Strategies for IT and Better Health: A Global Tour

1
Strategies for IT and Better Health A Global
Tour

• Ticia Gerber, Vice President, International
  Programs and Public Policy
• eHealth Initiative and Foundation
• George Washington University
• February 9, 2006

2
Global Partnerships for Health

• The last 12 months could be dubbed the
  international year of electronic health records,
  as electronic health information systems have
  been identified as a critical ingredient for
  reinvigorating health care in country after
  country.
• Richard Alvarez, Bulletin of the World Health
  Organization, May 2005

3
eHealth Initiative and Foundation Mission and
Focus

• Mission Improve the quality, safety, and
  efficiency of healthcare through information and
  information technology
• Areas of Focus
• Focus on states, regions and communities as the
  center of implementation aligning national
  standards with local solutions
• Develop and drive adoption of sustainable model
  for healthcare transformation through
  quality-based incentives
• Advocate for continued favorable national
  policies

4
eHI is the Go-to Organization For Health
Information Exchange Efforts
Advocacy
Grants
eHealth Initiative and Foundation
Knowledge
Hands-on Help
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Global Partnerships for Health

• International public health evolution framework
• (1800-1950) Tropical medicine Colonialism and
  imperialism
• (1950 1990) International health Cold War
• (1990 Current) Global health Rapid advance of
  the global economy
• (Elizabeth Fee, Ph.D, Examining a Framework The
  Three Phases of International Health, November
  2003)
• HIT part of growing global health movement
• What is global health?
• IOM defines global health as health problems,
  issues, and concerns that transcend national
  boundaries, may be influenced by circumstances or
  experiences in other countries, and are best
  addressed by cooperative actions and solutions."

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Global Partnerships for Health

• Global Health Challenges
• Re-emergence of old threats
• Avian Flu of 1918 which killed 20-100 m
  
• Emergence of new threats
• SARS
• Treatment Resistance
• Tuberculosis, Pneumococcus, HIV
• Intentional Attacks/Engineered Virulence
• Terrorism
• Increased Mixing
• International Travel - Two million people cross
  national borders as tourists, business travelers,
  immigrants, or refugees every day
• Food Supply (Increased portability and import
  practices) - US agricultural imports (56
  billion) equal to exports for first time in 2004,
  and increased
• Economic Goods and Service (Increased global
  trade and East-West bridge) Chinas merchandise
  exports grew 35 in 2005 to 593 billion and
  US-Chinese trade deficit increased to 200
  billion

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Global Partnerships for Health

• The great obstacle to serious progress towards
  global health goals remains the woeful state of
  the worlds public health infrastructure.
• Health information systems remain inadequate,
  making it impossible to monitor the delivery and
  coverage of interventions in a timely and
  effective way.
• Global Governance Initiative - Third Annual
  Report, Davos World Economic Forum, January 2006

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Global Partnerships for Health
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Global Partnerships for Health

• Medical diplomacy' should be used in
  conjunction with our existing foreign and defense
  policies to achieve progress and win the hearts
  and minds of people worldwide.  Good medicine
  makes better neighbors.
• Former U.S. Secretary of Health and Human
  Services Tommy Thompson, October 20, 2005
• Medical diplomacy is defined as exporting
  medical care, knowledge and personnel to help
  those most in need in Africa, Asia, the Middle
  East and elsewhere.

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Global Partnerships for Health

• US Medical Diplomacy Examples
• US provides 33 of annual donations to Global
  Fund to Fight AIDS, Tuberculosis and Malaria
• Global Fund created to finance a dramatic
  turn-around in the fight against AIDs,
  tuberculosis and malaria, as a partnership
  between governments, civil society, the private
  sector and affected communities
• Global Fund committed 4.4 billion in 128
  countries to support aggressive interventions.
• New global health category added to US budget
  Presidents FY-07 request is 381 million

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Global Health Partnerships - eHI Role

• eHealth Initiative has been critical driver in
  creating and cultivating e-Health policy change
  in U.S. (community, state, federal activities)
• We are extending our reach to collaborate with
  and learn from key healthcare stakeholders around
  the globe through the Leadership in Global Health
  Technology (LIGHT) Initiative
• LIGHT Initiative established in May 2004

