eHealth Initiatives in Wisconsin Electronic Healthcare Bringing it Home

1
eHealth Initiatives in Wisconsin Electronic
HealthcareBringing it Home

• Seth Foldy, MD, MPH, FAAFP
• Medical College of Wisconsin
• Susan Wood
• eHealth Chief of Staff
• Department of Health and Family Services
• HIPAA COW Conference
• September 29, 2006

2
Issues for Discussion

• Governor Doyles Executive Order creating the
  eHealthcare Quality and Patient Safety Board
• Health Information Security and Privacy
  Collaboration
• Fit with National Health Information Technology
  Priorities
• Fit with Current Health Information Initiatives
  in our State
• Significance for Wisconsin

3
Governor Doyles Executive Order

• Purpose - to improve the quality and safety of
  health care in Wisconsin
• It creates a permanent eHealth Care Quality and
  Patient Safety Board
• This Board will develop a plan for statewide use
  of electronic health records and exchange of
  information from these systems
• This initiative is a key component of the
  Governors Affordability Agenda working to
  improve access and quality in our health care
  system and to address the economic impact of the
  current health care system

4
A Public Private Enterprise

• The eHealth Board has 13 private sector and 7
  public sector members
• Chair is the Health Secretary in the Governor s
  Cabinet
• The current role for government is to convene
  stakeholders, develop consensus on principles and
  standards, staff planning efforts, and represent
  the interests of public health and public sector
  purchasers
• A wide range of private sector stakeholders are
  working to develop the Action Plan

5
Five Year Action Plan

• The eHealth Board created five work groups to
  develop components of the plan
• Patient Care
• Information Exchange
• Consumer Interests
• Governance
• Finance
• The Action Plan will be submitted to the Governor
  in December 2006 with recommendations to
• achieve statewide use of electronic health
  records and decision support systems at the point
  of patient care and
• provide a means for timely and appropriate
  exchange of data across medical settings

6
(No Transcript)
7
Progress Report

• Four work groups made preliminary reports to the
  eHealth Board August 3, 2006
• The Governance group began meeting in August
• Wonderful ideas and energy from work group
  participants
• Commitment to transparency and engaging
  stakeholders
• See all reports at the eHealth Board web site
  http//ehealthboard.dhfs.wisconsin.gov/

8
Health Information Security and Privacy
Collaboration

• RTI awarded contracts awarded to 30 states May
  2006
• Wisconsins proposal integrates work on the
  Privacy Project with the structure and
  processes being created for the eHealth Board
• Wisconsin is eligible to receive the maximum
  funding per state of 350,000.
• The funds will be used for staff costs in DHFS,
  for contractors to support these work activities
  and related meeting expenses
• Staffing About 12 people working part time on
  this project, staffing the four work groups
  required by the contract

9
Privacy ProjectExpectations

• Assess variations in organization-level business
  policies and state laws that affect health
  information exchange in the state
• Work closely with RTI, the National Governors
  Association and other states to exchange
  information and experiences regarding
  interoperable health information exchange
  barriers and best practices
• Identify and propose practical solutions that
  protect privacy and security of health
  information and permit interoperable health
  information exchange

10
Expectations (cont.)

• Develop plans to implement solutions in the state
  and, if applicable, at the federal level.
• Each state is also expected to work with health
  care professionals, patients and others to
  address privacy and security issues and identify
  solutions for broad application and to manage
  the project according to RTI requirements.
• The issues raised and solutions identified
  will set out a road map for Wisconsin in terms of
  eliminating barriers to health information
  exchange and provide a foundation for future work
  by the national agencies and facilitate health
  information exchange across the states

11
eHealth and the Privacy Project

• One of the strongest early lessons were
  learning from our research on electronic health
  information is that some of the main challenges
  for adoption are not technical issues. Rather
  they are issues of inclusion and trust. This work
  on privacy and security will leave an indelible
  mark on the ultimate formulation of a national
  health information network.
• Dr. Carolyn M. Clancy, Director of the Agency
  for Healthcare Quality and Research, announcing
  the grant awards

12
eHealth and Privacy Project

• As part of its charge the Board is expected to
  identify options for serving consumer health
  information needs and insuring health information
  privacy and security in electronic health
  information exchange as it develops the
  Wisconsin Action Plan for Health Care Quality and
  Patient Safety.
• The Wisconsin eHealth Board will serve as the
  Steering Committee for the HIPSC project -
  overseeing the activities of multiple working
  teams and linking their work with other key
  organizations especially HIPAA COW.

13
(No Transcript)
14
Where are we now?

