Health IT Helps Users Manage Systemic Transformation
Health IT is foundational to achieve a learning health system. The Institute of Medicine describes a learning health system as "one in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care process, patients and families active participants in all elements, and new knowledge captured as an integral by-product of the care experience."6
The speed with which we achieve a learning health system depends on relationships among all stakeholders, behavior and culture change among individuals, providers, and others, enhanced technology usability, redesigned workflows, and new models for accessing, contributing, sharing, and transforming information into actionable intelligence. Health IT can support and assist in applying the lessons and improvements discovered through the learning health system to achieve individual, local, and national health and wellness improvements.
Current Health IT Landscape
Hospitals and physician offices across the nation have made great efforts in transitioning from paper to electronic systems and processes since the federal government released its prior health IT strategy in 2011. This has resulted in remarkable growth in health IT adoption and use among these provider types.7 8 Additionally, hospitals across the country have achieved striking increases in electronic health information exchange.9
However, many barriers still exist for the U.S. to realize the benefits of ubiquitous health IT use and widespread interoperable exchange of relevant, timely individual information across the care continuum. Lack of steady and consistent access to advanced broadband internet services can be one barrier for the health system to function properly.
A health system where only some providers have health IT systems that provide them and their patients with access to consistently available and advanced broadband internet connections can lead to care gaps with consequences for patients that can be both burdensome and dangerous, such as medication errors or unavailable imaging studies. It can also lead to a misuse of resources among providers and public health entities.
A fully functional U.S. health system must be a technologically and culturally connected enterprise that facilitates the easy electronic movement of information. A solid health IT infrastructure will help to accelerate the interpersonal connections between each participant, and the information that moves between them. Health IT availability and use among providers that were not eligible for the Medicare and Medicaid EHR Incentive Programs lags behind those providers that were eligible for the programs.
These providers, including behavioral health, emergency medical services (EMS), long-term and post-acute care, play an integral role in helping to keep individuals healthy and have numerous situations that necessitate collaboration and sharing of information with the greater health community. Often individuals who receive services and care from these providers are among the most vulnerable, and the rich information available from these providers can have significant impacts on individuals' health and their care decisions with others in the health enterprise.
For example, EMS practitioners provide stabilizing care and transportation services; having access to a patient's salient clinical information as a first responder can improve patient health and safety. Access to linked outcomes data from hospitals can help EMS systems measure performance, improve their provision of care, and provide timely feedback to providers.
Behavioral health, long-term and post-acute care settings require access to a patient's information to ensure continuity in care services and prevent adverse events, such as medication allergies or errors, from occurring.
Public health entities and clinical settings need bi-directional interfaces. These will enable unencumbered provider reporting to public health entities and allow seamless feedback and decision support from public health to clinical providers relevant to chronic health and emergent threats.
Improving the information flow will require improvements to health IT usability. Stakeholders have reported that many physicians find that current health IT systems are cumbersome, disruptive to workflow, decrease their efficiency, sometimes jeopardize patient safety, and have limited interoperability.10
Claimed barriers to interoperability include the use of different technical standards, lack of business incentives that can lead vendors and providers to block the transmission of health information to other vendors and providers,11 deficits in trust, and differences in state laws and regulations that make it difficult to share health information across state lines.
The federal government seeks to work with stakeholders to pursue methods that improve health IT usability and reduce unnecessary impediments to information flow so that technology, policy, and business practices can effectively support health transformation.
Infrastructure to Support Person-Centeredness
The movement toward person-centered health creates new demands on individuals, providers, community organizations, and on the health information and technology infrastructure. Existing and emerging technologies provide a path to make information and resources for health and health care management universal, integrated, equitable, accessible to all, and personally relevant.
Health IT can help empower individuals, their families, and other caregivers to learn and communicate easily, engage in shared decision-making with their providers on their wellness and health goals, and manage their health in convenient and meaningful ways, resulting in better individual outcomes.
However, only one in eight Americans track a health metric like blood pressure or weight using some form of electronic technology. Federal agencies seek to expand the ability of individuals to contribute electronic health information that is personally relevant and usable to their care providers so that both can use it effectively in health planning.
