ERIC%20Focus-On%20Call

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Leveraging Health Information Technology and
Emerging Health Information Networksto Support
Healthcare Purchaser Goals For Quality, Safety
and Efficiency The ERISA Industry
CommitteeFocus on Call130 p.m. 300 p.m.
ESTFebruary 17, 2005
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Overview of Discussion

• Framing the issues for employers and healthcare
  purchasers
• An overview of emerging initiatives on health
  information technology
• Drilling down an overview of emerging
  employer-led initiatives
• Drilling down an overview of one states
  strategy for improving quality and efficiency
  through health information exchange Indiana
• Pulling it all together what does this mean for
  employers and healthcare purchasers?

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Framing the Issues for Employers and Healthcare
Purchasers

• Edwina Rogers
• Vice President, Health Policy
• ERIC

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Healthcare Challenges

• Rising healthcare costs
• Aging population will exacerbate the problem
• Quality and safety issues abound
• Fragmented healthcare system makes it difficult
  to stimulate and sustain widespread change
• Number of uninsured

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Use of HIT by physicians and hospitals saves
lives money

• Adverse drug events in 5 to 18 of ambulatory
  patients
• 190,000 hospitalizations per year result from
  ADEs
• American adults, on average, receive only 54.9
  of the healthcare recommended for their conditions

• Estimated 770,000 people are injured each year
  due to adverse drug events.
• Translation of medical research into practice is
  slowaverage of 17 years

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Why Health Information Exchange?

• U.S. healthcare system highly fragmented.data is
  stored--often in paper formsin silos, across
  hospitals, labs, physician offices, pharmacies,
  and insurers
• Physicians spend 20 - 30 of their time searching
  for information10 - 81 of the time, physicians
  dont find information they need in patient
  record
• 20 of lab and radiology tests are performed
  because prior results were unavailable and 1 in 7
  hospitalizations occur
• Physicians forced to deliver care without
  complete knowledge of the patient

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Value of Health Information Exchange

• According to Center for Information Technology
  Leadership, nationwide adoption of standardized
  healthcare information exchange among healthcare
  IT systems would save U.S. healthcare system
  337B over 10 year implementation period and
  78B/year thereafter
• Standardized, encoded, electronic HIE would
  provide net benefits to stakeholders
• Providers - 33B
• Payers - 22B
• Labs - 13B
• Radiology Centers - 8B
• Pharmacies 1B

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System has been slow to adopt HIT

• Less than 15 of physicians use IT
• Less than 10 of hospitals use CPOE
• Key barriers to date
• Standards
• Business case
• Leadership

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Our Speakers

• Janet Marchibroda, Chief Executive Officer,
  eHealth Initiative
• Dale Whitney, Corporate Health and Welfare
  Manager, United Parcel Service
• J. Marc Overhage, MD, PhD, Chief Executive
  Officer, Indiana Health Information Exchange

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Whats Happening? An Overview of Emerging
Initiatives on Health Information Technology and
Exchange

• Janet Marchibroda
• Chief Executive Officer
• eHealth Initiative

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We Now Have the Tools to Get There

• Standardsthey are ready
• Business caseperformance improvement and
  efficiency gains, over timeneed to translate to
  incentives models for implementation and
  sustainability
• Leadershipnational and regional leaders
  mobilizing across the country for HIT and health
  information exchange

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Administration Leadership

• President George W. Bush announces in April 2004
  plan for most Americans to have an electronic
  health record125 million in FY 06 budget
• May 2004 appointment of sub-cabinet level
  position National Health Information Technology
  Coordinator David J. Brailer, MD, PhD
• In February 2, 2005 State of the Union Address
  President Bush declares continuing support for IT
  to improve healthcare, by asking Congress to move
  forward on improved health information
  technology to prevent medical errors and needless
  costs.

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U.S. Agency for Healthcare Research and Quality

• 139 million in grants and contracts for HIT
• Over 100 grants to support HIT 38 states with
  special focus on small and rural hospitals and
  communities - 96 million over three years
• Five-year contracts to five states to help
  develop statewide networks CO, IN, RI, TN, UT -
  25 million over five years
• National HIT Resource Center collaboration led
  by NORC and including eHealth Initiative, CITL,
  Regenstrief Institute/Indiana University,
  Vanderbilt and CSC - 18.5 million over five years

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Centers for Medicare and Medicaid Services

• Section 649 Pay for Performance Demonstration
  Programs link payment to better outcomes and
  use of HIT
• Doctors Office Quality Information Technology
  Program (DOQ-IT) technical assistance for HIT
  in small physician practices
• Chronic Care Demonstration Program linking
  payment to better outcomes IT a critical
  component

