Health Information Exchange: Value, Incentives, and How to get there.

1. Health Information Exchange: Value, Incentives, and How to get there. David C. Kendrick, MD, MPH Asst. Provost for Strategic Planning, OUHSC Medical Director for Community Medical Informatics OU School of Community Medicine Greater Tulsa Health Access Network

2. Agenda • HIE Ongoing benefits: Value aside from ARRA • Financial • Clinical • New, one-time opportunities: ARRA Incentives in Oklahoma Terms • How do we get there?

3. 2007 COMMONWEALTH FUND ReportState Scorecard Summary of Health System Performance

5. 2009 State of the State’s Health Summary

6. Some Factors Economic downturn healthy people and jobs left Oklahoma Poverty remained Heart Disease – (Diabetes) Cancer Access to Care Obesity Oklahoma is the only state where the death rate has gotten worse….. Age-adjusted Death Rates Past 25 Years

7. Current Situation Hospitals (inpt) Rx Payers Demographics Medical claims Pharmacy claims Case mgmt records ER/UC Doctor offices Patient Imaging Safety Net Clinics and community agencies 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

8. What’s the value of HIE? • 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

9. Motivation • Clinicians have incomplete knowledge of their patients • Relevant patient data not available in 81% of ambulatory visits Tang 1994 • 18% of medical errors that lead to ADEs due to missing patient information. 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?

10. 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 • KepaZubeldia, MD • President and CEO, Claredi Corporation

11. HIE Value Construct Public Health Agencies Payers Pharmacies Providers Hospitals Clinical Laboratories Radiology Centers Other Providers

12. HIE Value Construct Electronic submission of reportable conditions and vital statistics Avoided ADEs, drug utilization savings, automated transaction sets Public Health Agencies Payers Pharmacies Providers Hospitals Avoided redundant tests, Electronic test ordering and results delivery Electronic Rx, refills, interaction checking, adherence data Clinical Laboratories Radiology Centers Electronic referrals, consultation letter delivery, chart requests Avoided redundant imaging, Electronic imaging ordering and results delivery Other Providers

13. Value to Oklahoma Public Health Agencies Provider $1.5 Payers Pharmacies $16 $136 Providers Hospitals $1.5 $127 $10 $141 $116 Clinical Laboratories Radiology Centers $39 $123 $99 Other Providers $39 $ Millions

14. Value by Stakeholder: Oklahoma Public Health Agencies Provider $1.5 Payers Pharmacies $16 $136 Providers Hospitals $1.5 $127 $10 $141 $116 Clinical Laboratories Radiology Centers $39 $123 $99 Other Providers $39 $ Millions

15. Net value of HIE Tulsa: Oklahoma City: Oklahoma: *Software as a service, Cloud computing, and Interoperability standards have lowered the cost of implementation and maintenance by an order of magnitude

16. But wait, there’s more . . . • CMS and Medicaid Incentive payments for “Meaningful use of an EHR”: • $44,000 to Medicare providers, $63,000 to Medicaid • Formula-driven bonus to hospitals: $2-11M per hospital • What does this mean to OK? • Assume 9,000 MD’s, DO’s, PA’s, NP’s are eligible • Assume the following hospital bed distribution:

17. CMS wants EMR and HIE adoption . . . *Assume N=9,000 MDs, DOs, PAs, and NPs focused 30% of the time on Medicare patients, and 12,474 hospital beds

18. 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

19. HIE Progress to date • Early summer: Small working group met and produced a document: • Outlined 14 “Items for consideration” • July 30th: Major stakeholder’s meeting. ~35 people • Reduced “Items for consideration” from 14 to only 3: • Meet requirements established by Federal legislation for funding • Establish planning process, including HIT Policy Committee • Identify the State Designated Entity • Agreed that OHCA could be the temporary custodial State Designated Entity until the planning process is complete or October 16, whichever comes first. • August 14: OKHITECH Summit held, wide invitation list, comments and feedback sought • August 14-21: Online comment period • August 20: State HIE Cooperative Agreement Program (SHIECAP) Released

20. State HIE Cooperative Agreement Program (SHIECAP) • Governor must identify State Designated Entity • Each applicant must have a State Coordinator for Healthcare IT • Focus: State Strategic Plan and Operational Plan • States without plans can spend as much as 6 months on a planning process • Applicants who fail to submit acceptable plans will be subsumed into other nearby states

21. State HIE Cooperative Agreement Program (SHIECAP) • Approval: Merit-driven • Funding: (mostly) Formula-driven • $4M base for 50 successful applicants • Additional funding up to $36M per applicant apportioned thusly: • applicant region‘s population (5%), • number of PCPs (40%), • Acute Care Hospitals (30%), and • Medically Underserved and Rural Providers (25%). • A final 10% of the total funds will be apportioned based on an assessment of the relative HIT need of the region, as determined by evaluation of the Letter of Intent. • Oklahoma’s likely take: $6-8M

22. Deadlines and current status • September 11: Letter of Intent Due • State Designated Entity- Done, at least temporarily • Review of existing capabilities statewide • Report of total expenditures to date in 5 key areas • October 16: Final application due • Details of planning process • Key individuals identified to execute the process • December 15: Award announcements • January 15: Work begins

23. Thanks! David-Kendrick@ouhsc.edu