Emerging Interest in States, Regions and Communities Across the Nation for Health Information Exchan

1
Emerging Interest in States, Regions and
Communities Across the Nation for Health
Information ExchangeEarly Learnings

• Healthcare Information Technology Summit
• Vermont Association of Hospitals and Health
  Systems
• Janet Marchibroda
• Chief Executive Officer, eHealth Initiative and
  Foundation
• Executive Director, Connecting for Health
• November 18, 2004

2
Pioneers in Health Information Exchange

• California
• Delaware
• Florida
• Indiana
• Los Angeles, CA
• Maine
• Maryland
• Massachusetts
• Michiana Health Information Network, IN
• Michigan
• Minnesota

• New York
• North Carolina
• Northern California
• Ohio
• Pennsylvania
• Rhode Island
• Santa Barbara, CA
• Tennessee
• Utah
• Vermont
• Washington, D.C.
• Washington State

Sample
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What Problems Are They Trying to Solve?

• Improving Healthcare Delivery at Point of Care
• Reducing Costs Achieving Efficiencies
• Biosurveillance/Public Health Initiatives
• Quality Improvement Initiatives
• Reaching out to Remote, Rural and Underserved
  Areas

4
Common Issues and Challenges

• Organization and governance engaging
  stakeholders
• Lack of upfront funding and sustainable model
• Competing entities reluctant to share information
  that would undermine competitive advantage
• Technical issues architecture, accurately
  linking patient data, applications, standards,
  security

5
Connecting Communities for Better Health Program
Goals

• Catalyzing activities at national, regional and
  local level to create electronic interoperable
  health information infrastructure
• Providing seed funding to community-based
  multi-stakeholder collaborations that are engaged
  in health information exchange
• Mobilizing pioneers and experts to develop and
  disseminate resources and tools to support health
  information exchange technical, financial,
  clinical, organizational, legal

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Connecting Communities for Better Health Program
Goals

• Widely disseminating resources and tools through
  a wide range of dissemination vehicles
• National, state-level, and local meetings
• Audio and web conferences
• Connecting Communities resource center
• Other organizations, such as medical societies
  and non-profit groups
• Public sector initiatives such as the AHRQ
  National HIT Resource Center and CMS Program to
  Support Physician Offices through QIOs
• Creating and widely publicizing a pool of
  electronic health information exchange-ready
  communities to facilitate interest and public and
  private sector investment

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Connecting Communities for Better Health Program
Goals

• Providing a cohesive and powerful voice for
  state, regional and community-based
  collaborations building health information
  exchange networks
• Building national awareness regarding
  feasibility, value, barriers, and strategies for
  health information exchange networks

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Response to Request for Capabilities

• What We Asked For in our 2003 Request for
  Capabilities Statements
• Multi-stakeholder initiatives involving at least
  three stakeholder groups
• Matched funding
• Use of standards and a clinical component
• What We Received
• 134 responses representing 42 states and the
  District of Columbia proposing collaborative
  health information exchange projects across the
  country

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What We Found

• Diverse models
• Varying stages of readiness
• Wide range of technical models
• Large use of laboratory and pharmacy data
• Standards adoption is not widespread
• Need for funding is clear
• Full results will soon be published in journal
  J. Marc Overhage, MD, PhD Lori Evans, Janet
  Marchibroda

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What We Found

• Stage of Readiness
• Beta 22
• Pilot Mode 28
• General Availability 28 (of the 64 only nine
  appeared to be fully operational)
• Other 22
• Diverse models
• Organizational Structures
• No organizational structure 5
• Loose affiliation 28
• Corporate 29

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What We Found

• Most Common Lead Respondent
• Other 28
• Hospital 23
• Provider Organization 16
• Academic Medical Center 10
• Community Health Information Organization 9
• Public Health 2
• Lead Organization
• Hospital Organizations 23
• Provider Organization 16
• Academic Centers 10
• Community Health Information Organization 9
• Other 29

