Originally Broadcast Wednesday, February 6, 2008

Washington, D.C.

Mr. Morales: Good morning. I'm Albert Morales, your host, and managing partner of The IBM Center for The Business of Government.

Concerns about quality, safety, and the rising costs in health care have driven the federal government and national leaders to look for solutions to the challenges facing the nation's health care system.

Over the last several years, the recognition of the importance of Health IT and health information exchange has grown significantly. While there is a broad recognition of the need for Health IT to address many of these challenges, there is also a need for leadership, coordinated action and common agreement among the many stakeholders.

With us this morning to discuss his work leading the federal efforts on health information technology is Robert Kolodner, National Coordinator at the Office of the National Coordinator for Health Information Technology within the U.S. Department of Health and Human Services.

Good morning, Robert.

Mr. Kolodner: Good morning.

Mr. Morales: Also joining us in our conversation is Tom Romeo, IBM's public sector general government industry leader.

Good morning, Tom.

Mr. Romeo: Good Morning, Al.

Mr. Morales: Rob, I always like to ground our listeners with some facts around our subject area, in this case, Health and Human Services, or HHS.

Could you spend a few minutes and give us a sense of the history and mission of HHS? Also, can you give us a sense of its scale, how it's organized, size of budget and the geographic footprint?

Mr. Kolodner: I'd be glad to, Al.

HHS's mission is to enhance the health and well-being of Americans by providing for effective health and human services, and also by fostering sound sustained advances in the sciences underlying medicine, public health and social services.

The budget of HHS is over $690 billion -- that is with a "b" -- and we have about 65,000 employees in all states and territories. There's a long history going back of -- a federal network of hospitals that eventually was organized into the Public Health Service that was established for merchant seamen.

The Department was created in 1953 and at that time was called Health Education and Welfare, and was established to bring together numerous health agencies and activities. In 1980, Education split away, and the Department was renamed Health and Human Services.

The fundamental charge is really to administer a variety of government health-related programs which touch the lives of every American, every day.

So for example, the agencies such as centers for Medicare and Medicaid, the Food and Drug Administration, Centers for Disease Control and Prevention, or National Institutes of Health, to name just a few.

Mr. Romeo: Thanks, Rob.

Now that you've provided us with a sense of the larger organization, perhaps you can tell us more about the Office of the National Coordinator for Health IT, and your specific responsibilities and duties as the National Coordinator for Health IT. Specifically, what's the size of your budget, and how does the office support the overall mission of HHS?

Mr. Kolodner: Well, the position of the National Coordinator was established with an Executive Order in 2004 by President Bush. The National Coordinator was charged with being responsible for guiding the nationwide implementation of an interoperable health information technology infrastructure in both the public and the private sectors.

The reason for this was not for technology's sake, but such an infrastructure is a necessary component in order to be able to reduce errors, improve quality and produce greater value for health care expenditures.

My office is charged with developing the vision for such an infastructure and for putting together a plan to achieve the goal that President Bush charged us with of getting the majority of Americans to have health care that's enabled by electronic health records by 2014. In terms of our budget for this year, fiscal year 2008, the budget is about $60.5 million. And we have about 30 employees, and then we have a number of contactors and a variety of contracts that go out into the states and communities.

Mr. Romeo: Great.

Regarding your responsibilities and duties, what are the top three challenges that you face in your position, and how have you addressed those challenges?

Mr. Kolodner: Tom, as you can imagine, the responsibility that we're charged with is really a very big and complex one. We're talking about having changes that are pervasive throughout the health care sector, which accounts for about 16 percent of the gross domestic product right now.

That means that when we're talking about having the use of electronic health records and a network to connect them, we're trying to touch 5,000 hospitals across the nation, somewhere between 200,000 and 300,000 doctors' offices, and a numerous number of pharmacies and laboratories.

In addition, one of the real challenges we have in the U.S. is that half of the care in America is delivered in doctors' offices where they have four doctors or less, or four providers or less. And so we're talking about very small units as opposed to large institutions.

The plan is designed so that the various activities will mature, and by 2009, 2010, 2011 they'll reach a point where the physicians and practitioners and hospitals can adopt that technology, and it provides them value because of the interactive nature and being able to meet their needs and fit into their work flow.

We're addressing this challenge through the variety of activities that we've undertaken. We know that such a change can't happen overnight; that this type of change tends to have a slow uptake initially, and then a rapid uptake down the line, and we expect that to occur somewhere in the 2009 to 2012 time frame.

In order to address this challenge, we really have a 10-year plan for bringing it about. We know that the first few years, we're laying the foundation, and that it's going to be somewhere between 2009 and 2012 where we expect to see the rapid adoption of the technology across the country, especially in what we know as the last mile of that, which is the small providers' offices in clinics across America.

