Improving Healthcare Quality and Safety by Leveraging Health Information Technology and Health Infor

1
Improving Healthcare Quality and Safety by
Leveraging Health Information Technology and
Health Information ExchangeOverview of Whats
Happening Nationally and Within States and
Communities Across the U.S.

• Wisconsin eHealth Board on
• Healthcare Quality and Patient Safety
• Janet M. Marchibroda
• Chief Executive Officer
• eHealth Initiative and Foundation

2
Overview of Discussion

• Background
• Overview of Whats Happening at the National
  Level
• Review of Whats Happening in States and
  Communities Across the U.S.
• Key Take-Aways for Wisconsin Stakeholders

3
eHealth Initiative and Foundation Mission and
Focus

• Mission Improve the quality, safety, and
  efficiency of healthcare through information and
  information technology
• Areas of Focus
• Focus on states, regions and communities as the
  center of implementation aligning national
  standards with local solutions
• Develop and drive adoption of sustainable model
  for healthcare transformation through
  quality-based incentives
• Advocate for continued favorable national
  policies

4
Our Diverse Membership

• Consumer and patient groups
• Employers, healthcare purchasers, and payers
• Health care information technology suppliers
• Hospitals and other providers
• Pharmaceutical and medical device manufacturers
• Pharmacies, laboratories and other ancillary
  providers
• Practicing clinicians and clinician groups
• Public health agencies
• Quality improvement organizations
• Research and academic institutions
• State, regional and community-based health
  information organizations

5
eHI is the Go-to Organization For State and
Regional HIT and Health Information Exchange
Efforts
Advocacy
Grants
eHealth Initiative and Foundation
Knowledge
Hands-on Help
6
eHIs Primary Activities

• Improve the quality, safety, and efficiency of
  healthcare through information and information
  technology by
• Developing and disseminating knowledge or common
  principles, policies and best practices for
  supporting transformation through HIT and health
  information exchange
• Providing seed funding for emerging state,
  regional and community-based multi-stakeholder
  initiatives
• Providing hands-on help or technical assistance
  to emerging collaborative efforts at the state,
  regional and local level
• Advocating for continued favorable national
  policies related to HIT and health information
  exchange

7
eHIs Accomplishments Supporting Communities

• Nearly 2,000 stakeholders involved in
  approximately 200 states, regions and communities
  engaged in health information exchange have been
  involved in our efforts. We now have over 500
  eHealth Initiative Connecting Communities
  Members
• eHI directly supported health information
  technology policy and planning initiatives in
  seven states, including Arizona, California,
  Kansas, Louisiana, Minnesota, New York, and Ohio,
  supporting public and private sector leaders who
  are building multi-stakeholder consensus on the
  principles, policies, and plans for supporting
  local innovation and building health information
  exchange network capabilities. Five additional
  states will be added to the portfolio in 2006
• eHIs newly awarded 4 million contract from DHHS
  will help to support health information exchange
  development among the Gulf states

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eHIs 2005 Accomplishments Supporting Communities

• The eHealth Initiative Foundation through its
  cooperative agreement with HRSA provided funding
  to nine communities engaged in health information
  exchange this year (one in Wisconsin), with
  significant learning and results.
• We are getting ready to award our next round of
  awards to regions and communities over the next
  month, which will provide seed funding to those
  who have engaged employers, plans and practicing
  clinicians in their markets to pilot test
  incentives that reward both quality and health
  information exchange capabilitiesproviding
  learning laboratories for sustainable models for
  both quality and HIT.
• eHI developed common principles for
  transformation through health information
  exchange, which will be launched within a
  tool-kit in early 2006, helping communities
  navigate the organizational, financial, practice
  transformation, health information policy, and
  technical aspects of health information exchange.

