John D' Halamka, MD

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John D. Halamka, MD
Keynote

• CIO, Harvard Medical School
• CIO, Beth Israel Deaconess
• CEO, MA-Share
• Chair, NEHEN

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Connecting Patients, Providers and Patients The
SOA Experience in New England
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The Time Has Come,Even in Health Care

• Streamlining cross-company processes is the next
  great frontier for reducing costs, enhancing
  quality, and speeding operations. Its where this
  decades productivity wars will be fought. The
  victors will be those companies that are able to
  take a new approach to business, working closely
  with partners to design and manage processes that
  extend across traditional corporate boundaries.
  They will be the ones that make the leap from
  efficiency to superefficiency.
• Michael Hammer, The Superefficient Company

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Brailers 5 Barriers

• Multitude of industry standards that have yet to
  be harmonized
• A lack of clear and unambiguous policies about
  data control
• Differing security policies among organizations
  and states
• The risk that EHR products won't work
• Lack of a business model that creates incentives
  for physician investment and adoption

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Case Studies

• NEHEN the transactor of community
  administrative data
• MA-Share the grid of community clinical
  utilities

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Community Utilities
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We Have An Opportunity For Coopertition

• HIPAA Provider Readiness for HIPAA
• Evolving Business Models
• Competing E-Health Strategies
• Rapidly Evolving Marketplaces
• Employer Cost Pressures
• Regulatory and Political Oversight

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Connectivity in the past

• Tower of Babel
• Everything is a point to point one-off
• Many relationships are take mine or leave it
• Clearinghouses and middlemen
• Own the connectivity channels
• Enable the participants to not invest in
  community processes and exchange optimization

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Convergence of Regulation, Technology and
Economics

• HIPAA, the internet and the cost pressures in
  healthcare have converged to create opportunity
• HIPAA standardizes the components around which
  healthcare trading partners can define
  dependable, efficient and common business
  processes
• Internet standards (TCPIP, SOAP, HTTPS) deliver
  the dependability of scaleable, secure and
  ubiquitous channels for electronic exchange
• The dynamics of the healthcare market place
  create tremendous incentives for coopertition
  among all the players

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But Its Not Just About Technology

• New technologies may be the glue, but the more
  important innovation is the change in the way
  people think and work.
• Rather than seeing business processes as ending
  at the edges of their companies, Geon and its
  partners now see them-and manage them- as they
  truly are chains of activities that are
  performed by different organizations.
• Michael Hammer, The Superefficient Company

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Its All About The Commitment

• Successful Extra Enterprise Integration relies on
  the ability of trading community participants to
• Receive, process and respond to electronic
  messages containing standardized components
• The ability of the trading entities to establish
  and maintain and secure, scalable reliable
  transport channels for electronic transactions
• The willingness and commitment to share (and make
  visible to both trading partners and competitors)
  common internal business processes

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New England Health Environment

• Not For Profit
• Regional
• High Tech
• Payer and Provider Concentration
• Culture of Innovation

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NEHEN

• Began with a technology leadership orientation
• Membership based on sharing of cost
• No provider or payer too large or too small
• Owned by its membership
• Focus on flexibility

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A Climate for Coopertition

• Within NEHEN we can
• Drive to Agreements Between Competitors
• Figure Out How to Talk to One and Other-
• Face to Face
• Machine to Machine
• Find the Value and Profit From
• Standards
• Common Practices

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Collaboration

• Focus on eliminating friction cost
• Emphasis on collaboration
• Leverage standards-reduce cost/burden

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History

• Focus on Specific Transactions- Keep It Simple
• Frame Relay/ VPN- Boston Globe Sniff Test
• Big Players provided start up capital and vision
• Money ? Integration
• Integration? Machine to Machine
• Machine to Machine Close Working Relationships
  ?B2B

