Together for Quality Making It Happen: System Fundamentals

1. Together for QualityMaking It Happen: System Fundamentals Mark FrisseVanderbilt University February 7, 2007 This project will result in an automated, inclusive, interoperable, real time HIS and a data driven quality improvement program. Alabama Medicaid Transformation Grant Application

2. This presentation • Is anyone really doing all of this successfully? • What can one learn from other data exchange efforts to advance the Together for Quality program? • What generic principles can be applied? • Are there examples of “best practices”? • What choices are right for Alabama? • Are there barriers or conflicts associated with each option? Based on what we know • What is straightforward? • What is challenging? • Where should leadership efforts be focused?

3. Selected Together for Quality Programs • Internal integration of HHS systems • Pharmacy management • Medication history • Prior authorization • Formulary management • Controlled substances • Clinical programs • High-risk Medicaid patients • Immunizations • Participants emphasize case managers • Participants include patients, providers….nearly everyone Source: Medicaid Transformation Grant Application

4. Overview • Statewide electronic health information system • Links Medicaid, state health agencies, providers, and private payers • Will provide Medicaid, other HHS agencies, providers, and private payers with secure, real time access to individual health information • Claims • immunization records • prescription data • laboratory results Source: Medicaid Transformation Grant Application

5. Why an interoperable data hub? • Only a system-wide change can address inadequacies and inconsistencies of patient care • Establishes a comprehensive quality improvement model for the Alabama Medicaid Program • Remove duplication • Avoidable emergency room visits • Support creation of a medical home Source: Medicaid Transformation Grant Application

6. “Wiring” Healthcare Current system fragments patient information and creates redundant, inefficient efforts Future system will consolidate information and provide a foundation for unifying efforts Payers Hospital Hospitals Public health Health Information Exchange Primary care physician Laboratory Labs Pharmacy Specialty physician Data Vaults Network applications Outpatient RX Payers Ambulatory center (e.g. imaging centers) Physician office Source: Indiana Health Information Exchange (modified) Ambulatory centers Public health

7. Data Reuse Data management Data access and use • Results delivery • Secure document transfer • Shared EMR • Credentialing • Eligibility checking Payers Hospitals Hospital • Results delivery • Secure document transfer • Shared EMR • CPOE • Credentialing • Eligibility checking Health Information Exchange Physicians Secure Access Labs Labs • Results delivery Network applications Data Vaults Outpatient RX • Surveillance • Reportable conditions • Results delivery Public health Payer • Secure document transfer Payer Physician office Ambulatory centers Public health • De-identified, longitudinal clinical data Source: Indiana Health Information Exchange Researchers

8. Technical assertions and issues • A common identifier for Medicaid beneficiaries will be developed • An overlay that allows agencies to interact at appropriate security levels • Claims data • Integrated laboratory data from third-party labs • Clinical decision-support tool (pharmacy) • Peer comparisons on patient acuity and outcomes measures Source: Medicaid Transformation Grant Application

9. Sustainability • A…firm foundation on which to build a permanently funded PDH that will ultimately be supported by primary partners and various funding sources. • Funding possibilities include both public and private sector funds, membership fees, and access fees from payer groups. • Identification of additional sources for revenue and the development of a permanent funding plan. Source: Medicaid Transformation Grant Application

10. Fundamentals: Patient data hub Features • Centralized • Medicaid claims Challenges • Management and oversight • Transparency • Use limitations • Patient involvement • Auditing • Sustainability • Extension – plan and provider “buy-in” • Examples: • Louisiana • TennCare • Indiana • Memphis • New York • Florida

11. Fundamentals: Reconciliation of HHS Agencies Features • Efficiency • Multiple uses • Planning • Quality Issues • Master person index • Access controls • Data mapping • Aggregate data

12. Fundamentals: Supplemental data Features • Better immunization records • Controlled substances • Labs – clinical decision support Issues • Collection of immunization data • Access: controlled substances • Gaining collaboration of clinical labs • Mapping lab results to appropriate patient

13. Use of data for clinical decision-support Features • Integration of data for patient care • Profiling • Population care • P4P Issues • What is covered under HIPAA? • Authorization and authentication • Individual vs. group data • Population data vs. individual use

14. Interaction with electronic medical records Features • Practitioners access all data about patient • Data populates hub automatically Issues • Provider cooperation • Markets – will all “certified” vendors have equal access? • Vendor integration and cost – who pays? • Data quality and auditing – who is responsible? • Secondary use of data – will it be “sold”?