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Momentum in Congress

• Several legislative vehicles include support for
  health information technology
• Medicare Modernization Act
• Health Care Quality, Modernization, Cost
  Reduction and Quality Improvement Act (S 2421)
  Sen. Kennedy
• National Health Information Technology Adoption
  Act (S. 2710) Sen. Gregg
• Information Technology for Health Care Quality
  Act (S 2907) Sen. Dodd

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Momentum in Congress

• Several legislative vehicles include support for
  health information technology
• More coordination and leadership within
  government
• Federal adoption of standards
• Revolving loan funds, loan guarantees, grants to
  eligible entities for the acquisition,
  development of qualified informatics systems
• Demonstration programs for linking payment to
  HIT, usage of HIT for chronic care management

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Private Sector Leadership

• eHealth Initiative Connecting Communities Program
  in cooperation with HRSA provides funding and
  support for 9 communities involved in health
  information exchange
• Connecting for Health releases Roadmap for
  Electronic Connectivity in July 2004 and Common
  RFI Response for Health Information Environment
  Collaborative Response from 13 organizations
• Over 50 programs in which purchasers and payers
  are providing incentives for HIT key themes
  emerging

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eHealth Initiative Connecting Communities for
Better Health

• 11 million program conducted in cooperation with
  HRSA to accelerate state, regional and
  community-based health information exchange
  collaboratives
• Launched Connecting Communities for Better Health
  Resource Center serving state, regional and
  community-based health information exchange
  initiatives
• Provided seed funding to regionally and
  community-based multi-stakeholder health
  information exchange collaboratives

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eHealth Initiative Connecting Communities for
Better Health

• Developing inventory of regional health
  information exchange initiatives
• Built coalition of over 100 communities launching
  health information exchange initiatives to
  provide a common voice to drive change
• Launched State HIT Policy Summit Initiative,
  designed to bring together state policy-makers,
  healthcare and business leaders to accelerate HIT
  and health information exchange 2 states
  launched and others in planning stages

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Communities Being Funded

• Connecting Colorado (Denver, CO)
• Indiana Health Information Exchange
  (Indianapolis, IN)
• MA-SHARE MedsInfo e-Prescribing Initiative
  (Waltham, MA)
• MD/DC Collaborative for Healthcare Information
  Technology (Baltimore/Washington Metro Area)
• Santa Barbara County Care Data Exchange (Santa
  Barbara, CA)
• Taconic Health Information Network and Community
  (Fishkill, NY)
• Tri-Cities TN-VA Care Data Exchange (Kingsport,
  TN)
• Whatcom County e-Prescribing Project (Bellingham,
  WA)
• Wisconsin Health Information Exchange (National
  Institute for Medical Informatics Midwest)
  (Milwaukee, WI)

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Health Information Initiatives Emerging in Nearly
Every State

• Alaska
• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• District of Columbia
• Florida
• Georgia
• Hawaii
• Idaho
• Illinois
• Indiana
• Kentucky
• Maine
• Maryland
• Massachusetts

• Michigan
• Minnesota
• New Mexico
• New York
• North Carolina
• Ohio
• Oregon
• Pennsylvania
• Rhode Island
• Tennessee
• Utah
• Vermont
• Virginia
• Washington
• West Virginia
• Wisconsin

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Connecting CommunitiesWhat Are They Doing?

1. Results delivery to clinicians office
2. Reminders
3. Consultations
4. Patient-provider communication
5. Enrollment checking eligibility
6. Disease management / reminders
7. Public health surveillance
8. Quality performance reporting
9. Others E-prescribing, Reimbursement, Billing,
   EHR

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What Stage Are They In?
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5

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

• 27
• Getting organized
• Defining shared vision, goals, objectives
• Identifying funding sources
• Setting up legal governance structures

• 25
• Transferring vision, goals, objectives to
  tactics and business plan
• Defining needs and requirements
• Securing funding

• 16
• Well under-way with implementation technical,
  financial, and legal

• 9
• Fully operational health information organization
  
• Transmitting data that is being used by
  healthcare stakeholders
• Sustainable business model

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How Employers Can Help

• Engage in health information exchange initiatives
  in your markets
• Build in contracting requirements with HIT that
  use standards to promote connectivity and
  interoperability
• Leverage data from health information networks to
  support quality improvement and reporting and
  consumer-directed efforts