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History
Oct. 1997
Feb. 1998
Apr. 1998
Oct. 1998
Nov. 1999
Dec. 1999
Feb. 2000
Jun. 2000
Jul. 2000
Jan. 2001
Apr. 2001
Summer 2001
Sep. 2001
Initial discussions
Pilot commences
Incorporation as NEHEN LLC
Seventhand eighthmembers join
Two affiliates join
Ninth and tenth members join
Members 12-14 join
Commitment in principle
Eligibility live at founding members
Sixthmemberjoins
Specialtyreferrals live
Claim statusinquiry pilotcommences
Eleventh member joins
Referral auth and inquiry pilot

• 40 Hospitals
• Over 7,500 licensed beds
• Over 5,000 affiliated physicians

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Technology Premise

• Designed a communication infrastructure that was
  vendor and system neutral
• Developed shared expertise in communication
  channels and formats
• Leveraged frame relay, VPN and HTTPS transport
  protocols

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Technology Overview
Payer-side
HPHC
THP
NHP
Batch Extracts and Real-Time Transactions
Hospital or Practice Management System
NEHEN Contract Affiliates
NEHEN Network
NEHEN Reports
NEHEN Database
NEHEN Payer Services
Patient Accounts
NEHEN Gateway
NEHENLite
Non-NEHEN Payer/Clearing House
Provider-side
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Seamless Transactions

• Always On capability so all participants own
  their share of the data integrity chain resulting
  in much less downstream re-work
• Data credibility portability enhances
  everyones decision processes
• Constituents grow in knowledge of each others
  friction costs

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Collaboration Fundamentals
Automation of These B2B Exchanges in a Consistent
and Well Managed Method Is the Number One
Conversation Between Payers and Providers
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Service Oriented Architectures make it all
possible
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What is HTS?
HTTPS Envelope
SOAP Wrapper
Payload (EDI)

• X.12
• HL7
• NCPDP
• HRXML
• Other?

• A Secure Transmission delivery method using the
  Internet using SOAP for routing

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Payer-Provider Direct Web Service

• Collaborative effort with to develop regional
  standard for Internet transport of HIPAA
  transactions
• Facilitates practice management system
  integration
• Leverages multi-payor opportunity as an advantage
  to providers

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Convergence of Business and Technology

• Solution
• HIPAA EDI, HL7, NCPDP..
• Internet
• Open Standards(SSL,Digital certs)
• SOAP / Web Services

• Need
• Transaction Data format
• Transport
• Transmission Security
• B2B Transmission Format

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The Core of HTS

• HTS synthesizes these standards and technologies
  with one additional component
• A Transmission Delivery, Format Schema the glue
  that binds
• SOAP schema contains e-mail like basics
• Addressing (sender, receiver), transmission
  security content identifier
• Facilities Routing
• Framework supports multiple B2B operational needs

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Provides Transmission Scalability
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Transmission Timing and Modes
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Summary NEHEN and HTS

• A transmission protocol for secure low cost
  exchange of Healthcare B2B transactions
• Platform vendor independent
• Ubiquitously accessible
• A communication framework that can be leveraged
  for all B2B exchanges across multiple payload
  types (administrative and clinical)
• Scalable flexible to support future needs
• A standards based solution and approach

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HTS Status

• Operational for more than 1 year
• 6 of 7 Required HIPAA transaction Types in
  Production
• 270/271, 276/277, 278, 835, 837, 997
• 277 Claims Acknowledgement with proprietary
  format, in development
• Real Time Transaction for Eligibility and Claim
  Status Inquiry
• Batch Transactions for Claims, Claims
  Acknowledgement, Remittance

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HTS Futures

• Continue to gain adoption of regional standard in
  Northeast for Providers and Payers
• NEHEN to promote standard
• Future portability, if new transmission format is
  adopted by region or federal level (e.g., the
  SOAP layer)
• Future format would be an incremental upgrade
• HTS Solution is build with versioning as planned
  activity
• HTS will be adopted to meet evolving WS-Security
  standards

