Theera-Ampornpunt N. [Electronic Health Records: What Does The HITECH Act Teach Thailand?]. Presented at: Health Informatics: From Standards to Practice. Thai Medical Informatics Association Annual Conference 2010; 2010 Nov 10-12; Nonthaburi, Thailand. Panel discussion, in Thai.

1. Electronic Health Records:Electronic Health Records:
“อเมริกาเข้มแข็ง” สอนอะไรไทย?อเมรกาเขมแขง สอนอะไรไทย?
นพ นวนรรน ธีระอัมพรพันธ์ M S (Health Informatics)นพ.นวนรรน ธระอมพรพนธุ, M.S. (Health Informatics)
ฝ่ายเวชสารสนเทศ คณะแพทยศาสตร์ รพ.รามาธิบดี
11 พฤศจิกายน 2553
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@Nawanan @ThaiHealthIT Except where referred
to or copied from
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other works

2. Outline
• Electronic Health Records & Health IT
• HITECH Act
• Meaningful Use of EHRs
Lessons for Thailand• Lessons for Thailand

3. Electronic
H lth R dHealth Records

4. The Challenge - Knowing What It Means
Electronic Medical
Computer-Based
Patient RecordsElectronic Medical
Records (EMRs)
Patient Records
(CPRs)
Electronic Patient
Records (EPRs)Electronic Health
Records (EHRs)Records (EHRs) Personal Health
Records (PHRs)

5. Electronic Health Records (EHRs)
• Electronic documentation of patient care by providers
• Sometimes defined as a patient’s life-long records

6. Electronic Health Record (EHR) Systems
• Are they just electronic documentation?
Diag-
nosis
History
& PE
Treat-
ments
...
nosis& PE ments
• Or do they have some other values?

7. Common “Goals” for Adoption
“Computerize”“Go paperless”
“Di it l H it l”
“Get a HIS”
“Digital Hospital”
“Modernize”
“Have EMRs”
“Sh d t ”“Share data”

8. Benefits of Health Information Technology
• Literature suggests improvement in health care through
– Guideline adherence (Shiffman et al, 1999;Chaudhry et al, 2006)
– Better documentation (Shiffman et al, 1999)
– Practitioner decision making or process of care
(Balas et al, 1996;Kaushal et al, 2003;Garg et al, 2005)
– Medication safety (Kaushal et al, 2003;Chaudhry et al, 2006;van Rosse et al, 2009)
– Patient surveillance & monitoring (Chaudhry et al, 2006)
– Patient education/reminder (Balas et al, 1996)
– Cost savings and better financial performanceCost savings and better financial performance
(Parente & Dunbar, 2001;Chaudhry et al, 2006;Amarasingham et al, 2009;Borzekowski, 2009)

9. Functions that Should be Part of EHR Systems
• Computerized Medication Order Entry (IOM, 2003; Blumenthal et al, 2006)
C t i d L b t O d E t• Computerized Laboratory Order Entry (IOM, 2003)
• Computerized Laboratory Results (IOM, 2003)
Ph i i N t• Physician Notes (IOM, 2003)
• Patient Demographics (Blumenthal et al, 2006)
P bl Li t• Problem Lists (Blumenthal et al, 2006)
• Medication Lists (Blumenthal et al, 2006)
Di h S i• Discharge Summaries (Blumenthal et al, 2006)
• Diagnostic Test Results (Blumenthal et al, 2006)
R di l i R t• Radiologic Reports (Blumenthal et al, 2006)

10. The Bigger Picture: Health Information Exchange
G t
Hospital A Hospital B
Government
p
Clinic CClinic C
Lab Patient at Home

11. Common Denominator
• Health Information TechnologyHealth Information Technology
• Electronic Health Records• Electronic Health Records
• Health Information Exchange• Health Information Exchange

12. Ultimate Goal = Health
• Don’t implement technology just for technology’s sake.
(Yasnoff et al, 2001 and many others)
• “Don’t make use of excellent technology.
Make excellent use of technology.”
(Tangwongsan, Supachai. Personal communication, 2005.)

13. U.S. Adoption of Health IT
Ambulatory (Hsiao et al, 2009) Hospitals (Jha et al, 2009)
Basic EHRs w/ notes 7.6%
Comprehensive EHRs 1 5%Comprehensive EHRs 1.5%
CPOE 17%
U S l b hi d th W t t i• U.S. lags behind other Western countries
(Schoen et al, 2006;Jha et al, 2008)
• Money and misalignment of benefits is the biggest reason

14. ็“อเมริกาเข้มแข็ง”
(ARRA/HITECH A t)(ARRA/HITECH Act)

15. American Recovery & Reinvestment Act
• Contains HITECH Act (Health Information Technology for
Economic and Clinical Health Act)
• ~ 20 billion dollars for Health IT investments
Goals:Goals:
1. Boost economy (economic health)
2 Widespread adoption of Health IT (clinical health)2. Widespread adoption of Health IT (clinical health)
Quality Patient Safety Costs

16. National Leadership
• Office of the National Coordinator for Health Information
Technology (ONC -- formerly ONCHIT)
David Blumenthal, MD, MPP
National Coordinator forNational Coordinator for
Health Information Technology
(2009 - Present)(2009 Present)
Photo courtesy of U.S. Department of Health & Human Services

17. Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.