15. Solution: Stakeholder Council Oversight • “Architects and engineers” • Critical examination – now – of major aims and concerns • Development of a roadmap consistent with the aims of state government and its citizens • Clearly-defined tasks for work groups with time lines • Realistic expectations: focus on Medicaid but address whether or not the same system – alone or as a central hub – will meet the care needs of everyone in Alabama • You may need sustained and consistent leadership from senior state officials – not just Medicaid Source: Medicaid Transformation Grant Application

16. Solution: Work Groups Policy • Responsible for the very difficult work of reconciling various interests with the Together for Quality Agenda. Health care is more than Medicaid Privacy • Its more than HIPAA; it is about public trust (patients, providers) Clinical • Must focus on a realistic view of care for individuals and populations Technical • Must focus on technical limitations, realities. Must help State deal with “Vendor frenzy syndrome.” • You don’t have to build it all or “own” it – e.g., Medication history Finance • Must view the Hub as a part of the overall care delivery infrastructure and not only as a separate entity Source: Medicaid Transformation Grant Application

17. Today’s decisions influence tomorrow’s markets • What will be the role of a non-profit organization fostering exchange? • How do your decisions influence market choice? Do they lead to innovation or monolithic bureaucracy? • What is the best way to align state, federal, employer incentives • What is the ideal infrastructure in terms of technology and intermediaries (plans, PBMs) • What is the measurable “end game”? • What “portfolio of initiatives” should be developed to focus on the best solutions for your state?

18. A regional effort in Memphis Three-county region that includes Memphis TN; Approximately 1 million residents Serious community health problems Major public hospital Multiple competing providers This is not a state-wide Medicaid initiative

19. A regional effort in Memphis • Based on real patient data, not claims • Governance through a 501(c)(3) corporation • Participation of major hospitals and clinics • Participation of state and local government • Involvement of the business community • University participation • Tennessee Tech • University of Memphis (pending) • University of Tennessee • Vanderbilt University • National collaborators • Cost: $12 million over 5 years

20. Goal: To understand what the market should be • Legal / policy framework • Public Health (Robert Wood Johnson grant) • E-prescribing (AHRQ contract expansion) • Quality (AHRQ contract expansion) • Community Action (Robert Wood Johnson; Healthy Memphis Common Table) • Understanding of emergency department use • Extension to safety-net clinics to strengthen “medical home” concepts • Technology – Vanderbilt technologies, Tennessee Tech • Retail pharmacy (coming soon) • Commercial vendors (coming soon)

21. The real opportunity: find alternatives to ED care This individual had over 40 ED visits to multiple emergency departments within a 7-month periods. Options:- more effective treatment in ED- more effective care outside of ED

22. What we have not resolved We believe much more work is required: • Public trust • Provider trust • Appropriate use • Transparency • Auditing and reporting • Identity management • Cost-effective integration with all certified clinical information vendors • Medicaid vs. future medical markets • Population data use vs. individual care

23. Links: http://www.volunteer-ehealth.org http://www.connectingforhealth.org/ http://www.mc.vanderbilt.edu/vcbh/ds/0606_privacy/ http://www.volunteer-ehealth.org/frisse/ http://www.volunteer-ehealth.org/frisse/frisse-policy-confidentiality/ http://www.volunteer-ehealth.org/news/info/2006/09/midsouth-ehealth-alliance-data-sharing.php

24. Additional slides Screen shots of current system Data are from a fabricated test data set

25. We can locate records and allow “opt out

26. We can show encounter data

27. Our user interface is based on user feedback

28. We can now display data across institutions

29. NPV (based only on urban ED) is $4.2 Million The State of Tennessee and the Core Healthcare Entities realize a higher financial gain when you consider the different stakeholder contributions. State of Tennessee Payback Period = 1.7 Return on Investment = 1.95 Core Healthcare Entities Payback Period = 0.5 Return on Investment = 17.5 Assumptions • Includes only hospital ED benefits • No adverse drug event benefits modeled • No population health or practitioner productivity modeled • Based on data obtained on the core healthcare entities • Deployment schedule is limited initially to EDs and Labor & Delivery; years four and five will extend to all healthcare providers • Inflation and volumes remain constant • The costs to move and support the RHIO data center are not included in the five-year forecasts • The RHIO support desk infrastructure is not established • The average cost for a core healthcare entity for implementation and operation activities is $30,000 per year. • Net Financial Benefit ($ Million) • Net Present Value (Million) Payback Period (years) = 3.3 Project Return on Investment = .56