• National context
• The Wisconsin eHealth Action Plan process
• Future vision
• Discussion

15
Motivation Poor Access to Health Information

• 40 of outpatient prescriptions unnecessary
• 20 of lab x-ray tests ordered because
  originals can not be found
• 18 medical errors from inadequate patient
  information.
• Patients get only 54.9 of recommended care
• 49 of notifiable diseases reported
• - B. Middleton PHIN 2005 Conference

16
Motivation The Unsustainable Cost of Health
Care

• 1.8 Trillion / Yr
• 15 of GDP 2X OECD Median (8.5)
• 18.7 GDP in 2014
• Medicares Projected Deficit 27 Trillion (7x SS)
• Unsustainable Growth Doubles Every 10 Years
• - Health Spending Projections Office of the
  Actuary, CMS J Health
  Affairs 2005
• -Health Spending in the US and the rest of the
  Industrialized World. J Health Affairs 2005

17
Public Health Improvement Needs

• Linking clinical and community-based
  prevention is needed more than ever
• Wisconsins national health ranking dropped to
  13th (from 9th in 2004) reflecting obesity, ?
  child poverty.
• Since 1990 the prevalence of obesity soared by
  105 - from 11.3 to 23.2 of the population
• Wisconsins infant mortality rate was
  substantially worse for minorities
• Our state ranked 23rd for cardiovascular deaths
  and 23rd for total mortality.
• Challenges of early outbreak detection, disaster
  management, efficiency of public health case
  management, and uptake of public services
• Source Americas Health Rankings for 2005,
  United Health Foundation

18
Annual costs of paper-shuffling in SE Wisconsin -
668 million, up to 900 lives
0.7 million in outpatient visits from
preventable adverse drug events
8 million in preventable Inpatient adverse drug
events
SAFETY
50 to 525 deaths
94 million in preventable redundant testing
REDUNDANCY
Est. 400 deaths
80 million in lost time 7 million in hospital
costs from missed prevention opportunities
QUALITY
Up to 566 million in administrative
costs associated with paper records
ADMINISTRATIVE
19
Consumers Want Health IT

• Americans who know about connected, interoperable
  health care systems recognize their benefits.
• Roughly 70 report that they would use one or
  more features of a PHR.

63 Percent Would Track Immunizations
69 Percent Would Monitor Their Record for
Mistakes
63 Percent Would Look Up and Track Their Own
Test Results
65 Percent Would Transfer Information to New
Doctors
75 Percent Say They Would Email Their Doctor
Source Connecting for Health Collaborative. The
Personal Health Working Group Final Report.
Markle Foundation. July 1, 2003.
20
Decade of Health Information Technology
Delivering Consumer-centric and Information-Rich
Health Care

• Office of the National Coordinator for Health IT
• Established by Executive Order 13335 (April 27,
  2004)
• Responsible for realizing the Presidents vision
  of Health IT
• Widespread adoption of interoperable EHR within
  10 years
• Medical information follows the consumer
• Clinicians have complete, computerized patient
  information
• Quality initiatives measure performance and drive
  quality-based competition
• Public health and bioterrorism surveillance are
  seamlessly integrated into care

From Jodi G. Daniel, ONC
21
US DHHS 10 Year Priorities

• Goal 1 Inform Clinical Practice
• Incentivize EHR adoption
• Reduce risk of EHR investment
• Promote EHR diffusion in
• rural and underserved areas

• Goal 3 Personalize Care
• Encourage Personal Health Record (PHR) use
• Enhance informed consumer choice
• Promote use of telehealth systems

Strategic Framework

• Goal 2 Interconnect
• Clinicians
• Foster regional collaboration
• Develop a Nationwide Health
• Information Network (NHIN)
• Coordinate Federal health
• information systems

• Goal 4 Improve Population Health
• Unify PH surveillance architectures
• Streamline quality and health status monitoring
• Accelerate research and dissemination of evidence
  into practice

From Jodi G. Daniel, ONC
22
From http//www.hhs.gov/healthit/documents/m200601
17/DeploymentCoordination.pdf
23
Aug. 8 2006 Stark Safe Harbor

• Stark Act exception rules to permit donations of
  electronic prescribing and EMR technology
• Such donations must include interoperability
• Issued by HHS CMS and OIG
• May be superceded by legislation

24
Executive Order Aug. 22, 2006

• Federal health care programs (excl. Medicaid) use
  interoperability standards in own systems
• Federal contractors ordered to use
  interoperability standards
• Transparency of agencies and contractors in
  quality measurements reporting
• Transparency in prices
• Implement quality efficiency improvement
  including pay for performance

25
Meanwhile, back in Wisconsin
26
eHealth Board Work Group Activities DRAFT (6/15)
Stage 1 Setting Priorities (June-July)
Stage 3 Drafting the Plan (Oct.-Nov.)
Stage 2 Finding Solutions (Aug.-Sept.)