In addition to changed actions and behaviors prompted by information and technology use, shared decision-making will elevate individuals' role as they partner in their care. To help individuals understand information more readily, an opportunity exists for technology and training to improve data visualization, which can lead to improved decision-making for both individuals and providers. This will benefit the design of effective decision support systems that improve shared decision-making and outcomes. Innovations that improve data presentation, through visual graphics and applications, can assist individuals with disabilities and help address the health and health IT literacy issues for diverse individual and caregiver populations.
Blue Button Initiative
Blue Button lets individuals go online and download their health records for improving health and facilitating greater access and control over personal health information. With origins in the Department of Veterans Affairs, the Blue Button initiative quickly expanded beyond the public sector. This effort encompasses more than 650 public and private organizations that have pledged to empower all individuals with electronic access to their health information, supported by outreach and education. Through standards, education, and outreach, this initiative has increased consumers' access to their health information from a variety of sources, including providers, health plans, laboratories, and pharmacies.
Well-designed health IT can propel a health care system based on trust, value, and quality improvement. Electronic health information and health IT can support care models that are best suited to complement and uphold individuals' choices and needs as they establish and achieve their health goals. Further, knowledge of how providers use information and technology and engage their patients with it will guide individuals to select high-quality providers that can support their health goals and improve overall health equity.
Empowering individuals as valued care partners will shift what providers currently document and measure in their continuous quality improvement processes; this will entail moving beyond measuring patient experience and clinical processes, and driving towards more measures and emphasis on outcomes that matter similarly to individuals and providers. Federal actions within this Plan aim to support the shift toward monitoring and improving the performance of a national health information infrastructure to support this person-centered vision.
Infrastructure to Support Care Delivery
Increasing use of health IT will help the nation achieve important health outcomes, including aiding in the prevention of chronic and debilitating disease, ensuring accessible and equitable care, making care safer and more person-centered, and advancing a culture of continuous quality improvement.
Health IT will also play a crucial role in supporting alternative care models that are person-centered and value-driven. Seamless interoperability will facilitate better tracking of outcomes meaningful to providers and individuals, efficient resource use and cost analyses, particularly for care provided across multiple systems and settings.
The federal government plays a key role in care delivery, providing direct care and contracting to provide care in the private sector. The federal government is the nation's largest provider and payer of care. Department of Defense (DoD), Department of Veteran's Affairs (VA), Indian Health Services (IHS), and the Department of Justice's Bureau of Prisons (BOP) deliver direct patient care to tens of millions of individuals.
The Health Resources and Services Administration (HRSA)-funded health centers provide quality-focused, comprehensive and preventative care in the nation's underserved communities to over 21 million individuals.
The Centers for Medicare & Medicaid Services (CMS) is the largest purchaser of health care in the United States, as its programs pay almost one third of the nation's health expenditures. Through Medicare, Medicaid, and the Children's Health Insurance Program, CMS programs cover roughly 126 million beneficiaries. These federal health systems and payers must coordinate with providers both inside and outside the federal health sector.
Delivery System Transformation
HHS Secretary Sylvia Burwell announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity, of care they give patients. A key goal of this initiative is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018.
Another key target is to have 30% of Medicare payments tied to alternative payment models by the end of 2016 and 50% of payments by the end of 2018.
The health IT infrastructure will need to enable the expansion of successful alternative payment models in a way that supports providers' ability to deliver high quality care to all their patients while reducing overall costs. Supportive health IT resources may include all-payer claims databases, registries, EHRs, health information exchanges, federal claims systems, and other data sources.
Commercial payers often look toward federal programs as they develop their own models, thus expanding federal influence beyond its public care role. The Office of Personnel Management (OPM) contracts with commercial payers to provide care options for federal employees, and can require plans to include provider requirements and certain benefit structures for individuals.
In similar ways, many companies in the private sector self-insure and can design plans that mirror federal alternative payment models to improve care. Through these roles, government policy and delivery practices can result in a collective effort that can establish best practices and a more uniform approach to using health IT and shared information to provide high-quality, well-coordinated care.
Systems, processes, and tools supported by health IT and health IT infrastructure can simplify and expedite care transformation. Building on efforts and tools initiated by the Affordable Care Act of 2010, HHS is augmenting reform in three important and interdependent ways to transform the health system.
