A Public Utility for Electronically Exchanging Clinical Information in Central Massachusetts

1. A Public Utility for Electronically Exchanging Clinical Information in Central Massachusetts HealthAlliance Hospital Grand Rounds March 3rd, 2009 Larry Garber, M.D. Fallon Clinic Medical Director of Informatics SAFE Health Principal Investigator

2. Agenda • Health Information Exchanges • What are they? • Why do we need them? • Review of SAFE Health project • HealthAlliance Hospital’s role in SAFE Health • Current status of SAFE Health project • The future of SAFE Health

3. EMRs are great, however…

4. Hospitals don’t easily interface to office EMRs • ERs don’t know your outpatient information • 30% of ER visits lack important medical information, half of which are “critical” • 15% of ER admissions could be avoided if the ER had outpatient information • 150,000 preventable ADEs ($8 Billion nationwide wasted) each year occur at the time of admission due to inadequate knowledge of outpatient medication history

5. Hospitals don’t easily interface to office EMRs • Your EMR won’t have ER notes or discharge summaries unless you scan them in • Only 6% of small practice EHR’s are interfaced to hospital information systems • 2 million adverse events each year are due to inadequate communication at time of discharge

6. Most offices don’t have lab and imaging interfaces • Costly to interface to lab and radiology systems • Only 50% of small practice EHR’s are interfaced to lab systems • 5-20% of lab and x-rays are ordered redundantly because original results can’t be found • 40% of Prostate Cancer malpractice cases in MA (2002-2007) were due to failure to transmit/receive test results

7. Most offices don’t have all of the patient’s physicians in their practice • Visits are split 50/50 between PCP’s and specialists • Average Medicare patient sees 6.4 different MDs per year • 25% of prescriptions are not known by the treating physician • Patient data missing 80% of time in one study • 25% of PCPs lack consult note 4 weeks after outpatient consultation • 20% of medical errors are due to inadequate availability of patient information

8. EMRs are great, however… Without interfaces to the other parts of the healthcare system, EMRs will fall short of their goal to improve the quality and safety of healthcare while reducing costs

9. EMRs are great, however… • Each interface costs $5,000 - $20,000 in hardware, software, and consultant time • A small office EMR should have at least: • Lab • Imaging • Hospital • Pharmacy • Other physician practices? • Interfaces can double the cost of EMRs

10. The Solution: Health Information Exchanges (HIEs) • Local Health Information Exchanges • Regional Health Information Organizations (RHIOs) • National Health Information Network (NHIN)

11. Health Information Exchange (HIE) • Each organization has 1 interface • Central hub only routes clinical data • Only patient demographic data stored centrally

12. Community Portals and Health Record Banks vs. True HIEs • Clinical data stored centrally and viewed through website (portal) • Often can use CCOW to synchronize user and patient context between EMR and portal • Clinicians have to learn to use two systems • Can’t directly use portal data in EMR (e.g. allergies, medication list, immunization history, etc…)

13. Personal Health Records (PHRs) vs. HIEs • Clinical data stored centrally • Larger focus on patient access to data (for now) • Less focus on downloads into EMRs or Provider/Ancillary/Payer healthcare transactions (for now) • Over time, the distinctions will blur as HIEs emphasize patient portals, and PHRs/PHPs interface more Providers/Ancillaries/Payers • Patient enrollment is a bottleneck to data flow

14. The Benefits of HIEs: • All achieved with MDs using their own EHR • Improved coordination of care • PCP  Specialist • Inpatient  Outpatient • Improved patient safety • Improved quality of care • Reduced redundant testing • Fewer hospital days • Fewer adverse events (3% reduction) • Better medical history on patients in ER (2% reduction)

15. Excellent Patient Service “I ran out of one of my pills. Not sure which one. I lost my wife’s note… ” • We can know our patients better than they know themselves

16. Other Benefits of HIEs: • Automated public health reporting • Automated bio-surveillance • Quality Measurements/Benchmarks • Facilitates research • Reduces the cost of interfaces • Reduces barriers to adopting EMRs

17. Value of National HIE Network • $337 Billion savings during 10-year implementation period • $78 Billion savings each year thereafter: • $34 Billion to providers/facilities • $22 Billion to payers • $13 Billion to reference laboratories • $8 Billion to imaging centers • $1 Billion to pharmacies • $0.1 Billion to Public Health agencies

18. Legislation for HIEs - State • MA Health Care Reform Act of 2008 • $15M for community-based HIEs and EHRs • All hospitals and community health centers must implement interoperable electronic health records systems by 2015

19. Legislation for HIEs - Federal American Recovery and Reinvestment Act of 2009 • $1B in up-front grants for EHR and HIE implementation • Up to $64K for MDs and $11M for hospitals if: • using EHR in a meaningful manner • submits clinical quality measures • EHR is connected to a Health Information Exchange

20. Secure Architecture For ExchangingHealth Information A Public Utility for Electronically Exchanging Clinical Information in Central Massachusetts

21. Funding for SAFE Health • $1.5 Million Agency for Healthcare Research and Quality (AHRQ) Grant #1 UC1 HS015220 (10/2004 9/2009) • $4.2 Million donated by: • Fallon Clinic • Fallon Community Health Plan • HealthAlliance Hospital • UMass Memorial Medical Center

22. Objective of SAFE Health Build and operate a health information exchange infrastructure for Central Massachusetts to securely enable real time aggregation and presentation of patients’ health information from multiple different organizations in order to improve patient safety, quality of care, and efficiency of healthcare delivery.

