Transcript Governance Meeting #1

Health Information Exchange 101
Problem, Definitions, Value, Policy
David C. Kendrick, MD, MPH
Asst. Provost for Strategic Planning
OUHSC
National perspective
• At >17% 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
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
2009 State of the State’s Health Summary
Oklahoma is the only state where the death
rate has gotten worse…..
1,050
Some Factors
1,000
1.
950
Age-adjusted
Death Rates
2.
3.
900
Tulsa
US
4.
5.
850
800
1980
1985
1990
1995
Past 25 Years
2000
2005
Economic downturn
healthy people and jobs
left Oklahoma
Poverty remained
Heart Disease –
(Diabetes)
Cancer
Access to Care
2007 COMMONWEALTH FUND Report
State Scorecard Summary of Health System Performance
OK
What WE CAN’T Do
• “Grow” more doctors quickly
• Create new hospitals overnight
• Force patients to:
–Exercise
–Stop smoking
–Lose weight
What We Can Do
Leverage Technology
• Complex populations
• Limited Resources:
–Create a lean healthcare system
–Improve Care Coordination
–Business case for:
• Funding
• Efficiency
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
Physician Organization in Relation to
Quality and Efficiency of Care
The 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
Where Will there be
Savings?
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
Current Situation
Hospitals
(inpt)
Rx
ER/UC
Payers
Demographics
Medical claims
Pharmacy claims
Case mgmt records
Patient
Safety Net
Clinics and
community
agencies
Imaging
Doctor offices
EHR
Claims
Rx
Case mgmt
Community
outreach
Other
PCPs
Labs
Manual connection (mail, fax)
Electronic connection
Specialists
Ancillary care
PT/OT/Aud/Diet
Public
Health
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
Definitions: EMR vs. HIE vs. HIO vs. CCC
HIE
Health Information Organization
RHIO
Greatest Value Your Data is Local (CCC)
Business Model - Self Supporting
Stakeholders/Users
Quality, Safety & Efficient Delivery
Govern, Sets Rules
Statewide Network of Networks
Disaster
Bioterrorism
National (NHIN)
Public Health
Scale State-wide: A Network of Networks
•Local governance
•Common technology
Anatomy of a HIE
Patient Portal
Electronic Master
Patient Index
Physician Portal
Health
Information
Exchange
Medical
Education
Population
Care Analytics
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
Organizing the Concepts
• What is the relationship between Health
Information Exchanges and the Patient
Centered Medical Home?
Reimbursement
Model
Patient
Centered
Medical
HealthHome
Information
Exchange
Health Information
Exchange
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
Medical Home
Goals
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
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
Motivation
• Clinicians have incomplete knowledge of their
patients
– Relevant patient data not available in 81% of
ambulatory visits
– 18% of medical errors that lead to ADEs due to
missing patient information.
Tang 1994
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?
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
HIE Value Construct
Public Health
Agencies
Payers
Pharmacies
Providers
Hospitals
Clinical
Laboratories
Radiology
Centers
Other Providers
HIE Value Construct
Avoided ADEs, drug
utilization savings,
automated
transaction sets
Public Health
Agencies
Payers
Avoided redundant
tests, Electronic test
ordering and results
delivery
Pharmacies
Providers
Hospitals
Clinical
Laboratories
Electronic referrals,
consultation letter
delivery, chart
requests
Electronic
submission of
reportable
conditions and vital
statistics
Electronic Rx, refills,
interaction checking,
adherence data
Radiology
Centers
Other Providers
Avoided redundant
imaging, Electronic
imaging ordering
and results delivery
What about funding?
• One time:
– ARRA stimulus dollars
– Other grants
• Ongoing:
– Business model must be developed
– ROI by stakeholder will drive the business model
ARRA Stimulus Dollars
Washington,
D.C.
Earmarks
Federal Agency
Grants
State
distributions
ONCHIT
Heath Dept
AHRQ
DHS
OHCA
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
From the final ARRA:
In 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
CMS really wants EMR
and HIE adoption . . .
†
*Assume N=1,500 MDs, DOs, PAs, and NPs and 7 hospitals see Medicare patients
†Penalties for non-adoption not yet elaborated, but assume mirror bonuses
From the final ARRA:
Regional 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
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