The second challenge is really privacy and security. We know that we must have that right to go forward; I certainly wouldn't trust putting my information on a system that I didn't think was secure, and I wouldn't want my information to be released without my permission. As we move forward, we're wanting to make sure that we have the proper infrastructure to provide that security, and that we have the necessary protections for privacy.

One of the challenges here is that we're serving both the health care needs as well the population needs. And as you can imagine, understanding the health of a community is important so that we can detect epidemics or other events, health events that might be occurring in a community, and we also want to be able to measure the quality of care that's being delivered and provide that actually as information to the individuals themselves so they can use that when they go about choosing which provider they would want to get care from.

The third area -- as far as that challenge goes, we're doing two things. We're working at the federal level and will putting out a framework later on this year, privacy and security framework. We will also -- we've been working with the states. We also have been working with the states, because a lot of the privacy activities occur at the state level, and there's been a variation in the state laws and in how they interpret the federal laws, and by engaging individuals across the states, we are able both to learn what's going on and to help foster the state activities to address this.

So the particular activity we started a couple of years ago has actually engaged over 4,000 individuals in 45 states and territories so far, and I look forward to continuing to have the additional states and territories get involved in that as well.

The third challenge is helping each individual to understand how such an infrastructure can help them to get better-quality safer care, and that we actually believe that having such an infrastructure will allow us to transform our health care system to where we really do achieve the person-centered health and care that we all deserve.

Mr. Morales: You certainly are taking on some of the largest challenges that our country faces here.

I want to switch gears for a moment and focus on you. I understand that you've held several positions at VA and VHA in the past. So I'm curious, how did you begin your career in medicine, and how did you get started in government?

Mr. Kolodner: Well, my career actually started because I had a father who was interested in technology, was a physician, but it was the technology part that he was most proud of. And I either inherited it or he infected me with whatever it might be.

So from the time that I went to college, I started playing with computers. In freshman year, I took a programming course and found one way or another to use computers through college and for medical school and for my residency.

And at that point it was really more fun and toys, but at the end of my residency, I was struck by the gap in quality of care because of the knowledge gap between what was published and what we were practicing day-in and day-out, and I wanted to find some way to close it.

So I joined the VA after I finished my residency, and started working with the technology people at that time, forming a team to say what is it that I needed as a psychiatrist that would help me to improve the care that I could deliver to my patients?

Mr. Morales: Interesting.

So as you reflect back on these experiences, I'm curious, how have these experiences prepared you for your current leadership role and perhaps shaped your current management approach and leadership style?

Mr. Kolodner: From the very beginning, I was aware of the limitations of the care that I could give because of information that was missing, information about the current state-of-the-art or information about the individual himself, and so I really worked to improve and address those problems.

That experience as a frontline clinician helped to guide me and make me sensitive to the fact that technology had into fit into the practice of medicine, rather than the practice of medicine fitting into the mould of certain technology.

And so at this point, I would say that we probably have -- our best electronic health records are probably not quite the Model T yet compared to what I hope to have in the future, but it really inspired me to want to move forward.

The other impact was that as a psychiatrist, I was not trained in the psychoanalytical model, but more of a medical model, and we worked as a team. So the whole idea of working together as a team was a very important process, and one that I brought into my activities with regard to technology and electronic health records, and I was able to move forward in my career, move up in terms of responsibilities, and eventually in 1993, I crossed to the dark side from clinician to administrator, moved to Washington and actually not just administrator, but crossed to being involved with the information technology.

Mr. Morales: That's great.

What's in interoperable Health IT? We will ask Dr. Robert Kolodner, National Coordinator for health information technology within the U.S. Department of Health and Human Services, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Dr. Robert Kolodner, National Coordinator for Health Information Technology within the U.S. Department of Health and Human Services.

Also joining us on our conversation from IBM is Tom Romeo.

Rob, over the last several years, the recognition of the importance of Health IT and health information exchange has certainly grown. Perhaps you could give us a better sense of what exactly is health information technology, or Health IT, and specifically, what are some of the key components that make up Health IT?

In the last segment, you talked a little bit about electronic health records, but are there more components?

Mr. Kolodner: Yes, there are several components, and they work together with one another. So the one that I mentioned before, electronic health record, is a tool or an application, set of applications, that providers can use when they give care. They record your record, record what they've done, record the outcome, be able to order meds or laboratory or other things and get the results back.

And while it also has your encounter, it actually is even better if they have broader information about your health and your social history that can be fed in. Another component of Health IT is the personal health record.

The personal health record has not only a documentation from their health encounters, but it also has additional information that affects their health and well-being. And so it really is something personal. It can be very exciting, and Secretary Leavitt has indicated that he thinks this may be the disruptive technology of the future, that as consumers establish their own health records, that they will begin to request and even demand of their providers that they receive their health information electronically, and that that will help to change society.

