Redwood Health Information Collaborative 2-18-09 Session Overview Health Information Exchange: Why? What? Who? How? Challenges Along the Way Results – Making a Difference.
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Redwood Health Information Collaborative 2-18-09 Session Overview Health Information Exchange: Why? What? Who? How? Challenges Along the Way Results – Making a Difference Acronyms to Enjoy RHIO = HIE = NHIN: Regional Health Information Organization governance model / funding mechanism Health Information Exchange clinical / consumer / claims / public health NHIE = National Health Information Exchange (standardized interface, certified technologies Nationwide Health Information Network “network of networks” EHR + PHR + HIE + PHIN + ??? 750,000 patients in multi-state region 2/3 of patients live in Tennessee Hospitals: 18 1/3 live in Virginia Physicians: 1200 5% in other states Public Health: 7 regional, 2 state Payor: 25% Medicare 20% Medicaid 18% uninsured 2-20% commercial Small – Med Employers: Eastman Chemical 7500 ETSU – 6500 Hospitals – 5500, 5400 CareSpark’s Mission Regional Population Has High Disparities of: • Diabetes • Lung Disease • Cardiovascular Disease • Cancer • Hypertension • Premature Mortality CareSpark region has $2,400 higher per capita patient care costs than other regions of the country CareSpark’s mission is to improve the health of people in NE Tennessee and SW Virginia through the collaborative use of health information Regional Health Status Trend are getting worse Drug Caused Death Rates 2002 - 2003 P u ne Fl H f /u D /C yo 120 p 65 o d 5y ll e >6 ro 0 l am 13 ex ,> e, ax in e nt ey ho 5 ly 9. al I I n M M ee C < l< M ho co ov M um cc TN va H M cr nu 1c D A C gb M D D H lS p r n ea ee lp cr 30 an ta <1 1c ec A or gb ol LC ho lS C ho I m M el ra Sm og p ns Percent Goals Met 20 H C LD C m AP am ou ck C lo b -b P M B To Quality Measures For VA Compared With Best Practices VA Best Other 100 80 60 40 17 Measures 2002 Data 0 Value is Derived from Better Medical Decisions Treatment Diagnostic Redundancy Patient Data Errors Electronic Medical Record Clinical Data Sharing Decision Support Source: SBCCDE, CITL, Gordian Project analysis What Will CareSpark Do? Outcomes Improvement •Individual health outcomes Population health status Decision Support (real-time, at point of care, across all systems) Patient-specific info (Rx, Dx, Hx) Clinical Best Practices PHR / EMR / CCR Cost-Efficient Use of Resources Reduced duplication, errors, administrative costs CareSpark’s Strategic Outcomes Population Health Clinical Premature Mortality Adult Diabetics, Rx filled, vision / foot, HBA1C<7 New Diabetes Cases Lipid Panel Flu Vaccines for 65+ ER Visits for Health Attack Post- MI followup LDL < 100 Pneumo Vax for ages 65+, <2 Stroke Therapy Cancer Screenings (PAP, Mammogram, colorectal) Financial Savings -- ROI • • • • Patient Clinician Facilities Purchaser (health plan, employer, taxpayer, individual) Awareness & Adoption of Best Practices Community Population Health Informaticist Public Health Individual (patient / consumer) Clinician Purchaser (Payors / employers) Community-Wide Collaboration Active, representative participation, including • Employers: Eastman Chemical Company, CGI, BAE Systems, City of Kingsport, • Payors: Blue Cross Blue Shield of Tennessee, John Deere Health / United Healthcare, Cariten PHP, Highlands Wellmont Health Network • Hospitals: Mountain States Health Alliance, Wellmont Health System, Johnston Memorial Hospital, Quillen V.A. Medical Center, Laughlin Memorial • Physician Practices: Holston Medical Group, Highlands Physicians, Health Alliance PHO, Cardiovascular Associates, ETSU University Physicians, Clinch River Health Services, Frontier Health, Southwest Virginia Community Care Network, Blue Ridge NeuroScience, C-Health • Health Education: East TN State University School of Medicine / College of Nursing/ College of Public and Allied Health, University of Appalachia College of Pharmacy, University of Virginia • Public Health: Sullivan and Northeast Regional Health Departments in TN, Cumberland Plateau and Lenowisco Health Districts in VA, Tennessee Department of Health, Virginia Department of Health and Human Resources • Community Non-Profits: Kingsport Tomorrow, United Way of Kingsport, Rotary Club of Kingsport, Kingsport Chamber of Commerce, Bristol Chamber of Commerce, NETWORKS Sullivan County Partnership • Patient Advocacy Groups: American Cancer Society, Minority Health Coalition, Mountain Empire Older Citizens • Local Technology Companies: Intellithought, LucentGlow, Deliberare, Holston Technology, the Creative Trust, ntara CareSpark RHIO Organizational Structure Board of Directors Nominating Health Information Control Legal Personnel Finance CareSpark Management Clinical Outcomes / Evaluation Population Health workgroup Financial Savings Workgroup Communications Technical Project Management Office Partner Partner Partner Partner Stakeholder Advisory Groups Patient Physician Public Health Facilities Audit Purchaser CareSpark Board of Directors Board Membership • Selected as individuals, not organizational rep’s • Expectation: put community good ahead of individual or organizational agenda • Self-perpetuating (nominating process, board members elect successors) • 1-3 year staggered terms, two-term maximum • Balance