Web Seminar June 5, 2013 Follow this event on Twitter Hashtag : #AHRQIX

1. Building Health Information Exchanges to Support Accountable Care Organizations and Medical Homes: Delaware’s Experience Web Seminar June 5, 2013 Follow this event on Twitter Hashtag: #AHRQIX

2. Using the Webcast Console and Submitting Questions To submit a question, type question here and hit submit. Click the Q&A widget to get the Q&A box to appear 2

3. Accessing Presentations Download slides from console Click on the “Download Slides” widget for a PDF version 3

4. What is the Health CareInnovations Exchange? Publicly accessible, searchable database of health policy and service delivery innovations Searchable QualityTools Successes and attempts Innovators’ stories and lessons learned Expert commentaries Learning and networking opportunities New content posted to the Web site every two weeks Sign up at http://www.innovations.ahrq.gov under “Stay Connected” 4

5. Innovations Exchange Web Event Series Archived Event Materials Available within two weeks under Events & Podcasts http://www.innovations.ahrq.gov Next Events Tuesday, June 18 at noon ET Chats on Change: Home Base Program for Veterans with PTSD 5

6. Today’s Event Moderator Gerry Fairbrother, PhD Senior Scholar AcademyHealth 6

7. HITECH* Spurred Dramatic Growth in Technology • Increase in electronic health records adoption • Meaningful Use provisions to promulgate standards and promote quality • Community-wide technology (Beacon Communities Program) • Health Information Exchanges (HIE) at state and regional level *Health Information Technology for Economic and Clinical Health 7

8. Growth in Technology Source: Hsiao CJ, Hing E Use and characteristics of electronic health record systems among office-based physician practices: United states, 2001-2012. NCHS data brief no 111. Hyattsville, MD: National Center for Health Statistics. 2012 8

9. Beacon Communities Eastern Maine Healthcare Systems Brewer, ME Western NY Clinical Information Exchange Buffalo, NY Inland Northwest Health Services Spokane, WA Mayo Center Clinic Rochester, MN Rhode Island Quality Institute Providence, RI Southeastern Michigan Health Association Detroit, MI Indiana HIE Indianapolis, IN Geisinger Clinic Danville, PA HealthInsight Salt Lake City, UT Rocky Mountain HMO Grand Junction, CO HealthBridge Cincinatti, OH The Regents of the University of California San Diego, CA Southern Piedmont Community Care Plan Concord, NC University of Hawaii at Hilo Community Services Council of Tulsa Tulsa, OK Delta Health Alliance Stoneville, MS Louisiana Public Health Institute New Orleans, LA 9 9

10. HIEs are Key “…Health information exchange (HIE) is a key driver of efficiency gains… …Therefore, the success of HITECH hinges, in part, on whether we can jump-start HIEs.” Adler-Milstein J, DesRoches CM, and Jha AK. Health information exchanges among US hospitals. Am J Manag Care. 2011 Nov;17(11):761-8. 10

11. Coverage and Locus Coverage and locus of Health Information Exchanges (HIEs) vary • State (Delaware – linked to other states) • Local and regional (Cincinnati, Ohio; Buffalo, New York; Indiana) • Market-based (Minnesota, Arizona) 11

12. Growth of Accountable Care Organizations and HIE • Accountable Care Organizations (ACOs) need population management at system level (data warehouse, registry function) • Move data from different electronic health record systems to point of care • Some HIEs have adjusted to become connectors between ACOs 12

13. Important Functionality of HIE • Technology to improve quality (data exchange, alerts, population management) • Beyond technology: Need to make business case and need for strong governance structure 13

14. More than Technology “HIE is dependent on government to change the way care is paid for… …Things not related to technology need to happen.” Blumenthal, David. Interview by Ravi Parikh for Medgadget. September 10, 2012. 14

15. Now We Will Hear From • Representatives of two different HIEs • How they are organized • Challenges and lessons learned 15

16. Presenter Jan Lee, MD Executive Director Delaware Health Information Network 16

17. Delaware Health Information Network (DHIN) 17

18. Getting Started • Governance, many stakeholders • Policies and procedures • Security and Trust Framework • Consent model: opt-in versus opt-out • Data model: federated versus consolidated or hybrid • Environmental scan: electronic health records versus paper, statewide availability of broadband • Market survey: what exchange services would providers value and actually use? 18

19. Community Health Record • Delaware Health Information Network (DHIN)’s core service • Federated Data Repository Architecture • Clinical data sent into DHIN hosting center from many sources: labs, pathology, radiology, hospital admission, discharge and transfer (ADTs), transcribed reports, medication history (subscription service) • DHIN delivers results to ordering provider…and aggregates into a longitudinal Community Health Record 19

20. Community Health Record Information accessed in several ways: • Directly populate a practice electronic medical record through interface • Auto-print for inclusion in a paper record system • View over a web portal (ProAccess) • Incorporate into a patient-controlled personal health record 20

21. Provider Adoption of DHIN Provider adoption as a percent of Delaware healthcare ordering providers (December 2012) 21

22. Current Membership in DHIN As of May 2013 • Acute care hospitals and Federally Qualified Health Centers (100%) • Providers (98%) • Skilled nursing (100%); assisted living (77%) • Labs (99%) and radiology groups (97%) • Health home, hospice and pharmacy • Division of Public Health, health plans, other HIEs 22

23. Benefits • Hospitals, labs and other data senders: Over$2 million cost saving from results delivery • Providers/practices with electronic health records • Payers/health plans: Estimated 30-33% reduction in redundant ordering of high cost labs and radiology studies over 2 years • Public health: Real world outbreak of swine flu detected in near real time • Patients: Many “stories” but no metrics 23