The personal health records is a second component. When you have this, all of this information that is available about individuals and their encounter or about their health, you also want to be able to draw from that information to understand things about the public health activities and about population health, to be able to advance medical knowledge, and so there is a public health information component as well.

Now, those are really the application level, and there are two other components that are with the infrastructure.

One is that you need to have standards. We need to make sure that the information that moves around means the same thing whether it is a lab test name and a value, or whether it be a description of a condition or a symptom. And then when we have these isolated islands of standardized information, we need to have a secure means to move that information around, or an interoperable network.

And we have been talking and developing the Nationwide Health Information Network, which isn't a separate network -- it's actually a secure means of exchanging the information over the internet, but making sure that that information is able to be transferred privately and securely.

Mr. Morales: Now, there have been concerns about quality, safety, and certainly the rising costs in health care, and these are driving the federal government to action.

To what extent is the national Health IT agenda a response to this situation, and how might the use of Health IT benefit the health care consumer and the public health in general?

Mr. Kolodner: The current crisis in health care and health care delivery system, that is, the recognition that the quality isn't what we all deserve and that the costs keep going up and up, has created the burning platform for change.

Many people have been working for the last 20 years to try and get progress in this area, and we really haven't gotten very far. It's really the recognition in the last several years that we can't afford to have the costs of health care doubling every so often and having so much of our gross domestic product just for health care, which then takes it away from any other discretionary purposes, has really galvanized the nation.

And if you look at the candidates today running for president, they have different ideas of how to address the health care system changes that are needed. The one area that they are uniform about is the need for Health IT. It is a necessary but not a sufficient component for bringing about the health care transformation. It is about putting in the means to deliver the high quality care, and with that high quality care, we can also be much more efficient.

There is a statistic that one of the President's advisory councils identified several years ago that about 20 percent of the tests that are ordered are ordered because a prior result is not available, and that one in seven hospitalizations occurs because the person's health information isn't available to the provider who is seeing them and trying to decide whether or not to admit them.

So we know that there are inefficiencies there, and by having the information infrastructure to be able to have that information available, we know we can give better quality care and address the challenges that we have -- having such an infrastructure in place is one of the necessary components to help us address the challenges we have in health care today.

Mr. Romeo: Great.

Well, a national adoption survey was performed to determine the rate within the U.S. of Health IT adoption, in the form of electronic health records or its components. Can you tell us more about the results of that survey, and what's the current rate of adoption, and what are some of the key factors that have slowed adoption?

Mr. Kolodner: Well, Tom, the problem when the office was founded in 2005 was that there were many different numbers regarding what is the rate of electronic health record usage across America.

And the first step that we took was to commission a study to agree upon a methodology for measuring what constitutes adoption of an electronic health record. We were able to use that to review the literature and determine that an estimated 9 percent of doctors had an electronic health record that had the minimum function that had been identified by the Institute of Medicine -- and that was in 2005.

In 2007, we actually conducted the survey, we mailed out the forms to doctors and received them back, and we got a sample size of about 1,500 doctors across the nation who were gathering more to get more-detailed analyses.

But that gives us a solid figure as far as what that adoption rate is, and that's 14 percent, using this minimum function criteria. So we see that in a three-year period between 2005-2007, there was a 50 percent increase in the use of electronic health records by frontline providers in the outpatient area.

Now, 14 percent is still low. But there was some movement, and this information allows us to track the effectiveness of the measures we're doing and the activities we're doing so that we can adjust them based on -- are they having the effect that we expect at the rate we expect them to have it.

We did ask the responders, the physicians, about what their major barriers were for adoption, and they obviously identified the issue of some finances -- whether that's the upfront capital or the maintenance of system. And part of this is that we have a system where the savings sometimes accrues, in the case of electronic the health records, to the payers, and the benefits are made to the patients from the better quality of care.

But the doctors are the ones who have to buy the system, and so we're looking at how do we make sure that there is a sharing of that savings with the physicians, and that's actually the purpose of one of the recent CMS demos that -- Medicare demos that has been announced and that we will be recruiting for later on this year.

The other kinds of issues that they identified were uncertainty about their return on investment, a loss of productivity, because when you first put a system in you aren't quite as efficient in performing your processes so it slows you down a little bit, and some legal issues about physician protection or whether there is legal liability if information were to be released not by them but by somebody else that they pass the information to.

Mr. Romeo: Rob, you've described a fairly complicated environment for health care in the United States. It seems like the success of a broad IT effort rests on a coordinated integrated collaborative approach among diverse stakeholders.

To that end, what is the American Health Information Community, or AHIC, and what are the recommendations it has provided to the Secretary of the HHS? And could you elaborate on the plans for AHIC's successor organization and the status of its implementation?