of leadership experience, necessary skill-sets, network contacts to achieve strategic goals, representative of stakeholder and regional demographic composition Current Members include: CIO of large health system, CEO of independent pharmacy, CEO of behavioral health provider, CEO of hospital-physician network, CFO of large insurer, Health Benefits director for large employer, President of large multi-speciality practice, CEO of community health center, Director of regional public health department, Chief of Staff for local V.A. hospital, Exec Director of regional seniors programs, VP for local university / rural health education CareSpark’s Core Strategies Provide patient information 1. and decision support on demand at the point-of-care Align financial incentives to assure 2. fair return on investment Empower patients 3. to make healthy choices & informed decisions Provide selected 4. aggregate data for population health improvement Common Portal Tennessee State-level leadership Coordinating organization facilitates rules of engagement: • Data-sharing Agreement • Legal Framework • Standards • Interoperability • Transparency H.I.E. • Value EMR / EHR/PHR Implementation • Quality/Cost Structured Notes & Paper Records Administrative Transactions (claims…) Secure Clinical Messaging (labs, imaging, email…) ePrescribing Roll Out Broadband % of Access, Stakeholders, Automation Framework for Trust and Collaboration Virginia Health IT Framework Virginia RHIO initiatives Key Strategic Decisions 1. Enable participation by all patients and providers in region 2. Enroll patients through default Passive Enrollment (“opt-out”) with option for Active Enrollment (“opt-in”) - Passive or Active enrollment managed through Master Patient Option Preference (MPOP) and Local Patient Option Preference (LPOP) 3. Hybrid Model, combining Federated Repositories and Centralized Repository for limited clinical data - Enabling decision support, monitoring and aggregate data analysis where regionally approved 4. Data Access and Uses Patient: view content of records, view access log Provider: payment, treatment, operations Public health: required reporting and authorized queries Payers: de-identified aggregate data Research: IRB-approved studies 5. Fee-Based Revenue Model - Contracts with insurers and employers - Transaction fees for data providers (labs, hospitals, large practices) - Contributions (cash and inkind) 6. Commitment to standards (IHE / HITSP, ISO) Convergence of Data Clinical Administrative Billing & Claims PatientCentered Care Research Best Practices Personal Health Record From Patient Perspective Perceived Benefits • Convenience • Access to critical information (allergies, rare diseases) • Reduced duplication = reduced cost • ability for proxy to manage care (adults caring for elderly parents from a distance) • Advanced directives Perceived Risks • Privacy (unauthorized access or release) • Use of data (denial of care, coverage, or employment) • Identity theft • Government as “big brother” • Incorrect matching of records • Incorrect data entry The Importance of Standards Standards for data content (what are the important pieces of information necessary? Is terminology consistent?) Standards for data transmission (how is data sent?) CDA = (clinical document architecture) exchange of fixed, legally defensible document upon request CCR = (continuity of care record) assembly “on the fly” from discrete data elements in multiple systems CCD = (continuity of care document) standard document that includes common discrete data elements Standards for security (access, authorization, audit) use existing international standards from other industries Standard policies (who decides what to share, with whom and for what use? consumer-directed permissions for access to / use address issues of liability and enforcement Funding / sustainability (who benefits, so who pays?) savings accrue mostly to purchasers (insurers, employers, taxpayers, selfpay consumers) “transparency” for capital and operating costs, ROI, quality outcomes CareSpark RHIO Consortium Partners National / International: ActiveHealth AllScripts Anakam Cisco CGI Dell GE Healthcare Healthvision / Quovadx Initiate Systems Intel Misys Oracle Siemens Wellogic Local / Regional: the Creative Trust Deliberare Holston Technology Intellithought LucentGlow OnePartner State: Tennessee Virginia Federal: DHHS / ONC Market / thought leaders committed to interoperability, collaboration and results CareSpark IHE Architecture Physician Practice 1 CareSpark Data Store Portal XDS Patient Identity Source (MPI) XDS Document Registry XDS PIX Service XDS PDQ Service XDS Document Repository ATNA Audit Repository Data CT Time Service XDS Key Store Clinical Data Repository - For Public Health Improvement Transformation IHE DocSource/ DocConsumer Hospital 1 Document Repository IHE DocSource/ DocConsumer Hospital 1 Phys Portal IHE DocConsumer FILTER Public Health Department 1 Clinical Data Repository Public Health Data Mart De-Identified Data Mart IHE DocSource/ DocConsumer Additional Providers and other data participants Document Repository IHE DocSource/ DocConsumer Data Participants CareSpark XDS Data Store For Patient Care Document Repository Technical Architecture CareSpark ` Patient See Note 1. ` Https MPI Client Filters and Encryptions Provider 1 Secure & Redundant