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Home is Where the IT Is Growing National Agenda
around Health Information Exchange

• Enormous momentum around improving quality,
  safety and efficiency through clinical exchange
  within Administration, Congress, and the private
  sector
• Key themes
• National standards for interoperability
• Alignment of value based purchasing with HIT
  infrastructure required to get there
• Government as catalyst
• Public-private sector collaboration

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Signs of Momentum for HIT and Health Info
Exchange Activities in Congress

• 12 bills introduced in 2005
• Most bi-partisan
• Unprecedented collaboration between the
  Republicans and Democrats on the importance of
  leveraging HIT and the mobilization of
  information to address healthcare challenges

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Signs of Momentum for HIT and Health Info
Exchange Activities in Congress

• Active legislation includes
• HIT bills
• Senate
• S 1416 Wired for Health Care Quality Act
• House
• Health Information Technology Promotion Act
• Medicare Pay for Performance
• Senate
• S 1356 - Medicare Value Purchasing Act
• House
• HR 3617 Medicare Value-based Purchasing for
  Physician Services Act

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Signs of Momentum for HIT and Health Info
Exchange Activities in Congress

• FORECAST
• Action on HIT legislation this year possible
• Important characteristics of bill negotiation
  process
• Bi-partisan HIT issue support
• 108th Congress spans both 2005 and 2006
• Multi-committee discussions and drafting
• House and Senate have very different solutions
  that must be worked out in conference
• Budget deficit environment (challenge of adequate
  funding, meaningful incentives)
• Lack critical mass of economic research on impact
  of HIT
• Federal priority-shifting in wake of Hurricane
  Katrina
• Congressional efforts must integrate with current
  Administration initiatives

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Signs of Momentum for HIT and Health Info
Exchange Activities in Administration

• Leadership on all Sides
• Office of Secretary of DHHS
• Office of the National Coordinator for HIT
• Agency for Healthcare Research and Quality
• Centers for Disease Control and Prevention
• Centers for Medicare and Medicaid Services
• Department of Defense
• Department of Veterans Affairs
• Office of Personnel Management
• Executive and cabinet-level leadership critical
  in advancing the issue

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Signs of Momentum for HIT and Health Information
Exchange Activities in Administration

• AHIC public-private community formed to provide
  input to Sec. Leavitt re how to make health
  records digital and interoperable and assure that
  privacy and security are protected
• Overseeing work in four break-through areas
  that will create realizable benefits to consumers
  in two to three years
• Biosurveillance
• Chronic care
• Consumer empowerment
• Electronic health records

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Signs of Momentum for HIT and Health Information
Exchange Four DHHS Contracts

• Standards Harmonization. 3.3 million contract to
  ANSI for convening Health Information Technology
  Standards Panel (HITSP) to review standards under
  development and develop a roadmap for single set
  of standards
• Compliance Certification. 2.7 million contract
  to Certification Commission for HIT to develop
  process and criteria for inspecting EHRs and
  other HIT
• Privacy and Security. 11.5 million contract to
  Health Information Security and Privacy
  Collaboration overseen by RTI International who
  will work with states to assess and develop plans
  to address variations in organization-level
  business policies and state laws that affect
  privacy and security practices that may serve as
  barriers to health information exchange
• Nationwide Health Information Network. Four
  contracts totaling 18.6 million to four
  consortia led by Accenture, CSC, IBM and Northrop
  Grumman to develop a blueprint for how a
  generalized network would share information
  across the U.S.

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Global Partnerships for Health eHI Role

• Leadership in Global Health Technology (LIGHT)
  Initiative Background
• eHI and its Foundation founded LIGHT Initiative
  in 2004
• eHI LIGHTs purpose is to facilitate learning and
  information sharing among HIT innovators and
  other nations, in both the developed and
  developing world
• Focus of these activities is to identify the key
  barriers, workable strategies and imperatives for
  implementing an interconnected, electronic health
  information infrastructure to support better
  health and healthcare 
• Participants include high-level healthcare
  officers and executives from the public and
  private sectors around the globe
• eHI LIGHTs project work and interests span six
  continents

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Global Partnerships for Health - eHI Role

• eHI LIGHT has
• Hosted two global HIT conferences involving over
  17 nations (Geneva, Washington DC)
• Begun discussions about mutual lessons learned
  and other issues with government health, science
  and technology representatives (England, Finland)
• Sponsored regional health improvement discussions
  and HIT summits for different epicenters around
  the globe (Example Finland, Japan)
• Developed an inventory of HIT-related efforts
  from different countries across the world
• Launched an on-line Resource Center with global
  HIT information
• Arranged site visits for global partners who
  are interested in learning from the U.S. HIT
• Convened eHI Working Group on LIGHT meets
  monthly
• Initiated outreach to relevant policymakers to
  increase global HIT collaboration and funding in
  the long-term.

