduce laboratory and radiology test ordering by 9% to 14% (Bates et al., 1999; Tierney et al.,1987, 1990), lower ancillary test charges by up to 8% (Tierney et al,. 1988), reduce hospital admissions, costing an average of $16,000 each, by approximately 2% (Jha 2001), and reduce excess medication usage by 11% (Teich et al., 2000). While these studies are encouraging, more work needs to be done to determine the economic benefits of HIT. This work is corroborated by findings in the DoD and VA, where the use of the CPOE has largely eliminated lost laboratory reports and pharmacy and radiology orders and the duplication of tests. Two studies have estimated that ambulatory EHRs could potentially save $78 billion to $112 billion annually, across all payers. This estimate includes $44 billion in annual savings from ambulatory EHRs (Johnston, et al., 2003) and $78 billion annually from interoperability of those EHRs, totaling $112 billion per year (Pan et al., 2004). There is also evidence that EHRs can reduce administrative inefficiency and paper handling (Khoury, 1998). These studies, while limited in number and scope, suggest that economic benefits of HIT could be large, and that further work is needed to determine the magnitude of these benefits. Accelerate diffusion of knowledgeMedical knowledge is rapidly changing from breakthroughs, such as those in molecular biology, that accelerate the introduction of new medications. However, even well synthesized knowledge faces many hurdles to being used in clinical practice. Estimates are that, on average, it takes 17 years for evidence to be integrated into clinical practice (Balas et al., 2000). Because of the enormous amount of information available, health care professionals find it increasingly difficult to keep current with new findings in their clinical practices. Research has shown that physicians incorporate the latest medical evidence into their treatment decisions 50% of the time (McGlynn et al., 2003). When clinical knowledge is coupled with HIT through electronic reminders and other context-sensitive workflow, positive changes in practice have been observed. For example, a health information system used more than 20 years ago at Massachusetts General Hospital showed improved quality of care when reminders were provided to physicians (Barnett et al., 1978). Other studies have suggested that physicians who receive electronic clinical reminders follow medical evidence more frequently than physicians who do not receive these reminders. (AHRQ, Research in Action, 2002.) Reduce variability of careMany studies have demonstrated that geographic location is a strong determinant of specialty care access and procedural decision making (Wennberg et al., 2002). These variations in regional patterns are principal determinants of differences in health status across rural and urban populations. While specialty care oversupply in urban areas is linked to higher costs, rural areas lack specialists. Advances in telehealth allow physicians to consult each other or to communicate with patients and remotely perform other diagnostic and therapeutic services. These technologies allow patients to be seen by the best specialist for their illness, regardless of where they live. They also enable physicians in rural and underserved areas to keep their knowledge current via distance education. Telehealth projects in such areas as home health and chronic disease management have shown significant cost savings for health care systems. Therefore, improvements in the use and commonality of information technology should only further improve the practice of telemedicine. Advance consumer roleConsumer expectations for health care are particularly important in today's environment. Consumers often lack information to understand their treatment choices or to select physicians and other clinicians appropriate for their needs, and they do not like to fill out forms with repetitive information. Consumers report that they often do not feel that they are the principal decision maker for their health care and may feel instead that critical choices are being made by their clinician or their health plan. Advances are being made in bringing consumers directly into decision-making roles regarding their care, many using HIT. One study (Fox et al., 2003) reported that 52 million Americans access health or medical information on the Web. Increasingly, consumers are accessing health information via the Web. The National Library of Medicine's MEDLINE is accessed by consumers as frequently as by health care professionals and researchers. Consumers most commonly use MEDLINE to access information about specific conditions or diseases (e.g., diabetes, asthma, cancer, etc.) and medications (e.g., Celebrex). Within the federal government, the VA is beginning to engage veterans by providing them with a personal health record (PHR) called My HealtheVet. My HealtheVet is a secure, Web-based PHR system that allows veterans access to key parts of their VA health record and to view and update their own health information. The DoD also provides a similar resource with TRICARE Online (TOL). TOL is the enterprise-wide, secure Internet portal that is used by DoD beneficiaries, providers, and managers worldwide to access available health care services, benefits, and information. Consumers are also beginning to have access to information about the performance of their clinicians so that they can select those who best meet their needs. For example, CMS now provides consumers with information about the quality of nursing home and home health providers, and is working to make hospital quality measures available as well. The National Committee for Quality Assurance (NCQA), through its online tools, posts comparative information about physicians, health plans, hospitals, and other providers. Strengthen privacy and data protectionSince the enactment of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), there has been heightened awareness by stakeholders of the need for strong privacy and security protections for identifiable health information. Federal standards adopted pursuant to HIPAA for privacy and security protections for individually identifiable health information have and will continue to strengthen the privacy and security of health information within the health care industry and to prevent potentially harmful practices and the effects of the inappropriate disclosure of this information. With the increasing use of HIT to manage and exchange information in the clinical setting, maintaining and improving consumer confidence in the privacy and security of their health information will continue to be essential to the success of these efforts. HIT, despite fear that it poses risks for the dissemination of health information, may in many ways provide better controls over information by providing more privacy and security for health information than paper-based medical records. Efforts to protect paper records may come at the cost of the portability. However, EHRs have the potential to provide a less burdensome means of meeting HIPAA privacy and security standards of providing and limiting access to records and of tracking who has had access to consumer information on an individual's specific health record. Building on these, the VA and the DoD are actively collaborating on enhancing security standards that enable the protection and security of health data, including identification, confidentiality, integrity, authentication, and certification. The baseline for this security was laid out in the HIPAA security rule. Promote public health and preparednessWhether in response to disease outbreaks spread through global travel or declining immunity, or from man-altered pathogens that intend to produce disease and death, the ability to monitor and react to outbreaks is important. However, much real-time information is needed to detect and pinpoint an outbreak, and this information requires marked changes in how health care information is collected, stored, and exchanged. There have been significant improvements in preparedness. Substantial investments are being made to get health information for public health and preparedness. DoD is providing discrete and aggregated data and forwarding diagnosis information to the Centers for Disease Control and Prevention (CDC) for study and analysis. In an average week, DoD forwards the ICD-9 and geographic information for 890,000 medical encounters, enhancing the CDC's ability to perform symptom surveillance in support of homeland defense and public health. |
Last revised: July 26, 2004
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