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Connecting for Health

• Public-Private Collaborative representing
  multiple stakeholders that are driving
  interoperability and connectivity
• Developed Roadmap for Electronic Connectivity
  released in July 2004
• Regional Prototype initiative is developing
  public domain standards guides for
• Accurately linking patient data from disparate
  sources without patient ID
• Provider identification
• Authentication and authorization approach
• Decentralized, federated architectural model

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Connecting for Health

• Coordinated collaborative response from 14
  organizations in response to RFI for National
  Health Information Network
• Establishing a health information environment
  that facilitates and structures connectivity -
  through encouraging adherence to precisely
  defined, uniform technical standards, common
  policies, and common methods, known as the
  "Common Framework".
• Connectivity built on the Internet and other
  existing networks.
• The "build" of the new information environment
  happens incrementally, through accretion of
  sub-networks - many of which already exist but
  need to have the ability to be linked together to
  provide maximum benefits to patient care.
• The environment is private, secure, and is built
  on the premise of patient control and
  authorization.

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Connecting for Health

• Coordinated collaborative response from 14
  organizations in response to RFI for National
  Health Information Network
• Personal health information remains with health
  care providers, patients and other trusted
  partners - and is accessed and exchanged only
  when it is needed, with proper authorizations and
  security.
• Create a national, public interest Standards and
  Policy Entity (SPE) that recommends the standards
  and policies that comprise the Common Framework
  and ongoing requirements for interoperability.
• Leverage existing open, non-proprietary standards
  to enable the exchange of health information.
• Accurate patient identification based on uniform
  and standardized methodologies but without a new,
  mandated, national, unique health identifier.
• Record Locator Services (RLS) are created and
  controlled regionally or within other
  sub-networks, to help authorized parties learn
  where authorized and pertinent information is
  housed

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eHealth Initiative Who We Are

• Mission Independent, non-profit,
  multi-stakeholder consortium whose mission is to
  improve the quality, safety, and efficiency of
  healthcare through information and information
  technology
• Strategy
• Identify and develop consensus strategies to
  overcome barriers to the use of HIT and health
  information exchange to drive better healthcare
  for patients financial, technical,
  organizational and clinical
• Provide seed funding and technical support to
  those engaged in HIT and health information
  exchangeparticular focus on practicing
  clinicians and regional health information
  organizations

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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

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eHealth Initiative Focus

• Align incentives and promote public and private
  sector investment in improving Americas
  healthcare through IT and an electronic health
  information infrastructure
• Develop the field to enable more widespread and
  effective implementation of HIT and an electronic
  health information infrastructure particular
  focus on community-based health exchanges and
  clinicians
• Continue to drive adoption of standards to
  promote an interoperable, interconnected
  healthcare system

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Overview of Market Experiments Promoting Quality
and IT

• eHealth Initiative Goal Achieve
  multi-stakeholder consensus on a set of policy
  options for providing incentives for HIT adoption
  and health information exchange
• Reviewed 25 market experiments
• Differential annual inflation updates
• Bonus payments
• Payment for virtual encounters or use of IT
• Reduced beneficiary out-of-pocket costs
• Grants and demonstration projects
• Reviewed results of initiatives and research

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Common Themes Physician-Directed Programs

• Rewards for acquisition less effectivemore focus
  on use
• Phasing out rewards for acquisition and use and
  phasing in rewards for performance, over time
• Small pay-outs have had little impact some
  movement to increase pay-outs given initial
  lukewarm response
• Amounts offered should be meaningful various
  reports say 10,000 to 24,000 per year
• Sponsor(s) of program should represent a
  meaningful proportion of the provider's business

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Common Themes Physician-Directed Programs

• Reward clinical applications that are
  interoperable, and that use standardswithout
  transmission of clinical data to applications at
  the point of care, one does not derive full value
  of the system
• Recognized need to align pay for performance
  initiatives to healthcare IT infrastructure
  needed to support performance improvement and
  reporting
• Great interest in adding chronic care management
  payment model
• Small grants for large purchases have had little
  impact
• Giveaway programs have had little impact e.g.
  free is not cheap enough

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Performance Improvement Programs Hindered by Lack
of HIT

• Performance measures that can be easily collected
  directly related to the level of HIT systems
  present
• For the most part, currently only claims data
  (administrative) is collected electronically for
  these programslimits type and value of measures
• Clinical data can provide more meaningful
  performance measures
• Collection of clinical data for performance
  measurement purposes is difficult and
  labor-intensive (requires chart pulls) without
  the introduction of clinical applications and
  health information exchange
• Use of clinical applications also enables quality
  improvement where it matters mostat the point of
  care

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An Overview of Employer and Purchaser-Led
Programs Promoting Quality and Efficiency through
HIT