18. “Meaningful Use”Meaningful Use

19. “Meaningful Use” of A Pumpkin
“Meaningful Use”
of a Pumpkin
Pumpkin
of a Pumpkin
Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

20. Meaningful Use of EHRs: ONC’s 3-Stage Approach
Stage 1
- Electronic capture of
health information
Better
Healthhealth information
- Information sharing
- Data reporting
Stage 2
Stage 3
Use of
Health
p
Use of EHRs
to improve
processes of
EHRs to
improve
outcomesprocesses of
care
outcomes
Blumenthal D, 2010

21. Components of Meaningful Use Regulations
• Medicare & Medicaid Incentives for Meaningful Use of EHRs
– Centers for Medicare and Medicaid Services (CMS)
• Rule on Standards, Implementation Specifications &
Certification Criteria
• Certification Programsg
– Office of the National Coordinator for Health IT (ONC)

22. Meaningful Use Incentives: Stage 1
Proposed Rule
• 23 Criteria for Hospitals to Pass
25 Criteria for Professionals (Clinics) to PassProposed Rule
(Jan. 2010)
• 25 Criteria for Professionals (Clinics) to Pass
Public Hearing
• Pace & Scope: too ambitious, demanding, inflexible
• Few providers would likely qualify -> Little adoptiong
C Obj ti (15 it i i d)
Final Rule
• Core Objectives (15 criteria, required)
• Menu Set (10 criteria, pick 5)
Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

23. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

24. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

25. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

26. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

27. Meaningful Use Final Rule: Core Objectives (Selected)
• Electronic capture of information
– DemographicsDemographics
– Vital signs
– Medication listMedication list
– Allergies
– Problem listProblem list
– Smoking
• Medication order entry• Medication order entry
• Drug-allergy & drug-drug interaction checks
P ti t t / f h lth i f ti• Patient access to/copy of health information

28. Meaningful Use Final Rule: Menu Set (Selected)
• Drug formulary checks
• Lab results incorporation into EHRs• Lab results incorporation into EHRs
• Generate lists of patients by specific conditions
M di ti ili ti• Medication reconciliation
• Electronic reporting to governmental agencies
• Advanced directives for elderly patients
• Patient reminders for certain services (for clinics)
• Patient access to health information (for clinics)

29. Final Rule on Standards & Certification Criteria (Selected)
• Content Exchange Standards
– HL7 CDA Release 2 & CCDHL7 CDA Release 2 & CCD
– NCPDP SCRIPT
• Vocabularies• Vocabularies
• SNOMED CT
LOINC®– LOINC
– RxNorm®
• Security• Security
– NIST-certified encryption algorithms
Et• Etc.

30. Critique:q
L f Th il dLessons for Thailand
Disclaimer: Personal opinions. Supporting scientific evidence may not be available.

31. Lesson #1
Clear aim toward improved quality &Clear aim toward improved quality &
efficiency of health careefficiency of health care.

32. Lesson #2
Large health IT initiatives requireLarge health IT initiatives require
leadership from the highest levelleadership from the highest level
of governmentof government.

33. Lesson #3
To achieve widespread health ITTo achieve widespread health IT
adoption substantial financialadoption, substantial financial
investment is necessaryinvestment is necessary.

34. Lesson #4
Leadership from a nationalLeadership from a national
organization with health informaticsorganization with health informatics
expertise is vital to successexpertise is vital to success.

35. Lesson #5
Criteria for “Meaningful Use” shouldCriteria for Meaningful Use should
be evidence basedbe evidence-based
to the extent possibleto the extent possible.

36. Lesson #6
Criteria for incentives should beCriteria for incentives should be
realistic and flexiblerealistic and flexible.

37. Lesson #7
Criteria for incentives should beCriteria for incentives should be
evolutionaryevolutionary.

38. Lesson #8
Accept local diversity in technologiesAccept local diversity in technologies
& requirements& requirements.
Don’t aim for homogeneousDon t aim for homogeneous
environmentenvironment.

39. Lesson #9
Leverage existing standardsLeverage existing standards
to the extent possibleto the extent possible.
Don’t reinvent the wheelDon t reinvent the wheel.