Mr. Kolodner: Well, AHIC is a federal advisory body, and it was started in 2005 to make recommendations to the Secretary of HHS on how to accelerate the development and the adoption of this health information technology.

It was formed by Secretary Leavitt in order to help move this forward and to achieve that 2014 goal that was set for the adoption of electronic health records. The members of the AHIC are leaders in both the public and private sectors.

And it also has public sector leaders from areas such as Medicare, Public Health, CDC, from the VA, and from DoD, which are major health care providers and from the Office of Personnel Management.

It is an advisory body. So it does not take action by itself but has - it's a way of engaging a broad spectrum of stakeholders to help set the agenda, or it's a way of getting a broad range of stakeholders to advise the Secretary about the priorities to pursue in terms of activities.

The problem that Secretary Leavitt has indicated is that we're still subject to the four-year cycle of the politics, and sometimes two-year cycle, and that the activities in order to plan out 4, 5, 8, years really need a steadier -- the activities that go out 5-8 years really need to have dependable means for support and for effecting the activities.

Another problem that we have is that the stakeholders in health care, providers, payers, insurers, consumers, when they sit down around the table, don't trust one another, and trying to solve problems together when you don't have trust is very, very difficult.

AHIC works because the Secretary convenes it, but we really need to find a way to bring together these competing stakeholders in a manner that allows them to work together and to trust that they are working in the best interest of the group and of the country.

So we let a grant this grant is really for them to establish a successor to the AHIC that can take non-governmental activities and transition those to a public-private entity in the private sector.

The government will be a very active part of that, pay for 40 percent of health care in one way or another, and be a major funder for population health activities, and for us to work together to create an organization that's structured in such a way that all are part of it but none can control it.

And so each of the sectors is able to select how their representatives are chosen, and that we can work together, not in a recipe for stalemate, but in a very effective means to move forward to establish the priorities for the interoperability and being able to network and move that information among the entities that need to have them.

At the next meeting of the AHIC in the last week of February in Orlando, they will be coming to talk about their plans, which involve having an outreach program for the first few months so that they engage stakeholders across the nation, and then to form a board of directors by this fall so that the AHIC-2 or whatever they call it is up and running and can take over these responsibilities for overseeing the standards priorities and interoperability and certification of products.

Mr. Morales: What can you tell us about the Nationwide Health Information Network, or NHIN, and its prototype architectures?

What's the next phase of this initiative, and what about the involvement of federal agencies in the NHIN effort and the expectation and challenges around their involvement?

Mr. Kolodner: Well, we're actually in the next phase of the NHIN; it's called the trial implementations. So we learned from prototype architectures that what we're talking about doing is feasible and that there are a number of different ways to approach it. We then took the best of those prototypes, put them together and set that as a starting point for the NHIN moving forward. And it's really a critical portion of the agenda, because as I mentioned, if you have this information and it's not available, then you can't get the benefits of this electronic health record.

For example, think about how many providers you see even if you're healthy. You see your dentist, you may see an ophthalmologist, you see an internist, you may see some specialist, and if you got a chronic illness, you see even more, and it's important for each doctor or nurse practitioner or physician assistant to be able to have that information to give you the best quality care.

So we have moved forward. We're going to be actually demonstrating the movement of the information among nine communities to whom we awarded contracts. We're going to do that in the September time frame, and there is also going to be a tenth entity that's going to be joining, and that is the federal entity.

So we're going to have the VA and DoD and Social Security Administration to show that the information can move using a set of standards that they've agreed upon. And in fact, we've formed them as a coordinated group to identify what's the best way, because each of them has a slightly different structure and way of handling information, and we need to be able to accommodate those.

We're also planning to issue a set of grants so that we can allow others to join in the demonstration as well this September. Once we show that we can move this information securely and reliably among these communities, then we're going to move forward to the next step -- we want to move forward and take the next step to begin seeing what will it take to use these in day-to-day operations.

Mr. Morales: Rob, along these lines, many of the electronic health records today have very strong functionality but lack portability, meaning that patients' health information can't be transferred among many electronic systems, and thus precluding availability of this information across multiple care settings.

Could you tell us about your efforts to remedy this situation, and how does the Health IT standards harmonization process factor into this effort?

Mr. Kolodner: We have a process that the Secretary calls the turns of the crank. The AHIC makes recommendations on priority areas -- for instance, its first priority areas were -- have doctors to be able to retrieve laboratory results even if they didn't order the tests. Have patients to be able to get the list of the medications they were on, and please, please, let's eliminate that darned clipboard and be able to move that information and fill in the most of the form electronically.

So those were the priority areas. We then developed scenarios that we described each of those within and gave them to a public-private group that's been formed that looks across and sees what standards are needed, what standards are available, and harmonizes those and picks the minimum set necessary to meet that need, with the intent that those standards will be used again and again as new priorities come down the pike.

