Health Information Exchange: Value, Incentives, and How to get there.

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Health Information Exchange Value, Incentives,
and How to get there.

• David C. Kendrick, MD, MPH
• Asst. Provost for Strategic Planning, OUHSC
• Medical Director for Community Medical
  Informatics
• OU School of Community Medicine
• Greater Tulsa Health Access Network

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Agenda

• HIE Ongoing benefits Value aside from ARRA
• Financial
• Clinical
• New, one-time opportunities ARRA Incentives in
  Oklahoma Terms
• How do we get there?

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National perspective

• At gt17 of GDP, healthcare costs have grown out
  of control
• The value delivered is limited US ranks below
  most other industrialized nations on most quality
  metrics, despite spending more
• Healthcare IT has been recognized as a part of
  the solution and now is prioritized and funded
• American Recovery and Reinvestment Act

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2007 COMMONWEALTH FUND ReportState Scorecard
Summary of Health System Performance
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(No Transcript)
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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
• Obesity

Age-adjusted Death Rates
Past 25 Years
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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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Where to begin?

• Cannot quickly grow more doctors
• Cannot make new hospitals appear
• Cannot force our patients to exercise, stop
  smoking, and lose weight
• Must make the best use of limited resources
• Leverage technology to create a lean healthcare
  system
• Must build the business case for funding this
  effort
• Focus
• Electronic Medical Records (EMRs) are important,
  but . . .
• Health Information Exchanges (HIEs) provide
  immediate benefit and greater cost savings
• Community-wide care coordination will provide yet
  more benefit and cost savings

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Definitions EMR vs. HIE vs. HIO vs. CCC
HIE
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Scale State-wide A Network of Networks

• Common technology
• Local governance

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(No Transcript)
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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 for coordinating orders of all
  types, including referrals, consultations,
  radiology and diagnostic tests, PT/OT, etc.
• Decision analytics- Tools and algorithms to
  assist with patient identification and
  prioritization of patients for interventions, and
  for each patient, prioritization of appropriate
  interventions
• Patient Portal- To give 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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Whats the value of HIE?

• 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?

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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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Value by Stakeholder Tulsa
Public Health Agencies
Provider
0.39
Pharmacies
Payers
4.4
33
Providers Hospitals
0.39
2.8
32
28
38
Radiology Centers
Clinical Laboratories
11
33
24
Other Providers
11
Millions
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Value by Stakeholder Tulsa
Public Health Agencies
Provider
0.39
Pharmacies
Payers
4.4
33
Providers
0.39
2.8
32
28
38
Radiology Centers
Clinical Laboratories
11
33
24
Other Providers
11
Millions
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Value by Stakeholder Oklahoma City
Public Health Agencies
Provider
0.48
Pharmacies
Payers
5.4
14
Providers Hospitals
0.48
3.4
14
35
45
Radiology Centers
Clinical Laboratories
14
39
30
Other Providers
14
Millions
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Value to Oklahoma
Public Health Agencies
Provider
1.5
Pharmacies
Payers
16
136
Providers Hospitals
1.5
10
127
116
141
Radiology Centers
Clinical Laboratories
39
123
99
Other Providers
39
Millions
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Value by Stakeholder Oklahoma
Public Health Agencies
Provider
1.5
Pharmacies
Payers
16
136
Providers Hospitals
1.5
10
127
116
141
Radiology Centers
Clinical Laboratories
39
123
99
Other Providers
39
Millions
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Net value of HIE
Tulsa
Oklahoma City
Oklahoma
Software as a service, Cloud computing, and
Interoperability standards have lowered the cost
of implementation and maintenance by an order of
magnitude
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But wait, theres more . . .

• CMS and Medicaid Incentive payments for
  Meaningful use of an EHR
• 44,000 to Medicare providers, 63,000 to
  Medicaid
• Formula-driven bonus to hospitals 2-11M per
  hospital
• What does this mean to OK?
• Assume 9,000 MDs, DOs, PAs, NPs are eligible
• Assume the following hospital bed distribution

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CMS wants EMR and HIE adoption . . .
Assume N9,000 MDs, DOs, PAs, and NPs focused
30 of the time on Medicare patients, and 12,474
hospital beds
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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

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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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Beyond incentives

• Federal Agencies offering
• 20B for healthcare IT
• 17B for Medicare and Medicaid incentives
• 3B short term and 300M immediately
• 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 state plan of
  action
• We must build that plan of action now

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HIE Progress to date

• Early summer Small working group met and
  produced a document
• Outlined 14 Items for consideration
• July 30th Major stakeholders meeting. 35
  people
• Reduced Items for consideration from 14 to only
  3
• Meet requirements established by Federal
  legislation for funding
• Establish planning process, including HIT Policy
  Committee
• Identify the State Designated Entity
• Agreed that OHCA could be the temporary custodial
  State Designated Entity until the planning
  process is complete or October 16, whichever
  comes first.
• August 14 OKHITECH Summit held, wide invitation
  list, comments and feedback sought
• August 14-21 Online comment period
• August 20 State HIE Cooperative Agreement
  Program (SHIECAP) Released

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State HIE Cooperative Agreement Program (SHIECAP)

• Governor must identify State Designated Entity
• Each applicant must have a State Coordinator for
  Healthcare IT
• Focus State Strategic Plan and Operational Plan
• States without plans can spend as much as 6
  months on a planning process
• Applicants who fail to submit acceptable plans
  will be subsumed into other nearby states

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State HIE Cooperative Agreement Program (SHIECAP)

• Approval Merit-driven
• Funding (mostly) Formula-driven
• 4M base for 50 successful applicants
• Additional funding up to 36M per applicant
  apportioned thusly
• applicant regions population (5),
• number of PCPs (40),
• Acute Care Hospitals (30), and
• Medically Underserved and Rural Providers (25).
• A final 10 of the total funds will be
  apportioned based on an assessment of the
  relative HIT need of the region, as determined by
  evaluation of the Letter of Intent.
• Oklahomas likely take 6-8M

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Deadlines and current status

• September 11 Letter of Intent Due
• State Designated Entity- Done, at least
  temporarily
• Review of existing capabilities statewide
• Report of total expenditures to date in 5 key
  areas
• October 16 Final application due
• Details of planning process
• Key individuals identified to execute the process
• December 15 Award announcements
• January 15 Work begins

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Thanks!

• David-Kendrick_at_ouhsc.edu

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Potential Model 1 Government Lead HIE
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Potential Model 2 Public utility with State
oversight
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Potential Model 2

• Common technology
• Local governance