This transformed system will use incentives to motivate higher-value care by increasingly tying payment to value through alternative payment models; it will change how care is delivered by requiring greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health; and it will harness the power of information to improve care for patients.12
Furthermore, the increased number of individuals now covered by new insurance options has expanded the need to coordinate their services and for providers and communities to manage populations more efficiently. A solid health IT infrastructure will facilitate this coordination and population management.
The Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (MACRA) requires the government to design programs that strongly emphasize high-value health care and unimpeded health information exchange. MACRA implementation will increase the widespread interest and business support for coordinating care, shifting care delivery and reimbursement from fee-for-service to value-based care.
This will expedite the necessity and increased desire for better information and related management and decision systems. High-quality, accurate, and relevant electronic health information improves the ability of providers to manage and advance population health. Interoperable electronic health information provides a foundation to measure, report, and provide feedback on care quality for a number of public-facing and internal purposes.
Expanded use of health IT that combines beneficial decision supports and appropriate quality measures will help the nation to achieve continuous quality improvement and important health outcomes. For example, these efforts will help support clinicians in practice transformation efforts by making essential electronic health information readily available for care decisions and patient health management.
The health IT infrastructure should support the creation and integration of evidence-based tools, persuasive health care provider incentives, alignment of payment and performance reforms that reward coordinated care, and augment an emphasis on achieving improved health and care among all individuals.
Health IT can also enhance routine medical care by delivering quality improvement services and prompts that are relevant to the providers' areas of expertise and specialty, reminding providers about the timing of appropriate preventive services for their patient's general well-being, and helping to efficiently coordinate care among providers.
Providers can also use health IT to monitor and interact with their patients to track progress and outcomes. The market has already developed dynamic tools and delivery methods that are revolutionizing care delivery and individual self-management. Federal programs and policies aim to create an adaptive environment that stimulates market innovations that advance these transformational activities, while trying to prevent additional health and technical disparities.
Infrastructure to Support Community Health
Having complete information about a person is critical to achieving population health goals, as comprehensive information helps providers easily identify and close care gaps, recognize and analyze patterns and anomalies, and perform localized research and engage in quality improvement initiatives. This requires health IT capable of receiving and integrating individual electronic health information from multiple sources to enable providers to aggregate and track information over time within and across groups.
Collectively, these efforts can assist providers to improve their patient panels' health, and when this information is shared and pooled with other information sources, it can contribute to broader knowledge advancements at the local, regional, and national level.
Equally important as technological advances, improved care in settings such as home- and community-based organizations can augment an individual's care experience. Health IT can help connect individuals with community resources and behavioral, preventive, and social services to support their goals, their health and wellness, and improve their quality of life.
A comprehensive health IT infrastructure can connect care for individuals who access services often considered at the periphery of traditional care delivery, including public health, and community-based organizations, such as hospice care, Medicaid managed care delivery systems, schools, and the criminal justice system. Each service provider has specific coordination needs and information uses that can be best served by native IT systems that integrate with the health care system when necessary to exchange information.
Technological tools, practices, and policies that are tested and distributed within the greater health infrastructure will establish methods to incorporate information from providers, community and social supports, and others that facilitate and enable personalized health within a connected health network.
These improvements also will help the various organizations and individuals establish effective work streams that lead to better outcomes and resource use in each sector of the broadly inclusive health enterprise. Federal policies that reinforce these changes and continue the focus and attention on person-centered decisions can amplify the work already underway in this area.
Addressing Opioid Drug-Related Overdose, Death, and Dependence
HHS is focused on implementing evidence-based approaches to reduce: 1) opioid overdoses and overdose-related mortality; and 2) the prevalence of opioid use disorder. In March 2015, HHS announced a targeted initiative aimed at reducing prescription opioid and heroin related overdose, death, and dependence. Deaths from drug overdose have risen steadily over the past two decades and currently outnumber deaths from car accidents in the United States.
The Secretary's efforts focus on three priority areas that tackle the opioid crisis, significantly impacting those struggling with substance use disorders and helping save lives. One key priority includes providing training and educational resources, including updated prescriber guidelines, to assist health professionals in making informed prescribing decisions and address the over-prescribing of opioids. Part of this priority includes supporting data sharing for safe prescribing by facilitating prescription drug monitoring programs (PDMP) and health IT integration and further adoption of electronic prescribing practices.