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Global Partnerships for Health

• Highlights of First Report of the Leadership in
  Global Health Technology InitiativeGlobal
  Connections Requirements, Enablers and
  Roadblocks to Implementing HIT and Electronic
  Connectivity for Better Health and Healthcare
  Worldwide

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Geneva LIGHT Summit Participants

• Australia
• Malaysia
• Mexico
• Peru
• Saudi Arabia
• South Africa
• United Kingdom
• United States
• Bangladesh
• Brazil
• Canada
• Colombia
• Cuba
• European Union
• Kenya
• Korea

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Geneva LIGHT Summit Participants

• Geneva Summit participants provided high-level
  overview of national strategy (if applicable) in
  each of the following areas
• National leadership and governance strategies
• Upfront funding and ongoing financing vehicles to
  assure sustainability
• Technical issues such as architecture,
  applications, standards, security, and accurately
  and responsibly linking patient data
• Methods to facilitate clinician adoption,
  clinical process change, and application of
  clinical knowledge at the point of care
• Engaging patients and citizens

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Geneva LIGHT Summit Learnings

• Despite the diversity of participant experiences,
  many shared common views regarding factors
  critical to
• Focusing on the local role and participation in
  system change
• Tool-kits to capture and disseminate learnings,
  best practices and software
• Accompanying consumer education and awareness
  campaigns
• Knowledge transfer both from those nations who
  have gone before and between regions and
  provinces engaged in the system
  transformation.prototype legal agreements,
  governance models, and insight on requirements
  and specifications are key
• Importance of data standards and interoperability
• Availability of computer literate graduates,
  especially in every rural areas, where medical
  centers are located
• Innovative use of low-cost technologies such as
  Palm Pilots, cell phones and simple computer
  systems
• Appropriately addressing privacy and security
  concerns at every step in the process.

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Geneva LIGHT Summit Learnings

• Common Challenge of Participants
• Maintaining HIT as a top item on the national
  agenda in shifting political and budgetary
  environments
• Antiquated laws and regulations
• Reducing deployment costs
• Jumpstarting system reform projects in nations
  where HIT systems are largely disparate and
  unintegrated and in which HIT strategic planning,
  standardized infrastructure and health
  information networks are severely lacking
• Monopolized telecommunications operations or an
  absence of integration among different network
  owners
• Addressing cultural barriers and stigmas
• Adapting HIT to different care and practice
  environments
• Changing skill mix, structures and care processes
  to support patient-centred HIT services
• Creating a truly integrative EHR
• Change management challenges
• HIT procurement cycles longer than desired system
  reform pace
• Matching high patient volume with smaller HIT
  supplier capacity

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Geneva LIGHT SummitAreas for Global
Collaboration

• The following were identified by summit
  participants as areas for global support and
  collaboration
• Developing a multi-national approach based on
  geographic location and cultural similarity
• Developing an aggressive, formal agenda for
  funding HIT initiatives in different countries
• Facilitating alignment between public and private
  sector activities
• Encouraging a more active role from organizations
  like WHO, USAID, the World Bank and UN bodies in
  developing countries
• Encouraging national EMR systems that are
  developed to incorporate globally accepted data
  standards and interoperability protocols

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Global Partnerships for Health

• WHO
• World Health Assembly reviewed and
  adopted resolution
• WHA58.28, in May 2005 urging Member States to
• Consider developing long term strategic plans for
  developing and implementing eHealth services
• Develop intrastructure for information and
  communication technologies
• Requested WHO provide technical support to Member
  States, and facilitate integration of eHealth in
  health systems and services, including in
  training.