Those are then recommended back to the AHIC, and AHIC recommends them to the Secretary. If the HHS Secretary finds it acceptable, he accepts them, and a year later then, it recognizes them. And that year period is so we can test those standards out, begin to allow vendors to have time to implement them, and when the Secretary accepts them a year later, that triggers off certain requirements from an Executive Order that was issued in August of 2006 where the federal systems have to use it when they are exchanging information. They have to build it into their health care contracts, and entities and hospitals in the private sector that want to donate electronic health records to individual providers and clinics can do so only if they meet these interoperability standards. And they're able to do that because of a time-limited exception to the Stark rule and to the anti-kickback statutes to allow that.

This then has the standards of prioritized, harmonized, accepted and incorporated into certified products that can move forward.

Mr. Morales: So along these lines, it seems that to advance the adoption of interoperability standards and to reduce the barriers to technologies will require the creation of a product certification program, as you described.

Could you tell us about your efforts in this area -- more specifically, about the Certification Commission for Health Care Information Technology?

Mr. Kolodner: Yes, Al. What we found is that doctors were concerned as to whether they could rely on products. There are over 200 electronic health record products in the marketplace for ambulatory settings alone, and about 25 or so for hospitals. And when they went into that marketplace, they really didn't have any idea as to what was good and what was bad and what might meet their needs.

And so we established a group, CCHIT, as you mentioned, that is a public-private group, and the federal government funds them to develop certification standards, and we started with ambulatory electronic health records and inpatient electronic health records, going on to networks and will be working our way through specialty electronic health records and personal health records.

For the electronic health records, they established a certification criteria for some functionality and for security, and at least in the first two rounds, just a minimum set of interoperability standards, because we hadn't yet moved them through the cycle that I talked about previously.

We've been really gratified that this area of our activities has really taken off, and in the first 18 months of certification, there have been 98 ambulatory electronic health records that were certified, which represents over 40 percent of the total products, and over 75 percent of the products that are installed across the nation. And this has really given providers some reassurance that they are getting a product that's worthwhile.

Now that's the starter set, and what we're doing is we're raising the bar each year, because we will be adding in additional functionality and additional standards that they need to meet so that we will be getting products that we know will be better and -- so we will be adding in each year additional functionality and additional standards that need to be incorporated in order to be certified.

This next summer is the first certification cycle, where the standards that were identified to meet that first set of priorities that I mentioned, that the AHIC recommended, will be incorporated in the certification cycle, and in order to be certified those products will need to support these interoperability standards. We're very excited about that.

Mr. Morales: Great.

What is value-driven health care? We will ask Dr. Robert Kolodner, National Coordinator for health information technology within the U.S. Department of Health and Human Services, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Dr. Robert Kolodner, National Coordinator for Health Information Technology within the U.S. Department of Health and Human Services.

Also, joining us in our conversation from IBM is Tom Romeo.

Rob, it strikes me that there are significant regulatory, legal, and professional standards that are going to have an impact on the practice of medicine and create some of these barriers of interoperable electronic health information exchange, as we've discussed.

Can you elaborate on the activities you're pursing to mitigate these barriers such as licensure?

Mr. Kolodner: Yes, Al. The licensure activities are really state level. And so we're working with the states to move these forward, so we commissioned a State Alliance for e-Health, which was formed by the National Governors Association under contract with HHS. It's made up of governors, state legislators, attorneys general, and commissioners of health across the nation. The State Alliance has spent the last year discussing these state licensure issues and cross-licensure issues as well as e-health, which includes telemedicine and telepharmacy. And they had a work group that made six recommendations that were aimed at simplifying these licensure processes for physicians and nurses and pharmacies.

And they're looking at moving those forward in what activities they can foster across the states to begin to resolve those barriers. At the February meeting of the State Alliance, the task force will present additional sets of recommendations that are related to streamlining the licensure for these particular professionals.

Mr. Morales: Rob, in general, today, the current administration does not support the provision of financial incentives to encourage the adoption of Health IT, believing that the adoption should be more market-driven.

Could you tell us about the use of Medicaid transformation grants? What are these grants, and to what extent do such grants promote the development of state health information exchanges?

Mr. Kolodner: Well, I'm going to talk both about the Medicaid transformation grants but also the recently announced Medicare EHR demo, because I think the EHR demo is more directly under purview of HHS, and it's one where we're going to be advancing Secretary Leavitt's efforts to shift health care in U.S. towards a system that's based on value.

If we just give dollars to buy a system, the concern there is that we don't know what the quality of the system is or whether it will used. And so we're looking at making sure we reinforce the use of systems and to improve quality.

And the demo is designed to provide a bonus payment to providers in the first year who have a certified electronic health record and who are able to do some simple reporting about the use of that. The second year, they actually have to report some quality measures. And the third, fourth, and fifth years, in order to qualify for the bonus, they need to actually achieve certain quality benchmarks.