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eHIs 2005 Accomplishments Supporting Communities

• The Connecting Communities Online Learning Center
  was expanded considerably offering hundreds of
  resources and tools related to health information
  exchange to thousands of stakeholders each month.
• eHI lent its expertise and experience to the work
  of the Agency for Healthcare Research and Quality
  National Resource Center for Health Information
  Technology, offering technical assistance to
  AHRQs over 120 grantees and recipients of state
  contracts
• eHI involved in one of the ONC contracts for the
  development of prototypes for a Nationwide Health
  Information Network and exploring alignment and
  input into the other three contracts

10
eHI State HIT Policy Initiative
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eHIs Tool-Kit for Transformation through Health
Information Exchange will Help States and
Communities

• A comprehensive on-line, interactive resource
  that walks a community through the six critical
  components of success
• Getting started Assessing environment, engaging
  stakeholders, developing shared vision and goals
• Organization and governance, legal issues
• Value creation, financing and sustainability
• Policies for information sharing
• Practice transformation and quality improvement
• Technical implementation

12
Understanding the National Agenda around Health
Information Exchange

• Enormous momentum around improving quality,
  safety and efficiency through clinical exchange
  within Administration, Congress, and the private
  sector
• Key themes
• National standards for interoperability
• Alignment of value based purchasing with HIT
  infrastructure required to get there
• Government as catalyst
• Public-private sector collaboration

13
Signs of Momentum for HIT and Health Info
Exchange Activities in Congress

• 12 bills introduced in 2005
• Most bi-partisan
• Unprecedented collaboration between the
  Republicans and Democrats on the importance of
  leveraging HIT and the mobilization of
  information to address healthcare challenges
• One with most promise is S. 1418. Similar bill
  introduced by House this year

14
Senate 1418 Wired for Healthcare Quality Act
Passed in Nov. 2005

• Key Elements
• Authorizes ONCHIT
• Authorizes public-private AHIC to advise
  Secretary, recommend actions, and standards
• Grants to providers, states and for
  regional/local HIT plans
• Demonstration program to integrate IT into
  clinical education
• Development of quality measures and government
  capability to accept electronically reported
  measures
• Creation of health information technology
  resource center

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Senate 1418 Wired for Healthcare Quality Act

• Competitive Grants for Qualified HIT
• For not-for-profit hospitals, federally qualified
  health centers, individual or group practices or
  other health care providers
• Must adopt standards, implement and report
  quality measures, agree to notify patients of
  wrongful disclosure, demonstrate need, and
  provide matching funds (1 for every 3)
• Preference given to rural, frontier or
  underserved areas or eligible entities that will
  link qualified HIT to local or regional health
  information plans

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Senate 1418 Wired for Healthcare Quality Act

• Competitive Grants for Implementation of Regional
  or Local HIT Plans
• Requirements
• Participation by multiple stakeholders within a
  community
• Principle mission or purpose is to use
  information technology to improve health care
  quality and efficiency
• Facilitate electronic exchange of health
  information within the local or regional area and
  among local and regional areas
• Adopt standards
• Demonstrate financial need
• Agree to notify patients if their individually
  identifiable information is wrongfully disclosed
• Matching funds (1 for every 2 of Federal funds)

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Senate 1418 Wired for Healthcare Quality Act

• Competitive Grants for State Loan Programs to
  Facilitate HIT
• Establish qualified State loan fund
• Require that loan recipients
• Submit a strategic plan to the HHS Secretary
• Require that health care providers receiving
  loans adopt standards, implement and report
  quality measures, agree to notify patients of
  wrongful disclosure, use the national resource
  center for HIT, and provide matching funds (1
  for every 1)
• Preference given to states that adopt value-based
  purchasing programs to improve health care quality

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Signs of Momentum for HIT and Health Information
Exchange Activities in Administration

• AHIC public-private community formed to provide
  input to Sec. Leavitt re how to make health
  records digital and interoperable and assure that
  privacy and security are protected
• Overseeing work in four break-through areas
  that will create realizable benefits to consumers
  in two to three years
• Biosurveillance
• Chronic care
• Consumer empowerment
• Electronic health records

19
Signs of Momentum for HIT and Health Information
Exchange Four DHHS Contracts

• Standards Harmonization. 3.3 million contract to
  ANSI for convening Health Information Technology
  Standards Panel (HITSP) to review standards under
  development and develop a roadmap for single set
  of standards
• Compliance Certification. 2.7 million contract
  to Certification Commission for HIT to develop
  process and criteria for inspecting EHRs and
  other HIT
• Privacy and Security. 11.5 million contract to
  Health Information Security and Privacy
  Collaboration overseen by RTI International who
  will work sith states to assess and develop plans
  to address variations in organization-level
  business policies and state laws that affect
  privacy and security practices that may serve as
  barriers to health information exchange
• Nationwide Health Information Network. Four
  contracts totaling 18.6 million to four
  consortia led by Accenture, CSC, IBM and Northrop
  Grumman to develop a blueprint for how a
  generalized network would share information
  across the U.S.

