columbia university · organizations that provide the systems for them. barriers to effective use...

Healthcare Transactions: Code Sets, Privacy, Data Security and HIPAA/GLB Compliance

Health Colloquium at Harvard and the HIPAA Summit Conference Series

Harvard University, Cambridge, MassachusettsAugust 19, 2001

Healthcare and Technology: Why We Are Behind Other Industries

Edward H. Shortliffe, MD, PhDDepartment of Medical Informatics

Columbia University




Healthcare and Technology: Are We Behind Other Industries?


Columbia University




Healthcare and Technology: Should We Lead Other Industries?


Columbia University

Varying Scenarios for the Future

Question: How will the increasing use of computing

and communications technology affect physicians, patients, other health workers,

and global health?

Personal Experience

• Academic pursuit of research and education in medical informatics

• Clinical practice of general internal medicine in academic teaching setting

• The hard questions when I returned to my laboratory after six hours in my clinic….

Barriers to Effective Use of Information Technology in Health Care

• Cultural–The technology has never been

embraced–Seen as support activity, outside the

usual foci of biomedical science–Poor appreciation of IT as a strategic

asset! IT leadership often not at the table for

day-to-day strategic planning


• Cultural (more)–Technical challenges (and need for

ongoing research) often poorly understood

–Fears of depersonalization of health care

–Often viewed as a distraction from organization’s (or practitioner’s) primary goals

–Reluctance to learn new skills in an area that seems foreign


• Making the business case– IT generally has had a poor track record

in health care–Problems often blamed on the technology

itself, rather than on the implementers, implementations, and available fiscal resources


• Making the business case (more)–Purchasers of health care IT are often

poorly prepared to make appropriate decisions! Buyers generally are not the users! Users tend to be poor consultants in the

process– IT viewed as a cost center

! Measuring benefits, and agreeing on metrics, can be challenging

! IT poorly integrated into cost (and reimbursement) models for health care financing


• Structural issues–Fragmented health care system–Historically poor incentives for IT

investment–Health care organizations are complex

social environments! Many IT users do not work for the

organizations that provide the systems for them


• Structural issues (more)–Too few individuals trained to work

effectively at the intersection between biomedicine and IT

– Inadequate participation of the health care community in evolving IT industry standards! Community generally has no choice but to

adopt what is provided by others

–Resulting challenges to integration within organizations and between institutions

Climate for Change

• Consumer activism– Increasing use of the Web by patients

• HIPAA– Data standards– Privacy

Facilitating role of the Institute of Medicineand the National Research Council

256 pages Revised edition (October 1997)Originally published in 1991

Institute of Medicine

272 pages (April 1994)


288 pages (July 1997)

National Research Council

Climate for Change



• Awareness of medical errors and the role of IT in support of quality

287 pages (April 15, 2000)


364 pages (July 2001)


Climate for Change




• Report to Harold Varmus at NIH proposing the Biomedical Information Science and Technology Initiative (BISTI Report)

Biomedical Information Science and Technology Initiative (1999)

CHARGE TO THE WORKING GROUP ON BIOMEDICAL COMPUTINGThe biomedical community is increasingly taking advantage of the

power of computing, both to manage and analyze data, and to model biological processes. The working group should investigate the needs of NIH-supported investigators for computing resources, including hardware, software, networking, algorithms,and training. It should take into account efforts to create a national information infrastructure, and look at working with other agencies (particularly NSF and DOE) to ensure that the research needs of the NIH-funded community are met.

It should also investigate the impediments biologists face in utilizing high-end computing, such as a paucity of researchers with cross-disciplinary skills. The panel should consider both today's unmet needs and the growing requirements over the next five years (a reasonable horizon for extrapolating the advances in the rapidlychanging fields of computing and computational biology).

