Christopher B. Sullivan, Ph.D. Florida Center for Health Information and Policy Analysis Agency for Health Care Admini

1. Florida’s Initiative to Empower Regional Health Information Organizations and Enable the Development of Health Information Exchange Christopher B. Sullivan, Ph.D. Florida Center for Health Information and Policy Analysis Agency for Health Care Administration

2. Florida’s Strategies for Empowering Regional Health Information Organizations This talk addresses three areas in the development of health information exchange in Florida: • A summary background of need for health information exchange in the coordination of change. • A summary of the Florida Health Information Network (FHIN) initiatives. • The current status of Florida’s Regional Health Information Organizations (RHIOs). • Florida’s ongoing strategies for developing health information exchange with particular attention to e-prescribing initiatives.

3. Major Challenges in Health Care • The increasing cost of health care. • Fragmented healthcare delivery and financing environment and challenges with continuity of care. • Struggle to care for the the poor, uninsured and patients with chronic diseases – i.e. Diabetes, Asthma, Heart Disease and cancer. • Historic economic pressures, geographic diversities and differing scope of care call for coordinated local solutions. • Leverage health information technology efficiencies while ensuring privacy protection of health care data. MJJ - 2007

4. Government Budget Office Estimate of Health Care Costs as % of GDP, 1960-2005 Retrieved from: http://www.cbo.gov/ftpdocs/87xx/doc8758/11-13-LT-Health.pdf

5. Government Budget Office Projection of Rising Health Care Costs as % of GDP Retrieved from: http://www.cbo.gov/publications/collections/health.cfm MJJ - 2007

6. Why Health Information Exchange? The nature of modern health care requires involvement of multiple medical providers to diagnose and treat many medical conditions. Effective coordination of care is dependent on communication of information about a patient’s medical condition. The exchange of patient data currently depends on telephone calls, mail, the transmission of fax copies of records or photocopies carried by the patient. A more timely, accurate, comprehensive and secure method of exchanging patient records is electronically through an electronic health record system that includes the health information exchange.

7. Need for Better Information Exchange Coordination of Specialty Referrals “Better coordination between referring physicians and specialists increases physician satisfaction with specialty care and enhances referral completion.”1 Communication Breakdown in the Outpatient Referral Process “68% of specialists report that they received no information from the primary care physician prior to specific referral “Four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists.”2 1. Christopher B. Forrest, MD, PhD, et al. (2000) Coordination of Specialty Referrals and Physician Satisfaction With Referral Care. Archives of Pediatric Adolescent Medicine. 2. Tejal K. Gandhi, et.al. (2000). Communication Breakdown in the Outpatient Referral Process. Journal of General Internal Medicine, Volume 15, Number 9, September.

8. Chronic Care Management Supported by Health Information Exchange • Chronic Disease Management requires the coordination of care with one or more specialists - an average Medicare patient sees up to 6 physician specialists annually. • Health information exchange can an enabler for effective chronic disease management by supporting the exchange of information across caregivers to coordinate care among specialists, the primary care physician and the patient. • Health information exchanges allow chronic disease management to be implemented without providers having to invest in duplicate information exchange infrastructures. MJJ - 2007

9. The Challenge to Define Health Information Exchange MJJ - 2007

10. What is a Regional Health Information Organization?

11. Vision for the Florida Health Information Network (FHIN) The vision for the Florida Health Information Network proposes integrating Florida’s community-based activity in clinical health information exchange through a statewide network, the FHIN. The FHIN will empower physicians to access timely and accurate medical records in order to deliver high quality medical care for their patients.

12. The Florida Health Information NetworkStarts at the Local Level AHCA’s strategic plan for promoting health information exchange is to empower local stakeholder collaborations focused on creating local health information networks. The FHIN is a collaboration of Regional Health Information Networks (RHIOs) funded by the FHIN Grants Program and by local in-kind support. Each RHIO is responsible for working with local providers to initiate the exchange of medical records through the RHIO portal. The Florida Health Information Network is being built from the local community up. 12

13. FHIN Grants Project Categories The driver of Florida’s plan for health information exchange is the FHIN Grants Program for Regional Health Information Organizations. • Planning Grants: Support appropriate health care stakeholders to develop a strategic plan for health information exchange in their communities. • Implementation Grants: Support projects that demonstrate health information exchange among two or more competing provider organizations. • Training Grants: Support practitioner training designed to increase physician and dentist use of electronic health record systems. • Over $5 million in grants since 2005.

