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Title: CTSI newsletter
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Creator: Clinical and Translational Science Institute, University of Florida
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Place of Publication: Gainesville, Fla.
Publication Date: April 2009
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From the Director

Biomedical
Informatics
Meet the BMI Team
Leaders

The Last Page....


Volume 2, Issue 3 April 2009


INSIDE THIS ISSUE I


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.273.8700


The one certain consequence of the President's allocation of new funds to
NIH is the time we'll all need to recover from the Recovery Act! Ex-
trapolate the number of whirling dervishes at UF chasing deadlines for
administrative supplements, competitive revisions, challenge grants, etc., etc.
across the nation's Academic Health Center landscape and there's little won-
der that NIH has been bracing for all sorts of IT calamities from the deluge of
submissions.

Fortunately, the CTSI's own IT prospects are becoming clearer and brighter
every day. Under the expert leadership of Dr. Mike Conlon, Interim Director
of our Biomedical Informatics (BMI) Program, critical core IT infrastructure
is developing to support the Institute's various programmatic activities and the
research undertaken by its investigators and trainees. However, we are starting
essentially from scratch, and getting where we want to be in BMI is a multi-
year process with plenty of challenges en route. Nevertheless, as the following
article by Mike and our colleague, Dr. Bill Yasnoff, points out, the rewards for
all of us are worth the journey.

A final important reminder: Because of the (welcome) distraction of Recovery
Act funding opportunities, we have extended the deadline for receipt of applica-
tions for the CTSI's latest RFA for its Pilot and Collaborative Projects Program
funding to 5 PM THIS THURSDAY, APRIL 30. Please send us your proposals
formatted as directed in last month's Newsletter and good luck!







Peter W. Stacpoole, PhD, MD
Director, General Clinical Research Center
Director Clinical and Translational Science Institute
Associate Dean Clinical Research and Training














Volume 2, Issue 3 April 2009


Anyone who has ever seen more than one doc-
tor or been to more than one medical clinic
knows how difficult it can be to have informa-
tion shared between them. Even when someone has
been referred by another provider, it often becomes
the patient's responsibility to explain their problem,
what was previously done to treat it and why he was
referred for additional testing or care. He may be
asked to produce his previous x-rays or lab results.
And before being seen, the patient is typically required
yet again to fill out a lengthy history asking him to
recall the lifetime of medical and health ills he has
faced, including all the many medications he is taking
and surgeries he has had things that can be tough to
remember on the best day by even the most knowl-
edgeable.

Multiply that scenario by more than 300 million
people in the United States, hundreds of thousands
of health providers, and more than a half million
health care facilities and it provides a glimpse of the
enormity and complexity of the task this nation faces
in creating the comprehensive and fully electronic
health record system being advocated by President
Barack Obama and others. Proponents say such a
system could substantially decrease health costs while
improving quality of care, reducing medical errors,
decreasing health disparities, and providing greater
freedom and control for patients. The success of that
challenge is dependent on cooperation and effort
across a variety of spheres, with biomedical informat-
ics at the forefront of those endeavors, including at UF
and the CTSI.

The first question patients are typically asked by their
health providers is, "What are you allergic to?" It's a


simple, routine question. But one that patients should
not be answering because it allows is too much room
for inaccurate recollection and errors that can result in
overprescribing, drug interactions, increased costs, and
serious repercussions including death, according to Dr.
Michael Conlon, Ph.D., UF's director of data infra-
structure and interim director of biomedical informat-
ics. The answer to that question and many others is
one health providers should be able to obtain from a
patient's medical record, no matter who saw the pa-
tient previously, where, or how long ago, Conlon said.

But as things are now, that is usually not the case.
"It's impossible to know what's in the medical records
because they're scattered all over the place," Conlon
said. And "the records are not shared."

Scattered records
Patients usually have a primary care doctor. They may
see specialists often several for conditions such
as cancer, heart disease, or skin problems. They get
their eyes checked by an ophthalmologist, and their
contacts and glasses from an optometrist. They see a
dentist to get their teeth fixed. They may go to a hospi-
tal for tests or procedures, or if they are in a car acci-
dent. They get their prescriptions filled at a pharmacy,
and sometimes several different ones as they can get
some drugs cheaper at certain places. If they have an
allergic reaction to food on the weekend, they may go
to a stand-alone clinic. All of these facilities and health
providers have their own records, and rarely is infor-
mation exchanged between them. As a result, virtually
no one receives care today with the benefit of com-
prehensive medical records covering all their previous
medical history.