And so it is a way of providing some financial support by tying it not just buying a system, but to having a system that in fact is effective and is able to increase that quality of care. And that's going to involve 12 communities across the country and 100 physician practices in each of those communities.

Now, the Medicaid transformation grants are about $150 million that's been awarded in 2007 into 36 states and Puerto Rico -- and the focus is to help Medicaid programs improve the access and the quality of the services to their beneficiaries by using health information technology.

Now, Medicaid is administered by the states, so the HHS provides the funds. But the activity actually occurs at the state level. And a few examples include working with various Medicaid programs to advance health information exchange opportunities, use of EHRs, electronic prescribing and enhanced use of electronic health records by providers, the electronic prescribing with automated eligibility checks, and the enhanced use of data to improve clinical quality.

Mr. Romeo: With the federal initiative to build nationwide interoperability, Regional Health Information Organizations, or RHIOs, have proliferated in various forms.

Could you elaborate on how your office and HHS assists the state and local RHIOs?

Mr. Kolodner: Well, the initial push was for geographically based health exchange organizations, or RHIOs. And we're still working with many of those. We're working to identify best practices.

One of the challenges that many of them have is, what is their business case? How are they going to be funded? How do they become self-sustaining? And that's been a real challenge in many of the communities. We also over this time have recognized that there are various ways that communities organize their ability to exchange information.

One model is this multi-stakeholder group that comes together and forms a new organization; another may be an integrated delivery network where you've a dominant player in a particular area and they end up providing the technology and the interoperability throughout that community.

There is another model that's occurring in Iowa, which is a group of providers who collaborate together and share the cost of a system that they all can use. So it's not a single integrated delivery network, but it's kind of a virtual integrated delivery network. And then the model of having a personal health bank, or personal health repository, serve as the way that information is shared among providers.

So we're looking at making sure that the Nationwide Health Information Network can support any one of those models and doesn't favor just one. But we do believe that a number of the communities that are successful, for example, with the RHIO model., we'll go forward with that and that there will be some others also that will bring those into being.

Mr. Romeo: Great.

Rob, you mentioned earlier that there are two critical elements to the safe exchange of health information at a national level, and those are privacy and security.

Could you tell us about your privacy and security efforts, and what remains to be done?

Mr. Kolodner: Well, let me make sure that I do reiterate and make it real clear that we know that if the health information exchange is not done in a way that's secure and doesn't retain the privacy of individuals, it will fail. And we can't afford for that to happen. We need that system to work and to be in place as soon as possible.

We started by working at the state level. As challenging as the federal level is when you have all the different states each having their own variety of laws and regulations, that's created unnecessary barriers to the exchange of information, sometimes within a state and certainly across states.

We formed both a state alliance that I mentioned earlier as well as the health information security and privacy collaboration, and that's the one that had engaged 4,000 individuals and really identified the variations in business practices in the state laws, and then each of the states that participated then put together an action plan and is starting to execute on that action plan to resolve the issues. And this year, what's very exciting is we have multiple states coming together to work on common areas.

Now, we also have the -- within the NHIN, from the very beginning we've incorporated security elements that are part of it and are there every step of the way. And we also have built-in a requirement that consumers get to have to say as to whether or not their information flows over these networks and consumer controls. So we're beginning to build that into the systems that we're testing and trying out. We're also, as I mentioned, working on a privacy and security framework that we'll be developing and making available later on this year.

The problem with policy is that it is very deliberative, it takes a long time. What we need to make sure of is the technology, which can go very rapidly, doesn't constrain or make the policy.

And so that's why within what we're doing within the NHIN, we're making sure that it has a large number of capabilities to be able to support the variety of privacy policies that exist at the state level as well as whatever privacy policy may be moved forward at the national level or the federal level.

Mr. Romeo: Rob, health care transparency is one of the items that may help restrain the growth of health care costs by giving consumers more information on the comparative costs and quality of their health care.

To this end, would you tell us more about value-driven health care. Specifically, what are the cornerstones of value-driven health care, and how critical is Health IT to the vision of a value-driven health care model?

Mr. Kolodner: Health IT is a critical component of the value-driven health care model. Health IT by itself is not a magic bullet. If you simply put in the technology, you would probably just raise the cost of health care.

What we need to do is to put in the electronic health records and Health IT components in such a way that they are used effectively to improve the quality. The value-driven health care brings both the consumer and the provider into the picture.

So if you think about it, you know more about the digital TV you go to buy and about the quality and trade-offs of the car you buy than you do about your health care, because you really don't know who gives the best-quality health care. You know who is recommended, but you really don't the quality.

And so what we're doing here is putting in Health IT, because that's the way we provide the tools that can be used to improve the quality, and then we measure and report the quality -- measure and report the cost. Quality over cost is your value.

