Health IT Standards in the United States and Around the World

At the Health Information Technology Policy Committee (HITPC) meeting last week, I gave an update on some of the health IT standards and technology highlights from last year, and a high-level view of the work ahead for this year's standards work.

Obviously, much of the work of the Office of the National Coordinator for Health IT (ONC) and the Office of Science & Technology (OST) is focused on the domestic challenges of interoperability and the technology requirements for meaningful use, but one of the committee members suggested that we should look beyond our borders to other countries to learn about (and leverage) health IT developments internationally.

The health care problems that we are trying to solve in the United States are the same health care problems that those in other countries are trying to solve. And they are big problems. So, we need to learn what works (and what doesn't) from other countries, and work together to solve those problems.

A Need for Health IT Standards and Interoperability in Health Care Around the World

At ONC, we frequently have visitors from other countries who are looking to the U.S. to learn about Meaningful Use, and to discuss the shared challenges that we have in managing health information. While there are significant differences in the way in which different countries fund and organize their health care systems, I find that invariably at some point in the discussion the conversation turns to interoperability and standards as part of the solution. Health IT standards and interoperability are both universal needs for health care in the United States around the world.

Fortunately, OST and ONC have been engaged in the international health IT community for a number of years. We support the Departments of State, Commerce, and Trade with health IT standards expertise that is intended to spur economic development and we have ongoing conversations with similar initiatives in:

• Australia
• New Zealand
• Canada
• Mexico
• United Kingdom
• Japan and
• Member states from the European community

Notable milestones from ONC's work with health IT community members from around the world include:

• The 2010 Memorandum of Understanding that was signed by Secretary Sebelius and Neelie Kroes, Vice President of the European Commission, which articulated a set of goals and principles that would guide international collaboration around health IT and health IT standards
• The attendance of the Secretary of Health from the UK at a federal advisory committee
• The continued discussions between ONC and NHS that are underway to organize a repeat visit and share progress

ONC's activities in the international health IT community are an important part of the work we do domestically and around the world.

Next week, I'll share some more specifics on the work we're doing with the international community that support our development of national health IT standards for interoperability.

Greater Accountability in Physician Education Drives New Approaches and Technologies

 Greater Accountability in Physician Education Drives New Approaches and Technologies
According to a recent article from Pharma Exec, “there is a new approach to lifelong learning for healthcare professionals”; an approach that is “effective and accountable, and uses technology platforms to deliver tailored content to improve patient care.”  This approach has been adopted in response to digital technology transforming continuing medical education (CME).   
“Gone are the days of dinner with a lecture,” replaced with a “more personalized approach to physician learning that provides the information a clinician needs—anytime, anywhere, on any device.”  Today, a dinner-and-a-lecture package is not good enough, and that is something that “every pharmaceutical executive needs to understand.” 
Instead, clinicians today are “expected to capture and report on clinical measures (pay-for-performance), remain patient-centric through coordination efforts, and stay up to date in their field of practice.  As a result, the need to provide relevant education anytime, anywhere, on any device is more important than ever.”  Consequently, the trend in CME is towards approaches that are more effective and efficient.  This “trend reflects—and perhaps is even driven by—the fact that CME plays such an important role in the healthcare system, providing a critical link in the process of translating evidence-based medicine into daily medical practice.” 