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.273.8700















Volume 2, Issue 3 April 2009

B IO E I A IN O M TI S T PAV TH WAY. .


Despite the computer revolution affecting most as-
pects of society, the medical establishment has been
slow to adopt computerized documents, with an
estimated 80 percent of health clinics still using paper
records and filing systems, according to Conlon. That
means information needed by a health provider seeing
a patient for the first time is commonly not available,
and even when it is, what's accessible is often summa-
ries that are incomplete, requiring patients to fill in the
gaps. Although many are becoming significantly more
involved in their health care, patients are not always
the best at recollecting the detailed and complex health
information that may be required, which can be further
influenced by stress and illness. Complicating matters
further is that high levels of education don't necessar-
ily correlate to health knowledge; the U.S. government
has shown that even well-educated people having
graduate-level master's and doctoral degrees some-
times have low health literacy levels.

Electronic health records
Many believe the way to overcome some of these hur-
dles is through electronic medical or health records,
also called EMRs or EHRs, and health record banking.
Consumers have already shown significant interest in
EMRs. In national surveys by global consulting and
technology services company Accenture in 2005 and
2007, a slight majority of people said they would be
willing to pay $5 or more a month for their records
to be digitized, said Dr. William YasnoffMD, PhD, a
biomedical informatics consultant to UF and the CTSI.
Some patients, especially those with chronic diseases
and those who see a number of different providers,
already routinely carry their paper records with them
so their doctors have all the information they need, he
said. Yasnoff, who is the managing partner of Alexan-
dria, Va.-based NHII Advisors and spoke as part of the


CTSI lecture series in November, has been intimately
involved with several government health information
technology initiatives. He worked with the Centers for
Disease Control and Prevention, and as Senior Advi-
sor for the National Health Information Infrastructure
at the U.S. Department of Health and Human Services
in Washington, D.C., where he organized and imple-
mented the activities leading to the creation by Presi-
dent Bush of the Office of the National Coordinator
for Health Information Technology in 2004.

The push for electronic health information continues
and is being expanded by the new administration, and
UF and Shands will be involved in efforts to develop
and implement such systems, Conlon said. Transition
to these systems, along with clinical and translational
science endeavors aimed at significantly decreasing
the amount of time it takes for proven improvements
in health care to make their way into widespread com-
munity use are dependent on biomedical informatics,
including those being undertaken at UF through the
CTSI, according to Yasnoff.

More than 16 percent of U.S. gross domestic product
(GDP) is spent on health care about $2.2 trillion
- with projections indicating that if these costs contin-
ue to grow at their current rate, they will rise to 25%
of GDP by 2025, according to the U.S. Department of
Health and Human Services. However, evidence sug-
gests adopting EMR systems could significantly de-
crease those costs, which economists repeatedly point
to as necessary to help repair the nation's financial
woes and ensure its future financial strength. In a 2001
report, the Institute of Medicine concluded that the use
of information technology in health care, including
through EMRs, could decrease U.S. health costs by 20
percent, which "could save many hundreds of billions


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.273.8700















Volume 2, Issue 3 April 2009

BI M DI A IN O M T C TO PAV TH WAY. .


of dollars," Conlon said. Beyond the medical cost
savings, EMRs also would improve care. In part, this
would be facilitated by a switch from the provider-
centric medical record currently in place focusing on
the advice, treatment, medications, tests, etc. that each
provider furnishes to being a patient-centric record
concentrating on the person's health and illness and all
that is associated with it, Conlon said.

Not everyone is sold on the idea that EMRs will save
the nation money. But Yasnoff said focusing on cost
savings misses the critical issue. Several organiza-
tions that have widely instituted the kinds of complete
electronic health information systems being proposed
for adoption nationally, have all seen costs go down
and quality improved as a result. Some of these orga-
nizations include Kaiser Permanente headquartered in
California, Group Health of Puget Sound, the Veterans
Administration, and Harvard Pilgrim Health Care in
New England. But more important according to Yas-
noff is that these kinds of electronic systems provide
more complete information on which policy decisions
can be made and monitored almost in real time with-
out the years of delay before their real impact is under-
stood, as is now the case. "If we don't have electronic
records, there's no chance we're going to save money,
there's no chance we're going to improve quality, and
there's no chance that we're going to be able to make
timely and reasonable health policy decisions because
we just don't have the information," he said.

