Health Information Exchange 101 Problem, Definitions, Value, Policy

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Health Information Exchange 101Problem,
Definitions, Value, Policy

• David C. Kendrick, MD, MPH
• Asst. Provost for Strategic Planning
• OUHSC

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National perspective

• At gt17 of GDP, healthcare costs - out of control
• Value delivered is limited US ranks below
  most industrialized nations on quality metrics,
  despite spending more
• Healthcare IT - part of the solution
  prioritized and funded
• American Recovery and Reinvestment Act
• Patient Centered Medical Home
  gaining as the delivery model of choice

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Healthcare Reform likely possible

• Details change daily, but will probably might
  include
• Coverage expansion for the uninsured, perhaps
  through a public plan or premium assistance
  programs
• Emphasis on preventive care
• More prominent role of the Patient Centered
  Medical Home
• Emphasis on Healthcare IT

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2009 State of the States Health Summary
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Oklahoma is the only state where the death rate
has gotten worse..

• Some Factors
• Economic downturn? healthy people and jobs left
  Oklahoma
• Poverty remained
• Heart Disease (Diabetes)
• Cancer
• Access to Care

Age-adjusted Death Rates
Past 25 Years
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2007 COMMONWEALTH FUND ReportState Scorecard
Summary of Health System Performance
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What WE CANT Do

• Grow more doctors quickly
• Create new hospitals overnight
• Force patients to
• Exercise
• Stop smoking
• Lose weight

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What We Can Do

• Leverage Technology
• Complex populations
• Limited Resources
• Create a lean healthcare system
• Improve Care Coordination
• Business case for
• Funding
• Efficiency

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Where to Focus?

• Electronic Medical Records (EMRs) important, but
  . . .
• Health Information Exchanges (HIEs)
• immediate benefit and greater cost savings
• Community-wide care coordination (CCC)
• more benefit and cost savings

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Physician Organization in Relation to Quality
and Efficiency of CareThe Commonwealth Fund,
April 2008
Evidence Increasingly shows that improved
systemness drives quality and
efficiency System a group of independent but
interrelated elements Designed to work as a
coherent entity
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Where Will there beSavings?
Majority From the Exchange of Clinical
Information among care providers Reduction in
duplicate Dx procedures Prevention of Medical
Error Source Center for Information Technology
Leadership 2005
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Current Situation
Hospitals (inpt)
Rx
Payers Demographics Medical claims Pharmacy
claims Case mgmt records
ER/UC
Patient
Imaging
Safety Net Clinics and community agencies
Other PCPs
Labs
Manual connection (mail, fax) Electronic
connection
Specialists
Ancillary care PT/OT/Aud/Diet
Public Health
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Health Information - Useful
Available at the POS Logically presented
Current Medicare patient - 5.6 providers/yr (7.7
providers/yr including 2 PCPs) Community Care
Coordination
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Definitions EMR vs. HIE vs. HIO vs. CCC
HIE
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Health Information Organization
RHIO Greatest Value Your Data is Local
(CCC) Business Model - Self Supporting Stakeholder
s/Users Quality, Safety Efficient
Delivery Govern, Sets Rules Statewide Network
of Networks Disaster Bioterrorism Public
Health National (NHIN)
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Scale State-wide A Network of Networks

• Local governance
• Common technology

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Anatomy of a HIE
Health Information Exchange
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Anatomy Detailed Version

• HIE - Central Data Repository for a core set
  of clinical variables
• eMPI - Master Patient Index tracks unique
  patients and ensures data integrity
• Community Order Entry/Physician Portal-
  Centralized system coordinating orders,
  referrals, consultations, radiology and
  diagnostic tests, PT/OT, etc.
• Decision analytics - Tools and algorithms for
  patient identification, prioritizing patients for
  interventions, prioritizing appropriate
  interventions each patient
• Patient Portal - gives patients access to their
  own community health records, ability to
  communicate with their providers
• eVisits, Schedule requests, Refill requests,
  Patient educational materials, Self-care logs
  (BP, BS, asthma, etc.), Health Risk Assessments
  (Depression screen, Cardiac risk), Review records
  shared across the community
• Comprehensive clinical education support
• Trainee portfolios, Evaluations, Delivery of
  relevant didactic educational materials

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Organizing the Concepts

• What is the relationship between Health
  Information Exchanges and the Patient Centered
  Medical Home?

Patient Centered Medical Home
Patient Centered Medical Home
Patient Centered Medical Home
Patient Centered Medical Home
Patient Centered Medical Home
Patient Centered Medical Home
Health Information Exchange
Reimbursement Model
Health Information Exchange
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Medical Home HIE
Fragmented Care More patients Complex
populations 1in 4 - Behavioral Health
Diagnosis (Duals Drive cost ) Medicaid 46
Medicare 24 Investing in the
Aftermath vs Ahead of the curve Resource Drain
from Missed Early Opportunities
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Medical HomeGoals
Integrated Systems More Efficient Use of
Resources Identify Prioritize patients for
Intervention (ahead of the curve) Link Providers
- Coordinate Care Raise Quality - Evidence Based
Guidelines Identify Quality issues Make Rapid
Changes
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Have we given this any thought?