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Overview of Activities at State, Regional and
Local Levels
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Why Focus on States and Communities?

• Wide-spread recognition of the need for health
  information technology and exchange/
  interoperability at the national level
• While national standards are needed, healthcare
  indeed is local and leadership is needed at the
  state, regional and community levels across the
  country to drive implementation
• Need for collaboration and development of
  consensus on a shared vision, goals and plan is
  needed among multiple, diverse stakeholders at
  the state and regional level

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What is Health Information Exchange?

• Health information exchange provides the
  capability to electronically move clinical
  information between disparate healthcare
  information systems while maintaining the meaning
  of the information being exchanged.
• The goal of health information exchange is to
  facilitate access to and retrieval of clinical
  data to provide safer, more timely, efficient,
  effective, equitable, patient-centered care.

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Why Health Information Exchange?

• U.S. healthcare system highly fragmented.data is
  stored often in paper formin silos, across
  hospitals, labs, physician offices, pharmacies,
  and insurers
• Public health agencies forced to utilize phone,
  fax and mail to conduct public health
  surveillance, detection, management and response
• Physicians spend 20 - 30 of their time searching
  for information10 - 81 of the time, physicians
  dont find the information they need in the
  patient record
• Clinical research hindered by paper-based,
  fragmented systems costly and slow processes

24
Value for Patients

• The true promise of coordinated care along the
  entire care continuum, and improved relationships
  with all care givers
• The ability to better manage their personal
  health information and records
• The ability to improve the physician-patient
  dialogue and relationship

25
Value for Clinicians

• Doing well while doing good
• Gaining a deep understanding of their individual,
  group and practices performance in delivering
  quality care to patients
• Initiating and tracking QI programs
• Better management and coordination of their
  patients care

26
Value for Purchasers and Payers

• Real-time, relevant, fair, and equitable
  information on the quality of services delivered
  by all clinicians
• Ability to better engage employees and their
  family members in managing their care

27
Survey of Over 100 State, Regional and
Community-Based Initiatives

• 109 respondents from 45 states and the District
  of Columbia
• Covered aspects related to goals, functionality,
  organization and governance models, information
  sharing policies, technical aspects, funding and
  sustainability

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Key Findings from Survey

• Health information exchange activity is on the
  rise.there are more efforts, and those that are
  out there are maturing
• Of the 109 health information exchange efforts in
  the survey
• 40 are in the implementation phase and
• 25 fully operational
• Nine were fully operational in 2004

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Stage of Health Information Exchange Programs
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6

• 12
• Recognition of the need for HIE among multiple
  stakeholders in your state, region, or community

• 14
• Getting organized
• Defining shared vision, goals, objectives
• Identifying funding sources
• Setting up legal governance structures

• 15
• Transferring vision, goals, objectives to
  tactics and business plan
• Defining needs and requirements
• Securing funding

• 37
• Well under-way with implementation technical,
  financial, and legal

• 12
• Fully operational health information organization
  
• Transmitting data that is being used by
  healthcare stakeholders
• Sustainable business model

• 11
• Demonstration of expansion of organization to
  encompass a broader coalition of stakeholders
  than present in the initial operational model

30
Key Findings from Survey

• The key driver moving states, regions and
  communities toward health information exchange is
• Perceived provider inefficiencies (77 of all
  respondents)
• Rising healthcare costs also seen as important
  driver (60 of all respondents)

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Key Drivers for Health Information Exchange
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Key Findings from Survey

• Organization and governance structures are
  getting more formalized and shifting to
  multi-stakeholder models with the involvement of
  providers, purchasers and payers
• 60 of advanced stage are incorporated
• 70 are non-profit models