23. SAFE Health Architecture

24. High Level Design Goals • No central clinical data repository • One central demographic repository (EMPI) • Preservation of data and transaction ownership • Minimize duplicate data from multiple sources • Secure and auditable; Protect patient privacy • Scalable and high performance • Interoperable with other local health information exchanges and the NHIN • No rip and replace – leveraging existing systems • Integrate seamlessly into varied physician workflows • Minimize cost

25. Levels of Participation – current & planned • Portal access – web browser access to display patient information • Practice management systemintegration – medical summary prints out automatically when patients arrive triggered by ADT • EHR integration – One or two-way integration with existing information systems to display patient information while in those systems and supply data to the SAFE Health network. • Clinical information supplier– Ancillary systems that receive orders and provide results, or health insurance carriers that only feed patient data to SAFE Health network.

26. Privacy and Security • User Authentication – performed by each entity • Patient Authorization • Opt-in consent for “Pulls” • Ordering/Referring/Authoring/CCd provider for “Pushes” • Privacy Notice covers “Pushes” as well as release of demographics to Core Server • Encryption - HTTPS • Audit trails – maintained within each Local SAFE Health server as well as the Core Server

27. Patient Opt-in Consent Automation • When patient who has been at more than one participating entity, arrives at a participating entity and a consent form hasn’t authorized all of the entities that the patient is registered at yet, a consent form automatically prints on the registration clerk’s local printer. • Consent is to authorize a participating entity to both disclose as well as view patient information • Patients can authorize any or all of the current entities participating in SAFE Health, or they can authorize all current and future healthcare providers in the state of Massachusetts

28. Patient Opt-in Consent Automation • Patients can authorize their medical insurance carrier(s) to provide information to SAFEHealth, but these payers can not view information. • Consent only needs to be signed once at one organization to authorized any or all entities • Consent can be revoked from any or all entities for future disclosures and viewing, but past disclosures cannot be revoked. • Patients cannot refuse to participate in the “Push” of results to ordering/referring/ authoring/CCd MD

29. Patient Opt-in Consent Automation • After the consent form is signed, a clerk clicks on patient’s name in the worklist to acknowledge that form was or was not signed and which entities were authorized, triggering clinical data to be exchanged between these authorized entities and imported into the local EHRs

30. Current Status of SAFE Health

31. Current Status of SAFE Health SAFEHealth went live on June 24th, 2009!

32. Current Status (continued) • For any patient that presents to the HealthAlliance Hospital Leominster Campus ER or Fallon Clinic Leominster or Fitchburg sites that chooses to participate, regardless of PCP site or health insurance • HealthAlliance Hospital Leominster Campus ER provides Fallon Clinic with ER Summaries

33. Current Status (Continued) • Fallon Clinic provides visit notes with: • Medication List • Allergies • Problem List • Immunization History • Code Status and Advance Directive Status • PCP and phone number • Vital Signs • Recent Lab and Radiology Results • No confidential notes

34. What do ER Doctors Want to See? Phase 1 Phase 2 Shapiro JS, Kuperman G, et al. J Am Med Inform Assoc. 2007;14:700–705.

35. Future Plans for SAFE Health • Integration with any hospital, physician practice/group, or other provider in the region that wishes to participate • Integration with any imaging center, reference lab, or other ancillary service in the region that wishes to participate • Integration with any health insurance carrier that is willing to provide patient information to the SAFE Health network

36. Potential Physician Concerns

37. Potential Physician Concerns • Will I be overwhelmed with too much data? • If the same data comes from 2 sources, will I see duplicates? • Will the data be incorporated into my EHR so I can use it to defend my decisions in court if necessary? • Will the incorporated data be in a discrete data format that matches my EMR so I can do decision support with it?

38. Potential Physician Concerns • Will my staff and I be overwhelmed getting consent to use the HIE from each patient? • Will it be too easy for patients to transfer their care to competing practices? • Will it be easier for lawyers to access my records? Can they case-find through the HIE?

39. Summary • Clinical data sharing has great potential to help us and our patients with: • Quality • Safety • Efficiency • Service • Implementation of an EMR • SAFE Health is a low-cost, secure Health Information Exchange for our region

40. Questions? www.SAFEHealth.org Larry Garber, MD LGarber@MassMed.org

41. Bibliography • Bates DW, Teich JM, et al. A randomized trial of a computerbased intervention to reduce utilization of redundant laboratory tests. American Journal of Medicine 106(2), 144-50. 1999. • Brailer DJ. Connection tops collection. Peer-to-peer technology lets caregivers access necessary data, upon request, without using a repository. Health Management Technology. 22[8], 28-29. 2001. • Financial, Legal and Organizational Approaches to Achieving Electronic Connectivity in Healthcare. Connecting For Health, October 2004. • Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Annals of Internal Medicine 138: 161-167. 2003. • Gurwitz JH, Garber LD, Bates DW, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289:1107-1116. 2003. • Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform. 2007 Dec;40(6 Suppl):S40-5. Epub 2007 Sep 7. • Overhage JM, McDonald CJ, et al. A randomized, controlled trial of clinical information shared from another institution. Annals of Emergency Medicine 39[1], 14-23. 2002. • Overhage JM, Suico J, McDonald CJ. Electronic laboratory reporting: barriers, solutions and findings. Journal of Public Health Management & Practice 7[6], 60-66. 2001. • Poon EG, Bates DW, et al. Dissatisfaction With Test Result Management Systems in Primary Care. Arch Intern Med. 164:2223-2228. 2004. • Stiell A, Forster AJ, Stiell IG, van Walraven C. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003 Nov 11;169(10):1023-8. • The Value of Computerized Provider Order Entry in Ambulatory Settings, Center for Information Technology Leadership (C!TL), April 2003. • Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The Value of Healthcare Information Exchange and Interoperability. Hlth Aff (Millwood) 2005 Jan-Jun;Suppl Web Exclusives:W5-10-W5-18.