Climate for Change




• Report to Harold Varmus at NIH proposing the Biomedical Information Science and Technology Initiative (BISTI Report)

• President’s Information Technology Advisory Committee (Health care report, Feburary 2001)

Information Technologies with Potential for Impact on Health Costs and QualitySome examples:• Cost accounting, and other financial systems• Hospital information systems• Outpatient record systems• Computer-based patient records and data

“warehouses”• Consumer education, information, and communication • Clinical decision-support systems• Regional, national, and global networking

– Electronic data interchange– Remote consultations (Telemedicine)– Distributed information access and decision support

Internet Hosts (000s) 1989-2001

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11/95: 7M Hosts

© Internet Society

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Federal HPCC Program

• 1989: Senator Gore and the promotion of High Performance Computing and Communications

• Chartered by Congress in the High Performance Computing and Communications Act of 1991

• Funding authorized for FY 1992 - FY 1996 for most HPCC agencies

• Creation of National Coordinating Office (NCO) for HPCC, initially at National Library of Medicine

• Annual “Blue Books” have prominently featured biomedical applications

http://www.itrd.gov/

Annual “Blue Book”

Interagency Working GroupOn Information TechnologyResearch and Development

Supplement toPresident’s Budget(FY 2002 Edition)

Participating Agencies

• Defense Advanced Research Projects Agency (DARPA)• National Science Foundation (NSF)• Department of Energy (DOE)• National Aeronautics and Space Administration (NASA)• National Institutes of Health (NIH)• National Security Agency (NSA)• National Institute of Standards and Technology (NIST)• Department of Education (ED)• Department of Veterans Affairs (VA)• National Oceanic and Atmospheric Administration (NOAA)• Environmental Protection Agency (EPA)• Agency for Healthcare Research and Quality (AHRQ)

288 pages 288 pages (1996)


200 pages (June 12, 2000)

National Research Council

Computer Science andComputer Science andTelecommunications BoardTelecommunications Board

David D. Clark, ChairmanMarjory S. Blumenthal, Executive Director

http://www.cstb.org

Study Objectives

• Define the technical capabilities the Internet must provide to support health applications

• Identify likely health care applications of the Internet and their demands for bandwidth, quality of service, security, access, etc

• Recommend an appropriate strategy for implementing these capabilities in the Internet and Next Generation Internet

• Distinguish capabilities that are unique to healthapplications from those more generally demanded of the Internet

Some Definitions

• Bandwidth: rate of transmission through a network

• Latency: time required to transmit data across the network (delay between time when a message is sent and received)

• Availability: “up time” of the network, including its individual links and services

• Security: composed of availability, confidentiality, and integrity considerations; ability to keep data from being maliciously or inadvertently lost or altered

• Ubiquity: a metric for the number and kinds of end users that a network can interconnect

Health Applications of the Internet

• Healthcare may not be unique, BUT–Perhaps a unique set of complexities–Rapid changes in topology of organization

• Six major application areas identified:–Consumer Health–Clinical Care–Administrative and Financial Transactions–Public Health–Professional Education–Biomedical Research

Technical Needs Demanded by Health Applications of the Internet

ApplicationArea

Bandwidth Latency Reliability Security Ubiquity

ConsumerHealth

++ + ++ ++++ ++++

Clinical Care ++++ +++ ++++ ++++ ++Health carefinancing

+ + +++ ++++ ++

Public Health + + +++ +++ ++Healtheducation

+++ ++ ++ + +++

Biomedicalresearch

++++ +++ ++ ++ ++

NOTE: Plus signs (+) denote the relative importance of the technicalfeature within the application domain

The Market Won’t Wait for Internet to Become “Clinical Grade”

General Findings

• Most current visible applications are consumer-oriented Web sites

• Potential of ubiquitous connectivity is great:–More informed public– Improved provider-provider and patient-

provider communications–Enhanced clinical decision support– Improve health outcomes and ability to

measure those outcomes

General Findings (cont’d)

• Health applications do not differ qualitatively in their demands for network services from e-commerce and other industries

• Current Internet technologies and functionality are insufficient for some health related applications, and economics are adverse

Organizational Issues

• Health care is diverse and decentralized -- “trillion dollar cottage industry” with no unified voice on technology issues