33
How are HIE Efforts Organized?
34
HIE Efforts are Forming Legal Structures
35
Key Findings from Survey

• Organization and governance structures are
  getting more formalized and shifting to
  multi-stakeholder models with the involvement of
  providers, purchasers and payers
• Providers continue to play the most dominant role
  but see an increase in others health plans
  (28), local public health departments (45),
  QIOs (35), employers (22), patient consumer
  groups (29)

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Whos Involved?
37
Key Findings from Survey

• Organization and governance structures are
  getting more formalized and shifting to
  multi-stakeholder models with the involvement of
  providers, purchasers and payers
• Clear shift towards leadership by neutral,
  multi-stakeholder entity (55)

38
Who is Leading These Efforts?
39
Key Findings from Survey What are They Doing?

• Primary focus continues to be on supporting care
  delivery
• Clinical documentation
• Reminders
• Results delivery

40
Health Information Exchange Initiatives What Are
They Doing?
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Key Findings from Survey What are They Doing?

• Advancements in functionality to support
  improvements in quality and safety are evident.
  In addition to traditional uses to support care
  delivery, a number are now expanding
  functionality
• 32 currently providing disease or chronic care
  management services (with additional 21
  expecting to within six months)
• 27 are currently supporting quality performance
  reporting efforts (with additional 18 expected
  within six months)

42
Growing Focus on Disease Management, Quality
Reporting
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Key Findings from Survey What are They Doing?

• Health information exchange efforts are
  delivering more information and increasingly
  using standards for data delivery
• More than 50 are exchanging or expecting to
  exchange outpatient and inpatient episodes, lab
  results, ED episodes, pathology and enrollment
  and eligibility
• 76 of advanced stage are using HL7 as messaging
  standards and 41 are using LOINC for laboratory
  reporting

44
Most Significant Challenges
45
Most Difficult Challenges

• Securing upfront funding- 91 of all respondents
  cited securing upfront funding as either a very
  difficult or moderately difficult challenge.
• Developing a sustainable business model- 84 of
  all respondents cited developing a sustainable
  business model as a very difficult or moderately
  difficult challenge.

46
Most Difficult Challenges

• Engaging health plans- 74 of respondents
  perceived the engagement of health plans as a
  very difficult or moderately difficult challenge.
  
• Accurately linking patient data- 80 of
  respondents indicated that accurately linking
  patient data was a very or moderately difficult
  challenge.

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Key Findings from Survey

• Funding sources for both upfront and ongoing
  operational costs still rely heavily upon
  government funds
• 46 of all respondents cited federal government
  contracts as current revenue source
• 48 of advanced stage cite federal government as
  source for ongoing operations

48
Federal Government Still Key Funding Source
49
Federal Government Still Key Funding Source
50
Key Findings from Survey

• But alternative funding sources for ongoing
  sustainability are beginning to emerge.
• Advance payments from hospitals (38)
• Physician practices (33)
• Public health (19)
• Labs (15)
• Payers (15), and
• Purchasers (9)

51
New Models for Sustainability Emerging
52
Emerging Guiding Principles
53
Characteristics of Successful Health Information
Exchange Initiatives

• Governed by a diverse and broad set of
  stakeholders within the region or community
• Develop and assure adherence to a common set of
  principles and standards for the technical and
  policy aspects of information sharing -
  addressing the needs of every stakeholder
• Develop and maintain a model for sustainability
  that aligns the costs with the benefits of HIE
  and
• Use metrics to measure performance from the
  perspective of patient care, public health,
  provider value, and economic value.