Discussion of digitizing health records is not new.
The federal Health Insurance Portability and Account-
ability Act, or HIPAA, adopted in 1996, contemplated
patients' ability to carry their medical information with
them when they moved from one job to another. How-
ever, its privacy provisions have garnered the most


attention, Conlon said. At least until now.

Health record banks
Electronic records, with their accompanying ease of
exchange and comprehensive patient-specific infor-
mation, are not enough, according to Yasnoff Also
needed is a mechanism for aggregating all the records
about each person and the arsenal of other relevant
health information and delivering them to provid-
ers at the exact point when they must make medical
decisions. Without this, health providers are making
decisions without the complete knowledge and in-
formation they need, which he likens to airline pilots
working without the backup we and they rely on.
"The pilot may be very experienced and competent but
everyone knows that human beings just do not func-
tion with 100% accuracy 100% of the time, and that's
why we have copilots and instruments and warnings
in the cockpit," he said. "In health care we don't have
that yet."

The means for compiling and transferring the in-
formation to providers is the health record bank aspect
of the initiative that would function similar to a bank
account, said Yasnoff. After seeing a patient, a pro-
vider would deposit the new medical information from
the visit into the patient's health "account." Only the
patient would have the ability to authorize a provider
to see any or all of the information in their account.
Based on instructions from the patient, the health
record bank would transfer to a provider only what
it had been authorized to release. In this way, each
person is able to "set their own personal, customized
privacy policy," he said.

EMRs alone are simply electronic silos of information
just like the paper files kept currently by each different


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.273.8700















Volume 2, Issue 3 April 2009

BI M DI A IN O M T C TO PAV TH WAY. .


health provider. But when you combine them with
a health record bank that can store and transmit the
information where it's needed and when, it's value "in-
creases dramatically" to both providers and patients,
he said. The nation's first three health record banks
became operational in March in three communities in
Washington state, and other states and communities
are in earlier stages of implementation.

Numerous options
The newest health information technology initiatives
are supported from the highest levels of government
down. However, developing truly interchangeable
EMR systems is a mammoth task, and one that will
take many years. As of now, proponents and those
closest to the issue haven't even determined the best
of several possible ways for implementing it, Conlon
said. "There's a lot of thinking about how personal
health records could happen."

One possibility is a single database on which all a
person's records would be stored. Online medical stor-
age systems of this type are currently commercially
available through Microsoft HealthVault and Google
Health, but these systems require partnerships with
medical providers and permission by individuals for
their doctors, clinics, hospitals and others to submit
personal health information automatically over the
Internet. Such systems must overcome tremendous
logistical hurdles, as well safety and security issues,
and privacy concerns, Conlon said.

Another possibility would involve a network of health
information that would remain distributed among vari-
ous providers, but would be shared when authorized
by a patient, however fraud and other difficulties are


a concern, according to Conlon. Health organiza-
tions like Shands are currently the most likely entities
to have interchangeable records, but focusing future
efforts on such institutional systems is problematic
because of the complexities involved in their mak-
ing records available to external providers. The U.S.
Department of Veterans Affairs has an advanced and
comprehensive system, Conlon said, yet it still has is-
sues, including that it currently doesn't interface with
the Department of Defense medical records of military
personnel.

Yasnoff believes the most viable option is for for-prof-
it companies that are independent of any health other
health organization to build health record banks in lo-
cal geographic communities. A non-profit community
organization consisting of local patients and providers
would govern the record bank, which would also be
regulated by the federal and/or state governments, and
collaborate with a for-profit to develop and operate it.
Consumers would have complete control over and ac-
cess to their records.

Consumer-controlled system
This consumer-centric system is the most feasible
alternative for several reasons, he said, including that
most health care is provided on a local basis, and that
the local community is where the public trust needed
to support these banks has the best chance of develop-
ing. In addition, for-profit organizations are generally
run more efficiently than non-profits and are better
able to raise the capital that will be necessary for the
technology and other infrastructure that will be need-
ed.

Continued on page 7


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.273.8700














Volume 2, Issue 3 April 2009





At a clinical encounter, the clinician requests information from the health record bank about the patient.
If the patient does not give permission for release of information, none is sent. Normally, patients would
give permission so their electronic medical records are sent to the clinician. Care is given, and the en-
counter data is stored in the clinician's Electronic Heath Record (EHR) and then transmitted to the health
record bank for use in subsequent encounters. Optionally, the physician can be paid a small fee for sub-
mitting the encounter data, thereby offsetting the cost of the EHR system.