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Global Partnerships for Health - Europe

• EU e-Health Action Plan
• EU Nations not bound by plans recommendations,
  but they do provide a useful basis for coalescing
  around certain objectives.
• Blueprint officially launched in 2004 and
  provides a framework for addressing common
  eHealth and ICT challenges.
• Plans overarching goal is to achieve a
  borderless Trans-European health information
  space by 2010 that recognizes the particular
  importance of interoperability and patient
  mobility, as well as strengthening disease
  prevention, health care personalization and
  patient involvement.

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Health Information Infrastructure Reform Examples

• Europe
• United Kingdoms National Programme for IT
  (Connecting for Health)
• NPfIT is composed of four key elements
• NHS care records service (national patient record
  spine, local service providers)
• Electronic appointment booking
• Electronic transmission of prescriptions
• Underpinning IT infrastructure.
• A central goal of the National Programme for IT
  is the creation of a single electronic healthcare
  record for every individual in the United Kingdom
  that 
• Contains a comprehensive life-long history of
  patients health, care and information,
  regardless of where, when and by whom they were
  treated
• Provides healthcare professionals with immediate
  access to summary of care encounters and clinical
  events held on a national data repository
• Supports the NHS in collecting and analysing
  information, monitoring health trends and to
  making the best use of clinical and other
  resources
• Holds essential information at the local level
  where most care is delivered

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Health Information Infrastructure Reform Examples

• United Kingdoms National Programme for IT
  (Connecting for Health)
• The electronic booking service, Choose and Book
  was introduced in Summer 2004 and eventually will
  be available across England.
• From 1 January 2006, patient able to choose date
  and time of specialist appointment and book.
• The first live electronic transfer of a patients
  medical record from one GP surgery to another has
  been successfully completed in trials.
• Within two years, Summary Care Record available
  containing key diagnoses and problems, current
  and recent prescriptions, and important
  information such as allergies, drug reactions,
  discharge and out-patient care summaries will be
  available to patients and health professionals in
  England.

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Health Information Infrastructure Reform Examples

• FinnWell - Healthcare Technology Programme
• Programme duration 2004-2009
• Programme volume approx. 150 million euro
• Finlands population 5 million
• Healthcare responsibility lies largely with 450
  municipalities, organized into 20 provinces or
  regions
• Only 10 of healthcare is private
• Finland viewed by some informaticists as the most
  advanced health information infrastructure in
  Europe

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Health Information Infrastructure Reform Examples

• FinnWell - Healthcare Technology Programme
  Objectives
• Improve the quality of healthcare
• Enhance the efficiency of healthcare
• Create new products of healthcaretechnology
• Promote business in healthcare
• Promote healthcare exports

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Health Information Infrastructure Reform Examples

• FinnWell - Healthcare Technology Programme
  Targets
• Technologies for diagnosticsand care
• Healthcare IT related productsand systems
• Operational processes ofhealthcare

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FinnWell - Healthcare Technology Programme

• FinnWell - Healthcare Technology Programme
• 90 of primary GPs have and use EMRs
• Speciality hospital care 60 have EMR but usage
  varies widely from 10-90
• Hear from Finns that EMRs not comprehensive
  enough and although used regionally, not hooked
  into any cohesive national infrastructure
• Once implemented, Finns estimate that a National
  eHR could save 200 million euros per year

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Global Partnerships for Health

• In Europe specifically, we desire to
• Engage with European health and technology
  leaders (EU, EHTEL, individual nations) to share
  current HIT policy and market developments and
  lessons learned
• Fill knowledge gaps, facilitate targeted and
  helpful collaboration
• Crosswalk progress on EU eHealth Action Plan and
  EU eHealth I2 project with US HIT agenda
• Note Growing interest in US about how domestic
  HIT policy aligns/compares with EU policy
• Share information gained from US community HIE
  projects (legal, technical, financial, clinical,
  consumer)
• US-European summit on health improvement and HIT
  discussed

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Health Information Infrastructure Reform Examples

• Australia - National HealthConnect program goal
  is eHR for every resident. Initial focus is on
  medication record.
• Long-term goals of the Australian HIT initiative
  include widespread eHR use, e-enabling clinical
  and patient support and the creation of a
  national health information network. Regional HIE
  efforts are also cropping up.
• North America
• Canada - Canada Health Infoway is a
  not-for-profit agency formed to foster and
  accelerate the development and adoption of
  electronic health information systems with
  compatible standards and communications
  technologies on a pan-Canadian basis. 
• Infoways six-year goal is to have the basic
  elements of interoperable electronic health
  records in place across 50 percent of Canada by
  2010.