54
Emerging Guiding Principles

• Approach for Getting Organized
• Convened by trusted, neutral party
• Engage all of the stakeholders in your region
  clinicians, hospitals, laboratories, community
  health centers, pharmacies, health plans,
  employers, patient groups, public health, and the
  state and local government
• Get clear upfront on your shared vision, goals
  and objectives, and principles for working
  together
• Focus on value
• Link to the challenges of your region or
  community
• Incremental approach

55
Emerging Guiding Principles

• Approach for Technical Aspects
• Utilize national standards as they emerge
• Build in your policies for information sharing as
  you build your technical architecture!
• Connectivity built on the Internet and other
  existing networks
• Environment is private, secure
• Minimally invasive approach leverages existing
  systems - no rip and replace
• Accurate patient identification based on uniform
  and standardized methodologies

56
Emerging Guiding Principles

• Engaging Practicing Clinicians in the Changes
  Required
• Innovation and investment will be needed to
  support small physician practices in migration
• Reduce burden of multiple reporting systems
• Build reporting into current work-flow
• Improve trust by leveraging emerging
  certification processes
• Realign incentives to promote adoption

57
Emerging Guiding Principles

• Financing and Sustainability
• Must create value for all participants, both
  globally and for each stakeholder interest
• Look for incremental value gains projects that
  will immediately return value as you move
  towards your longer-term goal
• Incentive amounts offered should be meaningful
• Purchaser or payer sponsors of the incentive
  program should represent a meaningful proportion
  of the clinicians patient panel
• Any applications covered by the program should be
  interoperable and standards-based

58
Emerging Guiding Principles

• Financing and Sustainability.
• Coordination and collaboration within the region
  or community is critical.
• Physician practices ordinarily contract with a
  large number of purchasers and payers.
• Incentives offered by a small number of
  purchasers or payers generally are not effective
• Reduce the potential for the free rider effect
• Most of the data required to deliver care within
  physician practices resides somewhere else
  (hospital, lab, pharmacy, health plan, etc.)

59
Emerging Guiding Principles

• Financing and Sustainability
• Rapidly emerging interest in aligning quality
  improvement initiatives with the HIT and health
  information exchange infrastructure required

60
eHIs Parallel Pathways Aligning Incentives with
Quality and HIT

• Aligning Incentives with
• Quality capabilities
• Physician HIT capabilities
• Health information exchange capabilities

Quality and Value
Quality Expectations
Health Info Exchange Capabilities
Physician Practice HIT Capabilities
Financial Incentives
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Aligning Quality Expectations with HIT and HIE
Capabilities
Reporting of Outcomes
H
Incentives
Implementation of HIT
L
Time
Phase 1
Phase 2
Phase 3
Quality self-assessment HIT implementation Chart
data reporting HIE formation
Use of HIT e-reporting of outcomes QI
initiatives HIE operational
Continued QI Full e-reporting of outcomes
62
The Private Sector has Many Programs in Place

• Physician-based
• Bridges To Excellence has a program focused on
  adoption of systems of care, including
  HIT.enormous uptake across the country
• The Integrated Healthcare Association in CA
  rewards physician groups for ambulatory POE and
  eRX systems
• Hospital-based The Leapfrog Group has launched
  a new national program that rewards good outcomes
  and adoption of CPOE systems

63
Many Health Plans have Incorporated Incentives as
Well

• CareFirst BCBS they licensed BTE and are
  expanding their program to reward many practices
  in the DC Virginia areas
• UHC, CIGNA, Aetna they are all recognizing
  physicians that adopt and use HIT to varying
  degrees

64
Key Take-aways

• Health information technology is here and
  interoperability is the name of the game
• Rapid changes in policy at the national, state
  and local levels
• Every stakeholder group is trying to figure out
  how this fits within their strategy
• National standards are emerging to support
  interoperability- stay in tune with thembuild
  them in as they get defined

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Key Take-aways

• Value-based purchasing will be here soon.keep
  this in mind as you proceed
• Engaging your purchasers and health plans is
  criticalwithout them you dont have a
  sustainable business model
• Remember that most of healthcare is delivered by
  small physician practicesengage them, and engage
  them early

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Key Take-aways

• Most important thing is to stay focused build
  your incremental roadmap based on value. at the
  end of the day, value is the only thing that
  matters
• Mobilizing health information is going to
  dramatically improve the quality and safety of
  healthcare in the U.S.

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• Janet M. Marchibroda
• Chief Executive Officer
• eHealth Initiative and Foundation
• www.ehealthinitiative.org
• 1500 K Street, N.W., Suite 900
• Washington, D.C. 20005
• 202.624.3270
• Janet.marchibroda_at_ehealthinitiative.org