• Consumer Interests
• Identify any privacy guards and legislative
  changes necessary to support plan
• Develop use cases

• Consumer Interests
• Identify consumer HIE / HIT priorities
• Recommend policies for data use and treatment of
  sensitive information

Updated Draft of Wisconsin eHealth Action Plan to
eHealth Board
Workgroup review draft Action Plan Staff adjust
as necessary

• Work groups review and assess proposed technical
  solutions
• Consumer Interests
• Privacy and security concerns
• Patient Care Workflow feasibility
• Finance Financial Feasibility
• Governance Political feasibility
• Information Exchange adjusts solutions if
  necessary

Overall project priorities and structure needs
identified. Chairs present progress to eHealth
Board. eHealth Board approves program and
fiscal priorities for further activity (?) Staff
begin drafting Action plan for work group
review

• Information Exchange
• Assess feasibility of priorities identified by
  Consumer Interests Patient Care.
• Propose technical solutions for priority areas.

• Patient Care
• Develop strategies to increase use of HIE/HIT in
  Wisconsin
• Develop use cases

• Information Exchange
• Develop short term strategies to share health
  information
• Develop technical requirements

• Patient Care
• Identify patient care HIE / HIT priorities
• Assess Wisconsins use of HIE/HIT

• Finance
• Refine cost estimates
• Recommend funding strategy

• Finance WG
• Identify criteria for ROI/low hanging fruit
• Identify potential and existing funding sources

• Governance
• Recommend principles for governance
• Create communication plan

Assumptions (1) Each work group engages
appropriate stakeholders in prioritization and
decision-making efforts (2) Chair
communication, staff communication, and regular
updates link the activities of one work group to
another
27
What Are HIT versus HIE?
Health Information Exchange
Information mgmt. inside organization, e.g. EMR,
LIS, CPOE
Information exchanged between organizations
28
HIE HIT Perspectives
Health Information Exchange
Health Information Technology
Health Information Exchange (HIE) is the
mobilization of healthcare information
electronically across organizations within a
region or community.  HIE 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 HIE is to
facilitate access to and retrieval of clinical
data to provide safer, more timely, efficient,
effective, equitable, patient-centered care.
(Source eHealth Initiative) HIE utilities
provide the technology, standards, and
organization structure that enable physicians and
other health care providers to securely exchange
and access patient information gathered from
multiple service sites.
Health Information Technology (HIT) is broadly
defined as the use of information and
communication technology in healthcare and
includes, but is not limited to, electronic
health records, personal health records, e-mail
communication, clinical alerts and reminders,
computerized provider order entry, computerized
decision support systems, hand-held computers,
information resources, and electronic monitoring
systems. (source Agency for Healthcare Research
and Quality)
Definition

• Includes multiple senders and receivers of data
  (many to
• many relationships)
• Typically focus on improving cross
  organizational communications and access to
  patient information
• Multiple beneficiaries and value propositions
• Shared infrastructure
• Public-private partnership
• Typically no participant can meet needs
  independently
• The whole is greater than the sum of its
  parts

Characteristics

• Typically defined, designed and
• implemented to serve the needs of an
• entity or organization

• Products may be part of the HIE

• Benefit and funding generally relate to specific
• organizations and their customers

STORING AND MANAGING INFORMATION WITHIN OR-
GANIZATION OR PARTNERS
Crib Sheet
EXCHANGING INFORMATION BEYOND ORGANIZATION AND
MAJOR PARTNERS
29
HIE and HIT Perspectives (contd)
Health Information Exchange
Health Information Technology

• Delivery of results and reports
• Ambulatory orders from physician practices
• Referrals and consults
• Secure messaging
• Historical patient record access

• Private practice EMR system
• Practice management system
• Electronic prescribing
• Laboratory system
• Hospital CPOE

Example Products/ Services
HIE SUPPORTS HIT
HIT SUPPORTS HIE

• Reduces costs of inputting information from
  outside the provider organization (eg., lab
  reports)
• Reduces interface costs
• Improves business case for HIT

• Produces electronic information for exchange
• Supports integration of exchanged information
  into routine workflow
• Supports more sophisticated decision support
  using comprehensive information from exchange

30
What Is A RHIO?Regional Health Information
Organization

• Non-Profit - Public / Private Electronic Health
  Record Data Exchange
• Clinical Records Shared (Across Provider Systems)
  to Facilitate Care

RHIOs National Health Information Network
(NHIN) Building Blocks
31
What is a Medical Trading Area?
32
The Road Map