• Dale Whitney,
• Corporate Health and Welfare Manager
• United Parcel Service

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Coordination of Efforts
CMSSec 649DOQ-IT
NCQA Pilots
Survey v 3.0
JCAHO ORYX
Mercer
Lewin
Regence BCBS
BTE(Physicians)
Leapfrog(Hospitals)
Leapfrog-BTE White Paper
NCQA PPSI
Efficiency Criteria
Effectiveness Criteria
Top Performing Providers
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The further we deviate from a common set of
measures, the less effective we are
A-CAHPS/ACES
NQF Endorsed Measures
Leapfrog Programs
Ambulatory Measures
NCQA Provider Recognition ProgramsDPRPHSRP PPC
(HIT)
CMS-AHA/National Voluntary Hospital
ReportingInitiative/HQA
H-CAHPS
Other AHRQ
Reward Program
Submitted to NQF
2004 Survey
AMA CMS NCQA
HRPA
HRPA
CFP
CFP
Other HEDIS Indicators
Other JCAHO
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Bridges to Excellence

• Purpose create programs to align incentives
  around higher quality
• Three principles
• Reengineering care processes to reduce mistakes
  will require investments, for which purchasers
  should create incentives
• Significant reductions in defects will reduce
  waste and inefficiencies in healthcare
• Increased accountability and quality investments
  will be encouraged by release of comparative
  performance data, delivered to consumers in a
  compelling way

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Bridges to Excellence
Cincinnati, OH /Louisville, KY Boston, MA Albany /Schenectady, NY
Launch Date June 2003 February 2004 May 2004
Program(s) DCL DCL, POL POL, DCL, CCL
Employers GE, Ford, UPS, PG, Humana, CCHMC, City of Cincinnati GE, Raytheon, Verizon, (IBM, AZ) GE, Hannaford Bros, Verizon, Golub
Plans Humana, Aetna, UHC, Anthem, BCBS Tufts, Harvard, UHC, BCBS MVP, CDPHP, UHC
of Covered Lives 200,000(7,000 Diabetes) 85,000(3,500 Diabetes) 45,000(2,000 Diabetes 1,000 Cardiac)
Recognized Physicians 70 500 40
Rewards Paid 90,000 740,000 7,000
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Bridges to Excellence

• National Business Coalition on Health has
  selected four member organizations as
  demonstration sites
• Employers Health Coalition, Fort Smith, AK
• Tri-State Health Care Coalition, Quincy, IL
• Heartland Healthcare Coalition, Peoria, IL
• Colorado Business Group on Health, Denver, CO

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Leapfrogs Hospital Survey Objectives

• Improve the quality of care delivered to patients
• Address criticism by hospitals that our measures
  were too limited
• Address request by rural hospitals for
  recognition by employers
• Address needs of employers for more measures for
  IR programs
• Use only nationally-endorsed measures

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Leapfrogs Fourth Leap NQF Safe Practices

• Improve the quality of care delivered to patients
• Address criticism by hospitals that our measures
  were too limited
• Address request by rural hospitals for
  recognition by employers
• Address needs of employers for more measures for
  IR programs
• Use only nationally-endorsed measures

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An Overview of One States Experience Indiana

• J. Marc Overhage, MD, PhD
• Chief Executive Officer
• Indiana Health Information Exchange

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Indianapolis, Indiana

• 1.5 million population base
• 12th largest city in U.S.A.
• Home to Indianas only medical school
• State Department of Health
• Referral center for entire state (7 million)

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Pilot ED visit charges


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Indiana Network for Patient Care (INPC)

• A local health information infrastructure (LHII)
• We serve as the Data Switzerland for the city
  of Indianapolis and the state
• Up and running for more than 9 years
• Started with a modest goal (Emergency Care)
• Extended by adding projects one step at a time
• Focus on clinical and public health issues,
  particularly electronic laboratory reporting

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Clarian MRF
St. Vincent MRF
Global Patient Index
Public Health
Global Patient Index
Concept Dictionary
Public Health MRF
Wishard MRF
Concept Dictionary
Electronic Medical Record System
Community MRF
IUMG MRF
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INPC Contents

• 1.3 million patients, 5 million registration
  events
• 700 million coded results
• 24 million orders
• 12 million dictated reports
• 8.8 million radiology reports
• 25 million prescriptions
• 480,000 EKG tracings
• 45 million radiology images
• 13 million document images