• Paucity of reliable information on costs and benefits of Internet applications in operational settings

• Unknown effects of Internet on relationships between patients, providers, and healthcare organizations

• Unknown personnel requirements for health care organizations to develop and implement Internet applications

• New organizational policies and procedures are needed (for example, e-mail between providers and patients)

Public Policy Issues

• Nontechnical factors impede innovation– State-based licensure and malpractice liability– Lack of robust payment mechanisms– Lack of implemented federal regulations on

privacy and security– Protection of intellectual property

• Access disparities need to be addressed – The Digital Divide amplifies health care

inequities– Near-term remedies -- schools, libraries, kiosks -

- ill suited to health needs

Policy Issues

• The Department of Health and Human Services should more aggressively address the broad set of policy issues that influence the development, deployment, and adoption of Internet-based applications in the health sector– Provide strategic leadership for Internet-related efforts– Convene public/private bodies on Internet and health– Explore cross-cutting issues affecting agencies– Encourage information sharing among agencies– Advance the national debate on IT issues in health– Create organizational structures to ensure that policy

issues are addressed

Conclusion

• Ensuring widespread access to the Internet is essential to achieving its promise in health applications

• Technical advances are needed across many areas of information technology if potential of the Internet is to be achieved in health

• Health care organizations are ill-prepared to adopt Internet-based technologies and applications effectively

• Difficult public-policy and regulatory issues constrain the adoption of Internet-based health applications

http://www.itrd.gov/ac

President’s InformationTechnology Advisory

Committee

(PITAC)

February 1999

http://www.itrd.gov/ac

President’s InformationTechnology Advisory

Committee

Panel on TransformingHealth Care

February 2001

Examples of IT Research Challenges Relevant to Biomedical and Health Care Applications

• Interactive large-scale biological simulations• Data-driven modeling of biological

processes• Data mining in large clinical and biological

databases• Multimodal information management: text,

audio, images, and motion• Biomedically motivated user-interface

hardware and software• Advanced networking services, including

high quality of service and wireless connectivity

Examples of IT Research Challenges Relevant to Biomedical and Health Care Applications

• Development and availability of high end systems to support biomedical research, simulations, and modeling

• Privacy, security, and authentication• Language understanding / text processing• Clinical records and their integration• Access to information systems for people

with disabilities• Automated policy inference• Research to understand better the

implications of IT on the health care system

Findings

• The U.S. lacks an accepted national vision for IT in health care

• A critical and enabling investment in biomedical computing infrastructure and enabling technologies has not yet occurred

• A number of difficult public policy and regulatory issues constrain adoption of IT health applications by health organizations and consumers

• Advances in IT are critical in order for DHHS to accomplish its mission to improve the quality of U.S. health care

Findings

• Biomedical reliance on IT innovations produced by other parts of government

• Adverse effects on pace at which biomedicine benefits from IT research

• Solutions may never adequately reflect the needs of biomedical community

• Need a larger cadre of researchers and practitioners who understand both health and computing & communications

Findings

• Suboptimal role and management of IT in DHHS:

• Decentralized management constrains both development of coherent IT vision and departmental activities applying IT in health care and biomedical research

• Lack of coordinated IT effort and leadership across the agencies within DHHS

More Findings

• Additional DHHS limitations:• Absent central leadership and

budget leaves agencies within DHHS functioning without coordination and guidance

• Individual agencies do not accept a mandate to support IT research, even if it is fundamental to their mission

• DHHS perceived as minor player in federal IT policy development

Recommendations

• DHHS should outline its vision for using information technology to improve health care in this country and subsequently devote the necessary resources to do the basic information technology research critical to accomplishing these goals in the long term.

• Establish programs to increase the pool of biomedical research and health care professionals with training at the intersection of health and information technology.

Recommendations

• DHHS should appoint a senior information technology leader to provide strategic leadership across DHHS and focus on the importance of information technology in addressing pressing problems in health care.

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