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What We Found

• Technical Approaches
• Personal Health Records 2
• Peer to Peer 20
• Federated 3
• Centralized Databases 54
• Not Yet Selected 18

13
What We Found

• Initial Funding
• Identified No Funding 32
• Non-profits 37
• Philanthropies 23
• Federal Source 22
• HIE Organization 18
• States 17
• Private 12
• Other 11

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What We Found

• Operational Funding
• Other 60
• Subscriber Fees 45
• Data Sources 20
• Government 20
• Pay for Performance 18

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Communities Being Funded

• Connecting Colorado (Denver, CO)
• Indiana Health Information Exchange
  (Indianapolis, IN)
• MA-SHARE MedsInfo e-Prescribing Initiative
  (Waltham, MA)
• MD/DC Collaborative for Healthcare Information
  Technology (Baltimore/Washington Metro Area)
• Santa Barbara County Care Data Exchange (Santa
  Barbara, CA)
• Taconic Health Information Network and Community
  (Fishkill, NY)
• Tri-Cities TN-VA Care Data Exchange (Kingsport,
  TN)
• Whatcom County e-Prescribing Project (Bellingham,
  WA)
• Wisconsin Health Information Exchange (National
  Institute for Medical Informatics Midwest)
  (Milwaukee, WI)

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Recap Communities Focus

• Strategically focused on critical areas that need
  to be addressed to implement health information
  exchange
• Replicable and sustainable technical architecture
  models
• Alignment of incentive models
• Use of replicable data exchange standards
• Addressing ways to accurately link patient data
• Multi-jurisdictional models
• Electronic prescribing issues

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Technical Models
18
Fully Integrated Monolithic Database

19
Patient Carried
20
Federated Consistent Databases
Dictionary MPI
21
Federated Inconsistent Databases(includes
peer-to-peer)
22
Information from This Weeks eHealth Initiative
Meeting Connecting Providers to Labs
23
Getting Data to the Correct ProviderPoint-to-Poin
t Push
24
Getting Data to the Correct ProviderPoint-to-Poin
t Pull (Query)
25
Getting Data to the Correct ProviderHIE Push
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Getting Data to the Correct ProviderHIE Pull
(Query)
27
Getting All Data About The Patient
Internet/Repository
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An Example Indiana Health Information Exchange
Vision

• Our strategy for achieving this vision is to
  wire health care first in Central Indiana and
  eventually across the entire state by creating
  a common, secure, electronic infrastructure that
  expands communication and information-sharing
  among participating providers, hospitals, public
  health organizations, and other health care
  entities. Ultimately, the system will give
  providers better information for treatment
  purposes at the point-of-care, and it will give
  researchers a richer pool of data to guide more
  far-reaching treatment improvements over the
  longer run.

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INPC Participants

• Includes 17 hospitals from the 5 major
  Indianapolis hospital systems (99 of non-office
  care)
• ED providers
• Hospitalists
• Hospital based specialists
• Approximately 30 of physician practices and
  growing
• Includes all four homeless care systems
• Public school based clinics
• Public health departments (county and state)

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INPC Contents

• In the system
• 1.3 million patients, 5 million registration
  events
• 24 million orders
• 489 million coded results
• 12 million dictated reports
• 8.8 million radiology reports
• 25 million prescriptions
• 480,000 EKG tracings
• 45 million radiology images
• Added Per Year
• 600,000 ambulatory encounters
• 50,000 inpatient encounters

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Other Data Sources
32
Data Reuse
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Connecting for Health

• Catalyzing changes on national basis to create an
  interconnected, electronic health information
  infrastructure to support better health and
  healthcare
• Founded and supported by the Markle Foundation,
  with additional support from the Robert Wood
  Johnson Foundation
• More than 100 collaborators from all sectors of
  healthcare

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The Assumptions

• A future of better, more efficient care can be
  accomplished through dynamic connectivity that
  allows information to move
• Where its needed
• When its needed
• In a private and secure manner
• Achieving this goal will require public and
  private sector collaboration
• A Roadmap is needed to chart the course

35

What is the Roadmap?