Health Record Bank Operation



Encounter
Data sent to
riTutih Clinician's Bank


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.273.8700















Volume 2, Issue 3 April 2009

BIMDIA INOMTC TO PAV TH WAY..


The health record bank's business model involves two
costs, one to run the bank and the other to cover the
cost of EMRs for providers, which together total an
estimated $16 a year per person on average based on a
million subscribers. Although the basic health record
account would be free to consumers, revenue would
be derived from various optional reminders and alerts
to which people could subscribe for modest additional
fees. Yasnoff estimates these fees would conserva-
tively amount to about $12 a year per person. Non-
intrusive ads similar to those found on Google would
generate about another $6 a person per year, or people
could opt out of the ads by paying those monies them-
selves. As a result, the expected per person revenue
exceeds costs by $2 per person per year, which results
in a profitable business, said Yasnoff, who describes
these costs in detail on his blog at www.yasnoff.com.

Not only would no government funds be involved,
but the model generates income without even taking
into consideration any health care cost savings that
may be realized, he said. The approach also protects
patients' privacy, ensures cooperation by the various
stakeholders, is financially sustainable, and can ensure
that all medical records in a community are electronic
and available for providers and patients. "This is a
business model that is totally self-sustainable based
on new value that is delivered to consumers," he said,
"and that's a huge advantage."

Perhaps the closest thing currently available to an
interchangeable record system is the so-called digital
dog tag provided to American combat soldiers. Not
only can these tags store their entire medical records
on a microchip, but medics can use handheld devices
to transfer medical information to the tags on the
battlefield. The entered data is used in the immediate


future by Department of Defense hospital providers
caring for the wounded soldiers, but also becomes a
permanent part of their electronic DOD health records.
The government is making an effort to further inte-
grate medical records for members of the U.S. military
into a comprehensive system that will contain their
lifetime of medical information starting from the day
they enlist. In early April, President Obama announced
that the DOD and VA were moving for the first time
toward creating a unified electronic health record for
members of the U.S. armed forces.

Although controversial for privacy reasons, health-
related microchips for civilians have also been devel-
oped, with the Food and Drug Administration giving
approval for the first such under-the-skin chip in late
2004. However, unlike their military counterparts,
these chips the size of a rice grain don't actually con-
tain health information, instead they transmit an iden-
tification number that identifies a person and provides
access to medical information stored in an associated
database.

Despite all the possibilities and the accompanying
uncertainties, one thing is guaranteed with respect to
EMRs: No matter the system, ethical and legal issues
will proliferate. For example, agreement about exactly
what someone has authorized to have released will
always be sticky. "There's nothing straight-forward
about this," Conlon said.

Government funding
The government seems to understand that, and has
committed significant funding to support these efforts
nationwide, money that UF and Shands will seek to
aid in the significant challenge they face in integrat-
ing their own records, which include several disparate


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.273.8700















Volume 2, Issue 3 April 2009

BIO E I A IN O M T C TO PAV TH WAY. .


information systems. The UF faculty physicians group
has one system, Shands Gainesville another, with a
separate one for Shands Jacksonville, and some other
Shands facilities having different systems still.

The U.S. Office of the National Coordinator for Health
Information Technology, whose budget skyrocketed
from $61 million to $26 billion under the new admin-
istration, will distribute $28 billion for various initia-
tives from the American Recovery and Reinvestment
Act of 2009. Among the act's goals is that each person
in the U.S. will have an electronic health record by
2014. Enhancements to help safeguard personal health
information will be ongoing as well, and as required
by the Act, the U.S. Department of Health and Human
Services released guidelines April 17 aimed at improv-
ing the security of this data and preventing harm that
can be caused if it is breeched.

The largest pot of those stimulus monies $19 billion
- will be used for incentives to Medicare and Medic-
aid providers to adopt systems that allow interchange-
able medical records that meet federal standards,
Conlon said. The earlier they do this, the larger the
payouts they will be eligible for, and as time goes on
the incentives decline. Five years after the program
begins, those who care for these government-insured
patients which include most providers will be
penalized for not having implemented such systems.
Standards have not yet been established, but UF and
Shands already are examining ways to develop a co-
ordinated system that will adhere to any new govern-
ment criteria, Conlon said.

Another $7 billion will be used to provide the im-
proved infrastructure and high-speed networks neces-
sary for providers to have the capacity to exchange


medical information. UF and Shands could use some
of these monies to hook up some outlying areas or
clinics and improve connections to Jacksonville, but
overall "we have very good network infrastructure,"
Conlon said.
The last pot of $2 billion will be used to facilitate
development of innovative health record systems and
health care delivery technologies through multidisci-
plinary research centers at universities and other insti-
tutions of higher education. The goal will be to obtain
funding to establish one at UF, Conlon said.