• Governor Doyle has asked the eHealth Board to
  identify
• existing eHealth resources including funding to
  support the development of a statewide eHealth
  information infrastructure
• technology options
• options for serving consumer health information
  needs
• how best to insure privacy and security in
  electronic health information exchange
• how to facilitate statewide adoption of EHR
  standards to enable statewide and national
  exchange
• how best to create organizational and governance
  structures for a statewide eHealth information
  infrastructure

33
Some draft ideas

• Encourage regional exchanges supported by
  statewide
• Standards
• Incentives
• Policy
• Infrastructure
• Economies of scale

34
Regional Exchanges Can Develop

• Electronic result and document delivery
• Improved information access
• Reduced info mgmt. costs
• Improved collaboration
• Improved reporting of public health conditions
• Improved communication with and between clinical
  partners

35
Regional Exchanges Can Develop

• Patient-centric (cross-organization)
• Visit and diagnosis lists
• Med, immunization and allergy lists
• Test and result summaries
• Support
• Better care coordination
• Better disease management
• Reduced redundant costs
• Improved care quality and safety
• Early outbreak detection and disaster resource
  management

36

Problems to solve along the way
Patient access tools
(With interfaces) data available for
EMRs, quality safety management
Automated mandated PH reporting
External data integration into EMR decision
support
Advanced confidentiality security
TRUST COMPLEXITY
Community-level decision support
Advanced provider patient consent
Patient-Centric Summary
Federated or centralized data-sharing infrastructu
re
Data normal- ization
Master patient record locator
Data sharing agreements
Low-level provider patient consent issues
Data quality management
User directory, authorization, authentication
Result documents delivery
Moderate confidentiality security issues
Fax or Internet access
CHEAPER, FASTER COMMUNICATION EASIER
COLLABORATION, PUBLIC HEALTH REPORTING
LESS REDUNDANT CARE SAFETY, EFFICACY, COST
ALERTS PT. TOOLS
37
Sample Recommendations

• Vendor agnostic
• Use emerging national standards for
  interoperability
• Enable patient access and management of personal
  health information
• Incentivize, aid HIT implementation
• Reduce restrictions on data exchange between
  treating clinicians

38
Sample Recommendations

• Enable public health-oriented decision support
• Patient-entered registration module
• Distribute costs and benefits among stakeholders
• Avoid rip replace
• Maintain existing data ownership

39
Inventory of HIT/HIE in Wisconsin

• The Governors Executive Order requires an annual
  assessment of the adoption of health information
  technology by Wisconsin healthcare providers
• Ambulatory survey
• MetaStar and Seth Foldy collaborating
• Survey of ambulatory practices, EDs, Outpatient
  Clinic EMR use
• To be repeated annually, comparable to national
  statistics
• Inpatient survey
• Rural Wisconsin Health Cooperative and Gunderson
  Lutheran and Seth Foldy collaborating
• Interview survey of hospital systems
• Work toward annual survey with WHA in future
• Health Information Exchange efforts inventory
• MetaStar and Seth Foldy collaborating

40
WI Health Information Exchange (WHIE)

• Governance
• Early funding
• User management pilot
• Business plan
• Draft agreements
• Projects
• Emergency Department sharing
• Results delivery
• Medication list

41
RHIO Development South Central WisconsinHealth
Information Data Exchange

• Madison Patient Safety Collaborative (MPSC)
• All Participants Use EPIC Electronic Health
  Record
• EPIC Based In Madison
• No Technology Barriers to Exchanging Data

42
Mapping Initiatives Converging Agendas

• Work planned 2007-2011 coinciding with eHealth
  Action Plan
• 20 initiatives
• Includes
• Wisconsin Healthcare Quality Collaborative
• Public Health Information Network
• WEDSS electronic disease reporting
• Child health systems
• Wisconsin Health Information Organization
• Wisconsin Immunization Registry and RECIN
• PeriData Statewide Perinatal Database
• Safety Collaboratives
• Biosense
• Region 7 EMSystem
• Wisconsin Medical Society unified credentialing
• This will be part of the eHealth Report

43
Whats next?

• The report from the eHealth Board will go to the
  Governor December 1, 2006
• Once approved, implementation will begin
• eHealth Board will sponsor an Implementation
  Summit at the Fluno Center in March 2007
• Privacy Project will continue through March 2007
  to complete all of its work.
• How to track and influence developments
• Participate in the HISPC work groups
• Communicate your interests to the work group
  leaders
• Monitor developments and react to proposals via
  the eHealth board web site
• http//ehealthboard.dhfs.wisconsin,gov

44
Thank you!

• Seth Foldy sfoldy_at_sbcglobal.net
• Susan Wood woodss_at_dhfs.state.wi.us
• Collaborators UW Population Health Institute,
  MetaStar
• Funders Wi DHFS, US-DHHS/ONC, Robert Wood
  Johnson Foundation, CDC, HRSA