CME is Effective  
CME is the source for “current information and expert perspectives which physicians, in turn, incorporate into their practice.  CME has become an inherent part of the system for one simple reason: It works.  Excellent content, effectively executed, with appropriate measurement and feedback has a positive impact.”   
For example, the article cited a review of 105 articles in the scientific literature, which found that “continuing education—especially when it incorporates multimedia or multiple education techniques—is effective in improving physician performance.”  These findings were consistent with an analysis of “136 articles and 9 systematic reviews by Marinopoulos and colleagues, who found that the consensus of the literature is that CME achieves and maintains stated objectives, including improving knowledge, attitudes, skills, practice behavior, and clinical practice outcomes.” 
In addition, “CME can have a dramatic impact on clinical outcomes, as was demonstrated in a study reported in Annals of Family Medicine,” which we previously reported on.  In that study, Swedish researchers documented that the use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with coronary heart disease.   
Furthermore, technology expands the possibilities for effective education.  “A carefully designed and executed study found that physicians who participated in varied formats of selected Internet CME activities were more likely than nonparticipants to make evidence-based clinical choices in response to patient case vignettes.”  Likewise, a meta-analysis of 201 studies found Internet-based CME to be effective.  In a case-control study, participation in an Internet curriculum on safe medication use measurably improved the practice choices of healthcare providers in case vignette surveys.   
Moreover, the days of simply measuring learners’ satisfaction with more superficial aspects of programming are “long gone.”  Today, supporters of medical education “demand precise, systematic evaluations of whether participants in their program perform at a higher level following education.”   
Because CME is effective, physicians enjoy it and assert that CME “offers several advantages over other medical information resources, including the quality of content, availability of credit, accessibility, and diverse formats.”  “If an issue affects medical practice and quality of care, there is almost certainly a CME activity addressing it”, given the 125,000 activities across the US offered by over 2000 accredited CME providers.   However, as we have recently noted, the quality of CME has been decreasing, and the number of providers has been dwindling as well.   
Nevertheless, physicians prefer educational over promotional activities when seeking information about advances to incorporate into their practice.  “In a survey of 2000 physicians representing 16 specialties, respondents said that they were more likely to turn to educational sources for such information than to colleagues or peers, pharmaceutical promotional meetings, pharmaceutical medical liaisons or sales reps (CE Outcomes, 2010; unpublished data).” 

CME Programming 
The article recognized that “education is not a one-size-fits-all proposition,” and “diversity in programming formats is important.”  Studies of programs using different formats and venues have demonstrated “that multicomponent, multiexposure approaches to delivering instruction information are very effective for improving knowledge retention.  Repetition builds retention, and repetition works best across multiple learning platforms.” 
The article notes that, “the most effective education models match method to need.  Tailored learning, for example, adapts course content to meet the identified needs of an individual learner.  An assessment gauges gaps in areas where additional information may be needed to improve quality of care or practice performance.  Educational activities can then be designed and prescribed to physicians to provide real-time information to remediate knowledge gaps and improve clinical practice.  The net effect is that tailored learning activities connect education to performance and improved patient outcomes.” 
“The trend in CME programming is toward these tailored education programs and away from mass educational efforts,” the article notes.  Leading providers are moving toward programs that “identify and more effectively meet healthcare providers’ needs.”  They are designing programs such as those advocated by Moore and colleagues, that: 

• Start with the desired end in mind
• Are cognizant of physician experiences and current state of knowledge
• Focus on material that can be used in practice; and
• Incorporate practice and feedback in realistic settings 

“The net result should be programs that translate acquired knowledge into daily medical practice, improving competence performance, and ultimately improving patient health.”  
Increasingly, programs offered by leading CME providers will be based on theories form the social sciences that offer insight into changing behavior.  For example, Medscape recently “commissioned a study using the theory of planned behavior to analyze factors that predict whether interventional cardiologists are likely to use radial coronary angiography.”  This theory maintains that one’s intention to use or engage in a new behavior is shaped by attitudes, norms, and one’s perceived ability to adopt the change.   
Researchers were able to identify and measure the impact of factors at the patient level, physician level, and institutional and systems level on physician behavior.  “The result was a detailed understanding of factors that influence interventional cardiologists’ use of radial coronary angiography, factors that can then be addressed in specifically tailored educational programs.” 
Such tailored, “theory-based programs are ideally suited to the delivery platforms made possibly by digital technology.”  These online platforms are much more than an add-on to live CME activities.  “They are unique learning environments that can seamlessly link assessments designed to help physicians identify their information needs with content that expressly meets those needs.  And they can place that information at physician’s fingertips where they are, whenever they want it, on whatever device they are using. 
Already there has been remarkable growth in physician participation in online education, with internet-based offerings accounting for 18% of all physician CME activities completed in 2005, increasing to 39% in 2011.”   

Conclusion
Ultimately, “the role played by online learning is certain to become even more prominent because it is so well adapted to new models of learning in CME, which attempt not only to impart information but also change behavior.”  This technology is “unsurpassed in its ability to provide tailored education that gauges the specific needs of the learner, delivers information to meet those needs and evaluates progress toward the desired goals.”