• 2004 Harvard Center for IT Leadership published
  a report on the value of health information
  exchange
• 77B in annual savings through Health IT
• Prompted, in part, the creation of the Office of
  the National Coordinator for Healthcare IT
  (ONCHIT), the Health IT Czar
• 2006 GKFF commissioned an OK-specific evaluation
  of the value of HIE

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Motivation

• Clinicians have incomplete knowledge of their
  patients
• Relevant patient data not available in 81 of
  ambulatory visits Tang 1994
• 18 of medical errors that lead to ADEs due to
  missing patient information. Leape JAMA 1995
• Medicare patients see an average of 5.6 different
  providers each year 5.6 silos of data
• What is the value of HIE for Oklahoma and
  specifically for the Tulsa region?

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HIE Expert Panelists

• David Brailer, MD, PhD
• Santa Barbara County Care Data Exchange, Health
  Technology Center
• William Braithwaite, MD, PhD
• Independent consultant, Dr HIPAA
• Paul Carpenter, MD
• Associate Professor of Medicine,
  Endocrinology-Metabolism and Health Informatics
  Research, Mayo Clinic
• Daniel Friedman, PhD
• Independent public health consultant
• Robert Miller, PhD
• Associate Professor of Health Economics, UCSF
• Arnold Milstein, MD, MPH
• Pacific Business Group on Health, Mercer
  Consulting, Leapfrog Group
• J Marc Overhage, MD, PhD
• Regenstrief Institute, Associate Professor of
  Medicine, Indiana University
• Scott Young, MD
• Senior Clinical Advisor, Office of Clinical
  Standards and Quality, CMS
• Kepa Zubeldia, MD
• President and CEO, Claredi Corporation

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HIE Value Construct
Public Health Agencies
Pharmacies
Payers
Providers Hospitals
Radiology Centers
Clinical Laboratories
Other Providers
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HIE Value Construct
Electronic submission of reportable conditions
and vital statistics
Avoided ADEs, drug utilization savings,
automated transaction sets
Public Health Agencies
Pharmacies
Payers
Providers Hospitals
Avoided redundant tests, Electronic test ordering
and results delivery
Electronic Rx, refills, interaction checking,
adherence data
Radiology Centers
Clinical Laboratories
Avoided redundant imaging, Electronic imaging
ordering and results delivery
Electronic referrals, consultation letter
delivery, chart requests
Other Providers
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What about funding?

• One time
• ARRA stimulus dollars
• Other grants
• Ongoing
• Business model must be developed
• ROI by stakeholder will drive the business model

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ARRA Stimulus Dollars
Washington, D.C.
Earmarks
Federal Agency Grants
State distributions
ONCHIT
Heath Dept
AHRQ
OHCA
DHS
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Opportunity Stimulus Package

• Federal Agencies offering
• 20B for healthcare IT, 3B short term and 300M
  immediately
• 1B for comparative effectiveness research
• 1.5B for community health centers
• Much will be distributed through grant process
• Will be highly competitive
• Many other communities have been in this game for
  years
• Our communities must
• Be unified behind a well-developed plan of action
• We must build the coalition now
• Greater Tulsa Health Access Network

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From the final ARRAIn order to be eligible for
Stimulus Grants

• Must be a qualified State-designated entity
• Designated by State as eligible to receive awards
• Non-profit entity
• Clear objectives to use Healthcare information
  technology to improve care quality and efficiency
  through secure data exchange
• Adopt non-discrimination and conflict of interest
  policies
• Broad stakeholder representation on governing
  board

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CMS really wants EMR and HIE adoption . . .

Assume N1,500 MDs, DOs, PAs, and NPs and 7
hospitals see Medicare patients Penalties for
non-adoption not yet elaborated, but assume
mirror bonuses
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From the final ARRARegional organization must
include

• Providers, including those focused on low-income
  and underserved
• Health plans
• Patient and consumer organizations
• HIT vendors
• Healthcare purchasers and employers
• Public health agencies
• Universities
• Clinical researchers
• Other staff who use HIT

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National Meaningful Use guidance

• In order to qualify for bonus payments (and avoid
  penalties)
• By 2011, the following must be exchanged
• Doctors Problem lists, medication lists,
  allergies, test results
• Hospitals Discharge summaries, procedures,
  problem lists, medication lists, allergies, and
  test results
• By 2013, the following must be exchanged
• Doctors Share all care transition data across
  the community electronically
• Hospitals Share all care transition data
  electronically