And then we need to make sure that there is an incentive so that the person seeking the care chooses the best value, or at least understands that if they're choosing one that's not the best value, they get to pay a higher cost or -- and then be sure that the person who is making the decision about who to go to or where to get their care has an incentive to choose the best value. And if they don't choose the one that's the best value, they have that choice but they may have to pay a higher price.

So it's putting this together in a community -- and this is done at a community level, that is the core of this value-driven health care and is the core of what the Secretary is now going across the country promoting, which is chartered value exchanges within communities that have brought together the multiple stakeholders to do with this activity.

Mr. Morales: Great.

Rob, it strikes me that in order to promote the adoption of Health IT, changing the behavior of both consumers and clinicians is a core requirement and presents a tremendous change management effort.

Could you elaborate on your strategies to effect this change specifically among clinicians who typically are not known for accepting change so easily?

Mr. Kolodner: I know that especially today, clinicians are seen as being reticent to make change, and yet if you look at the real activities over time, when there is a good technology, they adopt it. We're talking about a technology in this case that requires him to change how they practice medicine, to change their work flow.

There is not another industry that I know of that has the highest paid, most highly trained individual doing the bulk of the data entry, particularly at such a detailed level.

Now, that's the nature of health care. We've been doing that. We record it in paper. Now we need to change the work flow, so that they are doing it in an electronic health record and being used to actually have any information available that they can use rather than making decisions in the absence of information, which unfortunately happens more often than not in health care today.

So we need to recognize what we're asking them to do, and we need to provide the necessary training and provide environment that will attract them to use the system.

One thing that we're working on is a reduction in malpractice insurance for doctors who use electronic health records. I've mentioned the demo that Medicare is undertaking to see, does that provide the way to attract providers to use the systems.

What we need to make sure of is that when the provider uses that system, that they find a benefit from it. So having the information available, making it easier to not only send the prescription to the pharmacy, but also to do the refills, because now it's a matter of bringing up and clicking -- and that document's in the record, it sends the prescription to the pharmacy, and it does the background check for drug-drug interactions so that they know they are giving a safer quality care.

So we need to work with the providers, we need to make sure we understand what their issues are. And I can say that that having worked in the VA for 29 years, I saw that system go through an incredible transformation that allowed providers who wanted to give the best quality care to now know they had the tools to be able to give that care, and in fact, a combination of the IT system and the management holding them accountable brought about these types of changes and really a transformation in the way that that they were able to relate and care for their patients.

Mr. Morales: Great.

What does the future hold for the nation's health care system and the rise of Health IT? We will ask Dr. Robert Kolodner, National Coordinator for Health Information Technology at HHS, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Dr. Robert Kolodner, National Coordinator for Health Information Technology within the U.S. Department of Health and Human Services.

Also joining us in our conversation from IBM is Tom Romeo.

Rob, the Institute of Medicine has identified six characteristics of quality care, and the goal of transforming health care is to help providers ensure that the care they deliver meets the six IOM characteristics. Could you tell us a bit more about these characteristics?

Mr. Kolodner: Sure, the six characteristics that IOM described for quality of care are the following -- first, that it's safe; that we're not doing something that causes harm, like drug interactions, being an example of causing harm, looking for the interactions and anticipating them, I think obviously what we're going to be doing in the future. It needs to be timely. You don't want to have delays in terms of the delivery of that care or what's needed.

And so timely is the second. Third is it's equitable. All populations, all individuals share the benefits of that quality of care, and that there aren't some populations that are underserved or disadvantaged. It needs to be effective. We're not doing things that -- while they may not do harm, also may not do any good. We want to make sure that the interventions we have with those procedures, medicines or other activities work. We wanted to be patient-centric. So a person should have a choice about this, should have a say in what's going on, and it's about them and not about the institution.

And finally, that it should be efficient; that we don't waste resources, we don't waste time in the care-delivery process. So those are the six characteristics that IOM identified.

Mr. Romeo: Rob, it's widely known that poor-quality care translates into higher costs. According to a recent Commonwealth Fund report, chronic disease is a growing problem in the United States, with more than 157 million Americans having at least one chronic condition by the year 2020. And looking ahead, how does the adoption of Health IT enable the move from simply managing disease, going beyond even prevention, to ultimately a predictive-care model, being able to intervene sooner, rather than later?

Mr. Kolodner: The health care system that we have today is very much like the health care system we had 50 or even 100 years ago. We react to events, we intervene way down the line when chronic illness has developed, and we manage the consequences of those chronic illnesses.

And more recently, we've had more-effective treatments. We begin to try and prevent some of the consequences of those chronic illnesses. So if you've diabetes, we keep the diabetes under control; for diabetes, that by keeping their blood sugar under control, you can decrease their chance of having a heart disease or blindness, or have to have an amputation.