The latest initiatives are only beginning and face nu-
merous obstacles nationwide. However, the Biomedi-
cal Informatics program at UF and the CTSI should
help ease the transition. "Medical records are very
complicated, and we're trying to figure out how to get
it all together," Conlon said. "It's a challenge within
our own institution."

That raises the question of how successful the recent
- and expensive health information technology
initiative is likely to be, especially given such limited
adoption in the past. Yasnoff thinks the probability
is good for two main reasons, and he thinks there's a
good chance it will happen before the 2014 deadline
date. First, technology has improved so these kinds of
systems are now possible. More important is that is
has become a national priority, and with that has come
funding to support the effort.

"Given the fact that there's now a model that solves
all these problems, and people are starting to imple-
ment this approach around the country, I don't think it
will be long before the dream of comprehensive health
records for everybody at any point of care becomes
reality," he said.


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.273.8700












II New slette


Volume 2, Issue 3 April 2009






Michael Conlon, PhD, is the Associate Chief Information Officer for IT Architecture and
Director of Biomedical Informatics in the UF College of Medicine. His responsibilities
include development of academic biomedical informatics, expansion and integration of re-
search and clinical information resources as well as strategic planning for university infor-
mation resources. Previously Conlon served as PeopleSoft Implementation Officer and Chief
Information Officer of the UF Health Science Center where he directed network and video
services, desktop support, media and graphics, application development, teaching support,
strategic planning and distance learning.

He earned his doctoral degree in statistics from UF, and undergraduate degrees in mathematics and economics from
Bucknell University. He is the author of more than 150 scholarly publications and presentations. His current inter-
ests include enterprise change and organizational issues in the adoption of information technology, large scale data
systems integration, enterprise architecture, and computing administration.

William A. Yasnoff, MD, PhD, is a well-known national leader in health informatics and the
founder and managing partner of National Health Information Infrastructure (NHII) Advi-
sors, and the founder and president of the Health Record Banking Alliance. He also is an
adjunct professor of Biomedical Informatics at UF. In recognition of his pioneering contri-
butions to the field of public health informatics and the development of the nation's health
information infrastructure, he was awarded an honorary DrPH by the University of Louisville
in May 2006.

Previously, Yasnoff served as senior advisor, National Health Information Infrastructure
(NHII) for the U.S. Department of Health and Human Services. Beginning in late 2002, he initiated, organized, and
developed the HHS activities directed at promoting and encouraging the NHII, which led to the presidential creation
of the Office of the National Coordinator for Health Information Technology, establishing NHII as a widely recog-
nized goal for the nation. Before coming to the Washington, D.C. area, Yasnoff worked for the CDC as associate
director for science, Public Health Practice Program Office, and for the Oregon Health Division, where he developed
and deployed a statewide immunization registry that is still operating successfully today and an electronic informa-
tion network for public health officials. Yasnoff also spent many years in the private sector, and did consulting work
for a variety of commercial, academic, and government clients, addressing a wide range of health informatics chal-
lenges.

In addition to his UF affiliation, Yasnoff, who received both his doctorate in computer science and M.D. from North-
western University, is an adjunct professor of Health Sciences Informatics at Johns Hopkins, a professor (gratis) of
Health Management and Systems Sciences at the University of Louisville, and an adjunct professor of Biomedical
Informatics at the University of Illinois in Chicago. He co-edited the textbook "Public Health Informatics and Infor-
mation Systems," and has authored more than 300 scientific publications and presentations.


Clinical and Translational Science Institute University of Florida Gainesville, FL 352.265.273.8700















Volume 2, Issue 3 April 2009

THE L~~AS PA E. .


Employment
Did you know that there are multiple venues through which both internal and external jobs are posted?

For Job Seekers
https://jobs.ufl.edu University of Florida jobs postings.
http://www.union.ufl.edu/jobs/ Reitz Union student job listings.
http://www.sfa.ufl.edu/programs/workstudy Federal Work-Study Program.
http://www.sfa.ufl.edu/programs/ops.html Other Personnel Services jobs.
http://www.sfa.ufl.edu/programs/oce.html Off-Campus jobs.
http://www.sfa.ufl.edu/programs/vaworkstudy.html Veteran's Affairs Work-Study.







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