Network A Application Server Data Base Server EMPI Filters and Encriptions ` Provider 2 Internet MPI Client Filters and Encryptions Router Application Server Provider Load Balancer See Note 2. ` Provider using ASP App Firewall MPI Client Filters and Encryption Data Base Server See Note 3 CareSpark Secure & Redundant Network B Application Server EMPI Filters and Encriptions ` Small Doctors Office Active Health Note 1: Patient access will be via the internet thorough Https Protocol (SSL) Data Base Server Data Base Server Note 2: Although not pictured, the Internet connectivity, the Application Firewall and the Load Balancer will all be redundant, to avoid a single point of failure. NHIN Note 3: All non-patient connections to the Internet are secured connections, via SSL. Nationwide Health Information Network: “network of networks” NHIN Prototype Demonstration 2006-07 design for exchange between NHIN Trial Implementation 2008 * Core Services: CareSpark, West Virginia, Kentucky providers, Consumer permissions federal agencies Security exchange Standardized interfaces Summary medical record * Medication Management eRx, med history, decision support * Consumer Empowerment personal health record, registration and medication history CareSpark NHIN Architecture CareSpark (Hosted at CGI) Anakam Web Server Two Factor Anakam DB Server Portal Wellogic MPOP Web Server ESB PHR ActiveHealth Cloverleaf Oracle Two Factor Anakam Data Transformation Custom Interfaces MPOP Consent SOAP/HTTP Protocol XDS Document Repository XDS Rep Service ATNA Audit Repository ATNA WinSysLog XDS Patient Identity Source (MPI) EMPI Initiate NHIN request/response Transformation Message Socket TCP Providers Enhancement XDS PDQ Service XDS PIX Service ADT Service PostGreSql XDS Document Registry Anakam XDS Registry NIST Security Validation Flat File Any other inbound/out bound end point Routing XDS Reg Service Web Server Orchestration Version Control Subversion CT Time Client XDS Key Store e-Prescription AllScripts Technical/Financial Timeline Claims-based Decision support implemented document registry and Repository MPI build Jan 07 Jun 07 Enrollment of 25,000 members Physician Portal, authenticatio n Jan 08 Enrollment 35,000 members Real-time Decision support integrated with HIE Clinical document Exchange Jun 08 Datasharing agreement s Build clinical data repository Jan 09 Jun 09 Dec 09 Enrollment 250,000 patients NHIN Trial Implementatio n Grassroots Sustainability Strategic Business Planning Infrastructure Development Operating Support July 2004 – June 2005 July 2005 – March 2008 April 2008 – June 2009 $100,000 grant from eHealth Initiative $250,000 Commonwealth of Virginia $150,000 transactional fees for services $462,000 match from local partners $308,000 Accenture NHIN Prototype $450,000 contributions and donations $1,450,000 Consortium Partners (cash/inkind) $1,055,225 enrollment of members $1,000,000 State of Tennessee $750,000 contributions and donations Revenue Sources July 2005 – Dec 2008 Employers: Eastman Chemical Company King Pharmaceuticals Cariten PHP Johnston Memorial Hospital $ 600,000 $ 60,000 $ 8,000 $ 10,000 Contracts: State of TN Accenture (NHIN prototype) Commonwealth of Virginia NHIN Trial Implementation $1,016,900 $ 308,000 $ 250,000 $3,988,622 Consortium Partners $1,250,000 Enrollment Fees (CareEngine Services) $ 431,640 Transaction Fees $ 0 cash and inkind Total $7,923,162 CareSpark Data-Sharing Options Data Sharing Option Identified Data De-Identified Data Anonomized – patient data can never be re-identified Intended Data Use Patient Care and Treatment All data sent to CareSpark will be identified data in order to match patient records from multiple providers. Identified data will be available to authorized providers for access of additional healthcare information about the patient. Approved Population Health Improvement activities Identified data available to CareSpark will be de-identified according to the approved requirements and stored separately. Public Health Identified data available to CareSpark will be de-identified with the specified additional fields required for a limited dataset according to the approved requirements and stored separately. Pseudo-Anonomized – Patient data can be reidentified, if necessary, but only by the party who provided the pseudoanonoymized data Limited Data Sharing Result Future Initiatives • National – connect with V.A., CDC and personal health records • Tennessee – connect with state agencies (public health immunization registry, Tn eHealth Council efforts) • Virginia – connect with immunization registry, prescription management program • Local / Regional – support aggregation and analysis of data to address public health issues for region (chronic disease, prescription drug overdose) Lessons Learned – Regional HIE • Health care market does not conform to political boundaries • Evolving standards will assure interoperability across jurisdictions and between systems (clinical, payer, public health, personallycontrolled, research-oriented) • Leverage existing resources and investment through incremental transition • Build for maximum flexibility to accommodate change (technical, policy, funding, users, evidence-base on outcomes) Better Health for Central Appalachia www.carespark.com Liesa Jenkins, Executive Director 423-963-4970 [email protected]