• Shared vision of what to do nextdeveloped and
  agreed to by all major stakeholders
• A set of practical actions and achievable goals
  in a 1-3 year time frame
• Provides necessary cohesion for multiple
  stakeholder efforts
• Building on where we are, not overhauling
  everything at once

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Eight key areas of Roadmap recommendations

• Funding and Incentives
• Clinical Applications
• Legal Safe Harbors
• Engaging the American Public
• The Infrastructuretechnical architecture and
  approach
• Designing for Privacy and Security
• Accurate Linking of Patient Information
• Data Standards

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Key Recommendations July 2004

• Creating a Technical Framework for Connectivity
• Non-proprietary network of networks
• Common framework of standards, policies
• Decentralized, federated, based on standards,
  safeguards patient privacy, and built
  incrementally without use of a National ID
• Test standards working together through reference
  implementation and make widely available

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Key Recommendations July 2004

• Addressing Financial Barriers
• Financial incentives are needed - 3 to 6 per
  patient visit or .50 to 1.00 per member per
  month to cause tilt
• Safe harbors needed
• Align incentives with standards-based
  applications and connectivity
• Engaging the American Public
• Key messages and standards for PHRs

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Technical Recommendations The Roadmap does NOT
recommend

• A national patient identifier number
• A single proprietary solution
• A single centralized database
• A massive new government program
• A one-size-fits-all mandate
• A rip-and-replace overhaul

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Roadmap Infrastructure Recommendations

• Principles of infrastructure design
• Safeguards privacy
• Leverages both bottom-up and top-down
  strategies
• Builds on existing systems (incremental)
• Consists of an interoperable, standards-based
  network of networks built on the Internet
• Patient information remains where it is now and
  is not kept in a central database
  (decentralized)
• Data-sharing initiatives have local autonomy but
  follow certain standards and policies to enable
  interoperability (federated)

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Infrastructure A Common Framework

• Comprised of public domain standards, policies
  and methodologies that can be quickly replicated
  to provide
• Secure connectivity
• Reliable authentication
• A minimum suite of standards for information
  exchange
• Adhering to the Common Framework ensures that
  data exchange pilots, personal health records and
  regional systems can interoperate
• Grounded in the Roadmap, the RI will provide a
  concrete, functional demonstration of the
  critical common standards-based components of an
  interoperable, community-based infrastructure

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RI strategic objectives

• Create a body of work the Common Framework
  from a live laboratory
• Show that the Common Framework can be achieved
  across diverse settings and technologies
• Bring together multiple, competing institutions
• Disseminate findings
• Demonstrate ease of management and implementation

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What will the RI do?

• The RI will establish, demonstrate and
  disseminate a national Common Framework for
• Data standards
• Methodology for validating interoperable
  interfaces and applications
• Standard patient and provider identification
  methods
• Exchange of clinical information across networks
• Policies for information sharing
• It is comprised of network standards, common
  policies, documents and methodologies that will
  be shared in the public domain

44
Whats Needed Key Imperatives

• Alignment of incentives around quality healthcare
  and the standards-based tools that will help us
  get therehealth information technology
• Use of standards for applications, architecture,
  identification and transport must be taken to the
  next level to get to full interoperability
  Connecting for Health in collaboration with
  eHealth Initiative Foundation Connecting
  Communities looking for communities to help build
  these in the field!
• Innovation and collaboration to support small to
  medium physician practices as they migrate to an
  electronic system

45
Whats Needed Key Imperatives

• Leverage HIT investments and incentives to
  address multiple challenges
• Driving cost out of system through electronic
  connectivity
• Providing clinical knowledge and information at
  the point of care
• Promoting quality and performance improvement
  efforts including those related to measurement
  and chronic care management
• Supporting public health related activities