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RHII
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INPC Data Access
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Patient Name
Details
Report
Image
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InfoButtons
Links to knowledge sources
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Specialty Abstracts with Merged Data
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HIEI Taxonomy
Level Description Examples
1 Non-electronic data Mail, phone
2 Machine-transportable data PC-based and manual fax, secure e-mail of scanned documents
3 Machine-organizable data Secure e-mail of free text or incompatible/proprietary file formats, HL-7 message
4 Machine-interpretable data Automated entry of LOINC results from an external lab into a primary care providers electronic health record
No PC/information technology
Fax/Email
Structured messages, non-standard content/data
Structured messages, standardized content/data
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Central Indiana at Level 4
Total value 560M per year
86M
Radiology
Payer
Other Provider
N/A
321M
Provider
166M
353M
696M
Pharmacy
Laboratory
-23M
281M
14M
138M
-56M
Public Health
1M
Provider Net 244M per year
C!TL economic model
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Achieving full value requires structured data
Percent
76
5
19
Capture electronically
Connect interface
Standardize and store data
C!TL, BCG calculations
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Bringing it All Together

• Janet Marchibroda
• Chief Executive Officer
• eHealth Initiative

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Working Together to

• Set National Standards and Principles
• Performance Measures
• Health Information Technology
• Financing and Incentives
• Align National Standards and Principles with
  Regional and Local Market Experiments
• eHI Connecting Communities for Better Health
  Program, AHRQ HIT Grant and Other Emerging Grant
  Programs
• Bridges to Excellence and other Incentives
  Programs
• Rapidly emerging initiatives across markets
  across the country

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Working Together to

• Leverage National Vehicles for Driving Change
• Common RFI requirements and contract language
  such as those developed by the National Business
  Coalition on Health (eValue8)
• Expectations related to performance measurement
  emerging from public and private sector
  purchasers and payers

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Employer Strategy ABCs

• A Align Incentives
• B Begin educating employees and policy-makers
• C Contract for connectivity

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Parallel Pathways to Quality Healthcare A
Framework

• There is a timely and critical opportunity to
  strengthen efforts related to healthcare quality
  by providing the HIT infrastructure not only for
  collecting and reporting data, but more
  importantly, for supporting clinical decisions
  made at the point of care

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Parallel Pathways to Quality
Phase I Phase II Phase III
QUALITY EXPECTATIONS Report common set of consensus-based measures that use admin and some clinical data Expand reporting to include measures that use clinical data (contained in EHR) Achieve certain level of outcomes
PHYSICIAN PRACTICE HIT CAPABILITIES Use EHR Use EHR that is connected to other data sources Robust environment for clinical decision support and chronic care mgmt
HEALTH INFORMATION CAPABILITIES Organize and launch health information exchange Delivering data to physicians, payers and purchasers Sustainable model
INCENTIVES Reward HIT use Reward submission of measures Reward outcomes
VALUE TO PURCHASERS Communicate expectations and incremental roadmap Immediate gains in quality Reduce cost, improve timeliness and quality of reporting Significant gains in quality and efficiency Full migration to payment on outcomes Flexible infrastructure to respond to changes
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Parallel Pathways to Quality

• Align strategy across three key areas
• Quality improvement/measurement
• HIT capabilities in physician officeacross the
  community
• Incentives that promote both quality and (in the
  early stages) the processes and tools to get there

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Value to Purchasers and Payers

• Phase I
• Communicate expectations and incremental roadmap
  for getting to payment for outcomes
• Lay the foundation for a robust infrastructure to
  support higher quality, more efficient healthcare
• Achieve immediate improvements in quality and
  some cost savings
• Phase II
• Reduce cost and improve timeliness of performance
  reporting
• Improve ability to identify and target areas in
  need of focus and improvement

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Value to Purchasers and Payers

• Phase II (continued)
• Increase types and level of data to support
  improvements
• Considerable improvements in quality, safety and
  efficiency
• Phase III
• Full migration to payment based on outcomes
• Flexible HIT infrastructure that supports
  changing expectations and science

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Questions and Answers
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Speaker Contacts

• Janet M. Marchibroda
• Chief Executive Officer, eHealth Initiative
• 1500 K Street, N.W., Suite 900, Washington, D.C.
  20005
• 202.624.3263
• Janet.marchibroda_at_ehealthinitiative.org
• J. Marc Overhage, MD, PhD
• Chief Executive Officer, Indiana Health
  Information Exchange
• Regenstrief Institute, Inc., Indiana University
  School of Medicine
• 1050 Wishard Blvd, Indianapolis, IN 46202
• 317-630-8685
• moverhage_at_regenstrief.org
• Dale Whitney
• Vice President, Benefits, United Parcel Service
• dwhitney_at_ups.com