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• MA-SHARE

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National Health Information Network
Early market activity
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MA Scope

• Blue Cross Blue Shield of MA..2.6
  million members
• Harvard Pilgrim Health Care..790,000
  members
• Tufts Health Plan...747,000 members
• Fallon Community Health Plan185,000
  members
• Neighborhood Health Plan120,000 members

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Drivers

• 15 of Healthcare in Massachusetts is redundancy
  and inappropriate care 4.5 billion per year
• 98,000 preventable deaths occur each in the US
  due to medication error
• Employers and Quality Improvement organizations
  are demanding pay for performance for quality

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Why?

• Real-time clinical information available for ALL
  patients to treating providers- What they need,
  when where they need it to assure patient
  safety
• A clinical application to comply with The
  Leapfrog Group/National Quality Forum Safety
  Practices information transfer, clinical
  communication, safe medication use
• Address JCAHO Patient Safety Goals Improve the
  Effectiveness of Communication Among Caregivers

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Community Utilities

• Within a clinical service area
• Among clinical service areas regionally
• Among regions nationally
• Aggregation of data for quality measurements
• Real time Surveillance

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High Level Functional Architecture Vision

• Publish patient index (record location) from
  local data source to central registry
• Acquire address (record location) of EHR system
  and local patient index from central registry
• Retrieve medical data directly from data source
  on peer-to-peer basis
• Conforms to Web-services interop pattern
  Publish/Find/Bind

? Adapted from Linking Healthcare Information
Proposed Methods for Improving Care and
Protecting Privacy, Carol Diamond, Connecting for
Health, Markle Foundation, HIMSS 2005
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Service-Oriented Architecture

• RLS composite application made up of loosely
  coupled, coarse grained services
• Core Service Patient Index Service
• Central registry of distributed EHR systems and
  other CMPIs / EMPIs
• Gateway provides common infrastructural
  (plumbing) services
• Systems management including logging, auditing,
  service management
• Security authentication, policy, consent
  management
• Integration services messaging, transformation,
  orchestration, adaptor
• Common services reused across RLS and Gateway

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Patient Lookup Messaging Flow
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Prescription example
E-Prescribing Software

• Rx Gateway checks with health plan for pharmacy
  benefit eligibility and any other available data

• When physician is satisfied, electronic
  prescription is routed to pharmacy or agent
  (i.e., SureScripts)

Payer
Prescribing Physician
Pharmacy

• Electronic prescription is routed to Rx Gateway
  from e-prescribing software

Rx Gateway (component of CDX)

• Messages and other data can be routed back to Rx
  Gateway and into e-prescribing or other provider
  systems confirming prescription was picked up,
  etc.

• Prescribing physicians use the software of
  their choice to create an electronic prescription

• Rx Gateway checks with pharmacy benefit manager
  (PBM) or intermediary (i.e., RxHub) for formulary
  compliance, medication history

PBM
E-Prescribing Module
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Value Proposition

• Vendors
• Providers
• Payers
• Members

• Transactions are now commodities
• Theres no competitive advantage
• The Model doesnt shift costs, it drives costs
  out of the system for all

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Impact

• Major improvements in cycle times
• Business velocity optimization
• Huge reductions in cost
• Happier providers with better business operations
  and more useful decision-support
• More capacity to hold people accountable
• Ultimately Lower medical expense trends
• New product opportunities with better decision
  support tools for members and accounts

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Summary

• Massachusetts Payers and providers began with a
  goal of administrative simplification for
  administrative transactions
• Expansion underway for many clinical initiatives
• When focus is collaboration not competition
  mountains can be moved and standards can be
  achieved

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Questions

• Contact information
• Jhalamka_at_hms.harvard.edu
• For more information on NEHEN
• http//www.nehen.net/
• For more information on MA-SHARE
• http//www.mahealthdata.org