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Global Partnerships for Health Developing World

• Regenstrief Medical Record System
• Mosoriot, Kenya
• Rural health center
• Serves mainly subsistence farmers
• Current medical records
• minimal data recorded
• data recorded multiple times
• counting by hand
• Solution Mosoriot Medical Record System
  Project executed by Kenyan Ministry of Health and
  Moi University Faculty for the Health Sciences,
  in principal collaboration with the Indiana
  University School of Medicine, the Regenstreif
  Institute for Health Care and the Veterans
  Affairs Medical Center in Indianapolis.
• (Dr. Bill Tierney)
• First electronic medical record system used for
  ambulatory care in sub-Saharan Africa. 

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Global Partnerships for Health Developing World

• Mosoriot Medical Record System
• EMR created to serve a particular need ?
  HIV/AIDS
• run on a single microcomputer
• multiple power sources
• solar (85 available sunlight)
• backup UPS
• backup gas generator
• create system components
• registration system
• electronic version of encounter form
• data dictionary
• formats for standard Min. of Health reports
• Encounter forms to collect intensive initial and
  follow-up data
• Print a summary flowsheet of patient data to
  place in clinic chart

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Global Partnerships for Health Developing World

• Mosoriot Medical Record System
• Electronic data can be obtained without
  sophisticated, complex computer infrastructure
• Clinical information systems are possible in even
  the most resource-constrained places

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Global Partnerships for Health Developing World

• Mosoriot Medical Record System
• In the first 3 years, gt5000 patients were
  enrolled and made gt35,000 visits
• 2/3 to Moi Hospital clinics
• largest public HIV program in Kenya
• 50 on anti-retroviral drugs

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Global Partnerships for Health Developing World

• Next steps
• Migrate to a Web-based EMR
• Add 3 district hospitals
• Enter data in HIV clinics using wireless tablet
  computers ? flowsheets, care prompts
• Extend the AMRS to HIV clinics in other
  sub-Saharan Africa countries
• software downloaded by clinics in Ethiopia,
  Kenya, Mozambique, Namibia, Nigeria, Rwanda,
  South Africa, Tanzania, Uganda, Zimbabwe

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Global Partnerships for Health Developing World

• Foundations, NGOs and major international aid
  organizations such as World Bank stepping into
  global e-Health (ICT) arena
• Examples infoDevs knowledge map project
  charting role and use of ICT in the developing
  world
• ICT in the Commission for Africa report
• In addition to calling for increased
  international aid of 25 billion a year until
  2010 and a further 25 billion by 2015 and
  addressing issues of peace, security, trade and
  debt elimination, the Commission for Africa
  Report features many recommendations specific to
  health and global HIT such as calling for
• An emphasis on capacity-building and better
  information
• Rebuilding African healthcare and public health
  systems, which it concludes requires not only new
  funding but better use of existing dollars with a
  focus on optimal delivery and results
• A climate of increased public and private
  collaboration
• And a doubling of donor funding for
  infrastructure, which includes information and
  communications technology.

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Summary

• A myriad of countries are moving in a targeted,
  coordinated and expeditious way towards
  implementation of HIT and health information
  exchange
• Although embroyonic, critical point in global
  e-Health, interoperability and connectivity
  efforts
• eHI and its LIGHT Initiative enthusiastically
  seek out collaborative endeavors and partnerships
  and will contribute to global progress
• Look forward to the opportunity for mutual
  learning between the US and other nations

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• A small group of thoughtful people could change
  the world. Indeed, it's the only thing that ever
  has.
• Margaret Mead

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• Ticia Gerber
• Vice President, International Programs and Public
  Policy
• eHealth Initiative and Foundation
• www.ehealthinitiative.org
• 818 Connecticut Avenue NW, Suite 500
• Washington, D.C. 20006
• 202.624.3264
• ticia.gerber_at_ehealthinitiative.org