40. Lesson #10
Acknowledge that more than oneAcknowledge that more than one
level of interoperability needs to belevel of interoperability needs to be
achievedachieved.

41. Take Home Message
• Adoption of health IT still work in progress, even
in developed countriesin developed countries
• We can learn something from other countries
• We need to do something, soon.
• Don’t forget to build the workforce!!• Don t forget to build the workforce!!

42. Useful Online Resources
• healthit.hhs.gov
• www.himss.org/EconomicStimulus/
• www.amia.org/public-policy/testimony-www.amia.org/public policy/testimony
comments-reports
• www.nejm.org/doi/full/10.1056/NEJMp0912825
• www nejm org/doi/full/10 1056/NEJMp1006114• www.nejm.org/doi/full/10.1056/NEJMp1006114

43. References (1)
• Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and
inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108-14.
• Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Brown GD. The clinical value of computerizedpp p
information services. A review of 98 randomized clinical trials. Arch Fam Med. 1996;5(5):271-8.
• Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.
• Blumenthal D, DesRoches C, Donelan K, Ferris T, Jha A, Kaushal R, Rao S, Rosenbaum S. Health information, , , , , , ,
technology in the United States: the information base for progress [Internet]. Princeton (NJ): Robert Wood
Johnson Foundation; 2006 [cited 2010 Oct 14]. 81 p. Available from:
http://www.rwjf.org/files/publications/other/EHRReport0609.pdf
• Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010
Aug 5;363(6):501-4.
• Borzekowski R Measuring the cost impact of hospital information systems: 1987-1994 J Health EconBorzekowski R. Measuring the cost impact of hospital information systems: 1987 1994. J Health Econ.
2009;28(5):939-49.
• Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG. Systematic review: impact
of health information technology on quality efficiency and costs of medical care Ann Intern Medof health information technology on quality, efficiency, and costs of medical care. Ann Intern Med.
2006;144(10):742-52.

44. References (2)
• Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized
clinical decision support systems on practitioner performance and patient outcomes: a systematic review.
JAMA. 2005;293(10):1223-38.
• Hsiao C, Beatty PC, Hing ES, Woodwell DA. Electronic medical record/electronic health record use by office-
based physicians: United States, 2008 and preliminary 2009 [Internet]. 2009 [cited 2010 Apr 12]; Available from:
http://www.cdc.gov/nchs/data/hestat/emr ehr/emr ehr.pdfp g _ _ p
• Institute of Medicine, Board on Health Care Services, Committee on Data Standards for Patient Safety. Key
Capabilities of an electronic health record system: letter report [Internet]. Washington, DC: National Academy
of Sciences; 2003 [cited 2010 Oct 14]. 31 p. Available from: http://www.nap.edu/catalog/10781.htmlof Sciences; 2003 [cited 2010 Oct 14]. 31 p. Available from: http://www.nap.edu/catalog/10781.html
• Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D.
Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628-38.
Jh AK D l D G dt D S tt T B t DW Th f h lth i f ti t h l i ti I t• Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int
J Med Inform. 2008;77(12):848-54.
• Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support
t di ti f t t ti i A h I t M d 2003 163(12) 1409 16systems on medication safety: a systematic review. Arch. Intern. Med. 2003;163(12):1409-16.

45. References (3)
• Parente ST, Dunbar JL. Is health information technology investment related to the financial performance of US
hospitals? An exploratory analysis. Int J Healthc Technol Manag. 2001;3(1):48-58.
• Schoen C Osborn R Huynh PT Doty M Puegh J Zapert K On the front lines of care: primary care doctors’Schoen C, Osborn R, Huynh PT, Doty M, Puegh J, Zapert K. On the front lines of care: primary care doctors
office systems, experiences, and views in seven countries. Health Aff (Millwood). 2006;25(6):w555-71.
• Shiffman RN, Liaw Y, Brandt CA, Corb GJ. Computer-based guideline implementation systems: a systematic
review of functionality and effectiveness J Am Med Inform Assoc 1999;6(2):104-14review of functionality and effectiveness. J Am Med Inform Assoc. 1999;6(2):104-14.
• Van Rosse F, Maat B, Rademaker CMA, van Vught AJ, Egberts ACG, Bollen CW. The effect of computerized
physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a
systematic review Pediatrics 2009;123(4):1184 90systematic review. Pediatrics. 2009;123(4):1184-90.
• Yasnoff WA, Overhage JM, Humphreys BL, LaVenture M. A national agenda for public health informatics:
summarized recommendations from the 2001 AMIA Spring Congress. J Am Med Inform Assoc. 2001
D 8(6) 535 545Dec;8(6):535-545.