46
Whats Needed Key Imperatives

• Demonstration programs and projects should not be
  one-offs
• Align with replicable, sustainable models for
  incentives
• Align with efforts to create interoperable
  applications and standards-based electronic
  connectivity
• Assure lessons are shared with others through
  dissemination and communication vehicles

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What Were Doing to Help

• Developing a repository of best practices and
  tools
• Developing assessment tools to understand where
  you are and what you need to do
• Developing an inventory of all state, regional
  and community-based health information exchange
  collaboratives
• Launching HIT State Summit Initiative first in
  New York
• Disseminating resources through Connecting
  Communities Resource Center and Learning Network

48
What Were Doing to Help

• Creating a place for learning and dialogue and
  development of work products Working Group for
  Connecting Communities
• Disseminating information through Connecting
  Communities Annual Learning Forum and a Set of
  Regional Meetings
• Participating in the AHRQ National HIT Resource
  Center partnership led by NORC and including
  Regenstrief, CITL, Vanderbilt, CSC and eHealth
  Initiative
• Hold the Date for Dec 6-7 Meeting Focused on
  RHIOs Connecting Communities for Better Health
  Program

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Working Group for Connecting Communities

• Chairs
• Mark Frisse, MD, MBA, Director, Regional Health
  Initiatives, Vanderbilt Center for Better Health
• J. Marc Overhage, MD, PhD, Chief Executive
  Officer, Indiana Health Information Exchange
• Primary Lead Emily Welebob, eHI Program Director
  

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HIE Readiness Assessment Proposed Approach

• The HIE assessment is completed to
• Gain an understanding of the current state
• Identify success factors and areas of opportunity
  
• Provide recommendations to move forward
  successfully with HIE
• The HIE model and survey instrument are being
  based on industry research, literature review,
  and lessons learned from sites who have been
  successful and who have not been successful
• The assessment should be completed using
• Document review
• Interviews
• Site visits
• Survey instrument
• Assessment tool is currently under developmentwe
  need your help!

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HIE Readiness Assessment Assessment Factors
Sample

• Environmental Factors
• Organizational process and structure
• Culture
• Leadership / Commitment
• Champions
• Physician involvement
• Key Stakeholders
• Business community
• Consumer community, etc
• Technology (Process and Infrastructure)
• Communication
• Shared vision
• Change Management
• Legal Issues
• Funding/Sustainability Model
• Politics
• Business drivers
• Neutral parties

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Hold the Date!

• December 6-7, 2004 Community or RHIO-Centric
  Meeting Connecting Communities for Better Health
  Co-Sponsored by eHealth Initiative Foundation and
  WEDI
• Vetting a set of alternatives for the following
  RHIOs or state, regional and community based
  health information networks
• Financial and Sustainability Models
• Technical Architecture Models
• Organization and Governance Models
• Dealing with Key Legal Issues
• Addressing Privacy and Security

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What Does All of this Mean?

• We are finally building momentumthe stars and
  planets are aligning
• The focus has shifted from whether we should to
  how will we do this?
• This work will create lasting and significant
  changes in the U.S. healthcare systemhow
  clinicians practicehow hospitals operate.how
  healthcare gets paid forhow patients manage
  their health and navigate our healthcare system

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Closing

• Never doubt that a group of thoughtful,
  committed people can change the world. Indeed
  its the only thing that ever has.
• Margaret Mead

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My Contact Information

• Janet M. MarchibrodaChief Executive Officer,
  eHealth Initiative
• Executive Director, Foundation for eHealth
  InitiativeExecutive Director, Connecting for
  Health
• 1500 K Street, N.W., Suite 900
• Washington, D.C. 20039
• 202.624.3270
• Janet.marchibroda_at_ehealthinitiative.org