And so we need to start, as we're doing, by doing a better job of controlling blood pressure, of controlling diabetes, controlling those conditions that we know can lead to far more dire consequences. But what we really want to do is to move it further back.

Now, where does Health IT fit into this? Doctors, no matter how intelligent they might be, find that it's difficult to remember to do all of the activities, all the prevention, all of the checks every day for every patient. And as much as they might like to do that, one of those doctors -- one of the early pioneers in Health IT talked about the imperfectability of man, and that unfortunately includes providers.

So the computer provides a tool to help make sure that the health care provider does the right thing when they need to do it every time, or can document why they didn't, or can set a reminder -- don't have time now, I'll do it -- remind you the next time. But what we really want to do is to move even farther down the line earlier. It's not only less expensive; but more importantly, it's better quality life for individuals. And especially as we get the revolution that's going on in terms of understanding genomics and the underlying basis for many of these diseases, we will be able to predict and intervene before the hypertension develops, before the diabetes develops, before the coronary artery disease occurs, and be able to give individuals a better life.

And by the way, it happens to cost less for society, and for those who do still develop some of the conditions, that we will make sure we will give the best possible care, taking care of the management of that condition, and doing any necessary prevention going into the future.

Mr. Morales: So on this predictive discussion, I'd like to transition out to the future. What are some of the major opportunities and challenges that your office may encounter in the future, and how do you envision your office will evolve over the next, say, three to five years?

Mr. Kolodner: Well, one of the things that we had been charged with doing, that we're in the process of working through the system, is to release a strategic plan. People have said, what are all these things you're doing -- and we have a lot of activities going on. And so we're putting that plan together; not only to communicate all the things we're doing and how it fits together, but also to be able to document how the activities of our office are those of a coordinator. And they are synergized and benefit from a myriad of activities that are undertaken by other federal agencies that are working within their own space, and that also are supplemented by the tremendous innovation and activities going on in the private sector.

Now, the challenge of our office is that it's unlike any other that I know of, because it's trying to bring about a change in a very rapid time frame, which means that unlike some activities, we don't just set up an office, establish it and have the same structure for 5, 10, 15 years. Each year, the environment is different. There was nothing going on in 2004. In the last three years, we've been able to make more progress in areas such as standards, than we had made in the last 10 or 20 years. That means that the environment is different. So what we need to do next is different.

We didn't have an advisory body to set the priorities. We established that in 2005. That's going to be transitioning to the private sector as a public-private entity this year. Our role will be different. It doesn't mean we go away; it just means that we have to essentially adjust each year and say what's needed next. Okay, we've moved down the road so far, what do we do next? And so as the standards activities matures and we can -- not have to start it up and establish it and test it, and fund it.

But we can be a part of the whole community, keeping it going. Privacy and security; we started by fostering the states; they've got that activity underway. We need to be working at the federal level. We'll be working with a variety of stakeholders and reaching out in that area, moving it forward. And the coordination is different for each one of the stages. So our challenge in the office is how do we communicate a new role when it's constantly changing, rather than what people think, which is establish the office it should look next year the way it did last year.

Mr. Morales: So Rob, you've had a very successful vocation within medicine and as a public servant. What advice might you give a person who is thinking about a career, either in the medical field or perhaps as a public servant, or ideally as both?

Mr. Kolodner: Well, I've really enjoyed my time, both as a physician in giving care, and then the opportunity to be an administrator in helping the system to give better care, leveraging the work of others. And I very much recommend it to others who find that they would like something exciting, something that's changing. What I'm doing today is unlike anything I ever would have anticipated having the opportunity to do. And I would encourage the people wholeheartedly to pursue it vigorously.

Mr. Morales: That's great, that's fantastic advice. Unfortunately, we have reached the end of our time, and that will have to be our last question.

I want to thank you for fitting us into your busy schedule. But more importantly, Tom and I would like to thank you for your dedicated service to our country, both at the VA and now at HHS.

Mr. Kolodner: And if anyone would like further information, if you go to our website at www.hhs.gov/healthit, you can find the activities that we're doing in fostering the collaborations that we're moving forward, and look forward to helping the nation to have better health. It is something that's not about technology; it's very much about making it personal, and all of us getting the quality of care that we all deserve, and having the health and well-being that we deserve.

Mr. Morales: Great, thank you.

This has been The Business of Government Hour, featuring a conversation with Dr. Robert Kolodner, National Coordinator, Health Information Technology, within the U.S. Department of Health and Human Services. My co-host has been Tom Romeo, IBM's general government industry leader.

As you enjoy the rest of your day, please take time to remember the men and women of our armed and civil services abroad who may not be able to hear this morning's show on how we're improving their government, but who deserve our unconditional respect and support.

For The Business of Government Hour, I'm Albert Morales, thank you for listening.