Public health entities require interoperable electronic health information to detect, track, and manage illness outbreaks. Improved and coordinated access to information from inside and outside the formal delivery system among public health entities and home- and community-based supports increases their ability to analyze population health trends, identify at-risk populations, address local social and health determinants, pursue proactive illness prevention and health promotion strategies, and promote healthy choices for all populations and diverse communities. It can also help protect communities during public health emergencies and increase the ability to conduct and contribute to medical product safety surveillance.
Through improved information sharing and facilitating strong relationships between clinical and non-clinical entities and providers, health IT can lead to faster, more efficient methods for public health departments and social services providers to protect and support community health and perform more effective needs assessments. These organizations need to build the technical, administrative, and workforce infrastructure to receive, manage, and make use of the increasing volume of electronic health-related information and technological facilitators.
Infrastructure to Support Research, Scientific Knowledge, and Innovation
Research drives innovation and scientific discovery. As health IT use increases among individuals, providers, and public health entities, it creates a rich source of data. This affords exciting new opportunities to use health IT and new data to enhance clinical decision support, deepen quality improvement, reduce health disparities, improve post-marketing surveillance of the effects of medical drugs and medical devices, enhance care transitions, and enable research on prevention, diagnosis, and treatment of disease and disability.
The federal government plays a central role in funding and performing original research, training researchers, and maintaining literature databases and other resources, and has a responsibility to identify methods and resources, such as health IT, that can improve upon this role.
Individuals will benefit from scientific and technological change in their self-care and community. Their effective interactions with the care delivery system and increased involvement in system improvements and research will help determine how the system is redesigned and deployed. However, information from care encounters provides a partial picture of an individual's health. Increasingly, individuals will have the ability to contribute information through mobile apps, sensors, social media, and medical devices.
A learning health system will promote improved care that is individualized and delivered in a collaborative and respectful manner. It should also leverage electronic health information from multiple sources. An integrated system will facilitate analysis of real-world variations in tests and treatments, identifying the best outcomes, and help accelerate dissemination of this information to providers, individuals and the public in appropriate formats.
Interoperable electronic health information collected as a byproduct of care can allow care teams to develop solutions to improve the health of the individuals receiving care and services and measure the effectiveness of their actions. This can create a continuous feedback loop that not only leads to quality improvement, but also supports more rapid translation of research findings into better care and health. Disseminating these results can inform the delivery system, influence guidelines and protocols, and significantly curb the time between discovery and action.
A learning health system should also facilitate the expedited translation of science and evidence into treatment paths that match individual preferences, assisting individuals and their care team with understanding the risks and benefits from competing therapeutic options.
Care teams and researchers can leverage this information to provide person-centered care and design research studies likely to produce higher quality results, particularly in precision medicine, and in high-impact health challenges, such as heart disease, diabetes, and other chronic illnesses.
Approaches such as human-factors engineering can help stakeholders learn how to best use or develop new health IT to improve health and health care, and identify which kinds of electronic health tools and their applications are most effective in reaching personal, population, and public health goals.
Precision Medicine Initiative
The Precision Medicine Initiative is a new research effort to revolutionize how we improve health and treat disease. The initiative will pioneer a new model of patient-powered research that promises to accelerate biomedical discoveries and provide health care providers with new tools, knowledge, and therapies, augmenting the ability to choose which treatments will work best for which patients.
Near-term goals of the Precision Medicine Initiative are to intensify efforts to apply precision medicine to cancer through innovative clinical trials of targeted drugs for adult and pediatric cancers; use of combination therapies; and increase knowledge to overcome drug resistance.
A longer-term goal of this initiative is to create a research cohort of more than one million American volunteers who will share genetic data, biological samples, and diet and lifestyle information, all linked to their EHRs if they choose.
Research can also lead to improved workflows and better and safer use of health IT. Many health IT studies focus on whether health IT improves health care and health outcomes; however, not as many studies consider how to implement health IT solutions in ways that ensure that it meets its full potential.
Federal science and research play an important role in advancing evidence on how health IT can improve health outcomes, reduce health disparities, and improve care delivery, as well as how to make these systems easier and safer for people of all abilities to use. Achieving these objectives requires significant collaboration between the private and public sector.