24. What’s Next? Current Services • Results delivery • Discovery tools: record locator service (RLS), common master person index (CMPI) • Public health reporting: syndromic surveillance, reportable labs, immunization update • Electronic health records (EHR) interfaces 24

25. Under Development/Planning • Event notification service • Immunization query • Image viewing • Consumer engagement • Connect with other HIEs, federal exchange partners via eHealth Exchange • Integrate newborn screening • Connect with Delaware prescription monitoring program • Incorporate continuity of care documents into the community health record 25

26. …and Next? New data types for the Community Health Record • Ambulatory • Medical Device • Medication History • Claims Analytic Tools • Clinical Quality Measures • Business Intelligence • Population Health 26

27. Lessons Learned • Consensus building is slow but essential • Begin with the willing • Find out what your market values and will use; do that extremely well • Use a small number of highly valued services to drive adoption and utilization • Provide value for everyone; not just the technology elite • Measure, measure, measure! Know the business case for participation • Success begets success 27

28. Overcoming Barriers • Technology • Trust • Natural reluctance to change • Late adopters versus early adopters • Meet them where they are; not where you wish they were • Business model for an HIE whose members are business competitors If it were easy, anyone could do it! 28

29. Respondent Jennifer Fritz, MPH Deputy Director, Health Information Exchange Office of Health Information Technology Minnesota Department of Health 29

30. Minnesota (MN) History Policy Levers encouraging HIE* • MN e-Health Initiative (2004) • MN Health Records Act (privacy law) re-codified to enable HIE, still stricter than most states *Before Health Information Technology for Economic and Clinical Health (HITECH) 30

31. HIE Governance Structure Post-HITECH • HIE Oversight Law (2010) • MN e-Prescribing mandate (2011) • State-Certified HIE Service Providers (4 as of May 2013) • Interoperable electronic health record mandate (2015) 31

32. State Certification and Oversight • Establishes oversight by Commissioner of Health to protect the public interest on matters pertaining to health information exchange • Requires State Certificate of Authority to operate Health Information Organizations (HIO) and Health Data Intermediaries (HDI) • Allows market-based approach for provision of HIE services; multiple HIE service providers (HIO/HDI) may be certified and operate in the state 32

33. Other eHealth Exchange Nodes eHealth Exchange HIO #1 Statewide Health Information Exchange Hospitals Private Practices Other settings Minnesota Approach: One HIE 33

34. Other settings Hospitals Private Practices HIO #1 HIO #2 Statewide Health Information Exchange Hospitals Private Practices Other settings Minnesota Approach: Two HIEs Other eHealth Exchange Nodes eHealth Exchange 34

35. Other settings Hospitals Private Health Data Practices Intermediary HIO #1 HIO #2 Statewide Health Information Exchange Shared HIE Services Hospitals w Directory Services Private Health Data w Consumer Preference Practices Intermediary Management Other settings Direct Exchange Minnesota Approach: Multiple HIEs Other eHealth Exchange Nodes eHealth Exchange 35

36. Market-Based Approach Versus Single HIE Pros • Allows for private sector investments and innovation • More adaptable to changes in technology trends or requirements (e.g., meaningful use) • Gives providers multiple options for HIE services Cons • Can create confusion in the marketplace • Interoperability requirements • Many aspects to monitor (technology, policy/legal, changes in national trends) 36

37. Accountable Care and HIE • Adult day services • Behavioral health • Birth centers • Chiropractic offices • Clinics: primary care and specialty care • Complementary/ integrative care • Dental practices • Surgical centers • Government agencies (state, county, city) • Habilitation therapy • Home care • Hospice • Hospitals • Laboratories • Long-term care • Pharmacies 37

38. Future of HIE in Minnesota • Interoperability: Need for shared services and agreements between multiple entities, including common standards • Continued certification of entities providing HIE services and monitoring of HIE marketplace • Potential updates in laws pertaining to HIE 38

39. Future of HIE in Minnesota • Provider education and technical assistance on HIE options • Privacy and security to increase provider adoption of HIE • Interstate/national connectivity • Movement from basic HIE (e.g., direct secure messaging) towards advanced HIE (e.g., analytics, greater automation, and population management) 39

40. Reflections on Delaware’s Lessons Learned • Consensus: Difficult but essential for sustainability • Start small with those motivated and those that have a specific use case that can be met by HIE • Provide a range of HIE options for different HIE needs (basic to advanced) • Demonstrating Return on Investment (ROI) and Value on Investment (VOI) is critical; harder to do when there are multiple HIE options available 40

41. Reflections on Delaware’s Barriers • Monitoring and adapting technology according to changes in medical practice • Scalable trust is emerging as a need for HIE sustainability • Natural reluctance to change: Importance of HIE solutions that are in the provider workflow at the point of care 41

42. Reflections on Delaware’s Barriers • Early adopters can be champions to others • Meet them where they are, not where you wish they were • Business model for an HIE whose members are business competitors: Need to overcome for accountable care 42

43. Final Observations • Many type of entities provide HIE services; interoperability is a challenge • Sustainability requires a sound business model and identification of value added services • Low provider adoption is linked to low meaningful use requirements • Don’t underestimate non-traditional settings • Accountable care requires easily sharing clinical data; HIE need to adapt to shifts in market demands 43

44. Questions? Click me to get Q&A box to appear 44

45. The Innovations Exchange • Visit our Web site: http://www.innovations.ahrq.gov/ • Learn more about Delaware Health Information Network • Follow us on Twitter: @AHRQIX • Send us email: info@innovations.ahrq.gov 45