14. The Florida Health Information Network FHIN Grants Program Funded Grantees from FY 2005 – 2008

15. Northeast Florida Health Information Consortium (NEFHIC) 15

16. NEFHIC Technical Capacity ASP Model – Safety net data repository server hosted in Cerner’s secure data center with redundant hardware and power. Records for 90,000 clients loaded with feeds from 7 participants, including hospitals and clinics. System operational and accessible via the Internet using 128-bit secured communications. Pilot testing of user access and data retrieval is complete.

17. Partners Public Funders Free Clinics Private Funders Health Dept. Social Services Hospitals PBC Community Health Alliance (An Alliance of Funders and Providers Serving Health Care Consumers) Collaborative Projects Care Expansion Language Access Project Access Shared EHR Common Eligibility Palm Beach County Community Health Alliance (PBCCHA) 17

18. PBCCHA All-Care Shared Health Record Real-time electronic interface to existing data systems used by hospitals, clinics, and other safety net providers. Shared summary records created for all uninsured, Medicaid, and other patients. No duplicate data entry. Free clinics, Federally Qualified Health Centers, PBCMS Project Access and key competitor safety net hospitals are participating. Viewable via secure Internet connections - after patients have signed authorizations. 18

19. pMAN Connectivity – Dedicated fiber-based Private Medical Area Network & VPN gateway VPN Small organizations can connect either directly to the RHIN or through a VPN gateway Organizations can connect bi-directly to feed their data and receive data directly into their EMR In the early Phases CHP, CRMC & TMH will provide a one way feed of their data. They have the largest repositories and the priority is to make their data available ASAP Big Bend RHIO Regional Health Information Network (RHIN) Architecture

20. Big Bend RHIO RHIN Services Data Sharing – Patient demographic and clinical data feeds from major providers. RHIN Web Portal – Secure web interface for clinicians. User Access & Audit Control – Detailed audit logs across the entire system. Disaster Recovery & Business Continuity. Patient Portal – Web interface for electronic patient registration form and Personal Health Record (PHR). 20

21. RHIN Portal Views from the Big Bend RHIO Secure Internet Access RHIN Web Portal patient search

22. Data Exchange: Big Bend RHIO Applications e-Prescribing and Medication History Clinical data display including: labs, radiology reports, allergies, problems, providers, and medication history

23. FCC Rural Broadband Pilot Program In November 2007 the Federal Communication Commission awarded $9.6 million to the Big Bend RHIO and AHCA to build a gigabit fiber network to nine rural hospitals and surrounding clinics in the Florida Panhandle. • This contract will allow the Big Bend RHIO to connect these hospitals with gigabit fiber and extend its RHIN services to them. • The FCC pilot project will provide 1 Gigabit connectivity to nine rural hospitals. • Once the nine rural hospitals are connected with gigabit fiber, they will receive the data exchange services of the Big Bend RHIO. 23

24. Connecting Rural Hospitals in the Florida Panhandle

25. Broadband Rural Network Will Benefit from Big Bend RHIO Services • Once the optical fiber is laid, a wireless broadband network will be built to provide connectivity to providers in the local community. • Creating these broadband optical fiber connections brings the nine rural hospitals into the Florida Health Information Network. • Each hospital will be able to send digital image files (X-rays, Cat Scans, MRIs) downstream for diagnosis by specialists. • County health departments, Federally Qualified Health Centers, free clinics and primary care physicians will be encouraged to connect to the broadband network.

26. Florida Health Information Privacy and Security Project • National Project was intended to provide the Office of the National Coordinator of HIT with information about privacy and security practices and laws in 33 states that were part of the project. • Each state identified business practices related to electronic health information exchange and analyzed practices and laws that are barriers to interoperability. • The goal of the project was to develop state specific solutions and develop a plan for eliminating barriers to health information exchange. • The long term outcome is to facilitate development of an interoperable nationwide health information network.

27. Major Barriers to Health Information Exchange • Inconsistent and fragmented laws at state and federal level – conflicts between Florida statutes and HIPAA. • Lack of standard requirements for when to use patient consent – proposed uniform consent form. • Mistrust among health care entities, liability concerns and fear of violating rules or litigation. • Solution is to develop priority legislative recommendations for legislative action that would have the most immediate impact. • Reporting of lab records (s. 483.181 FS). • Exchange of hospital records (s. 395.3025 FS).

28. Medicaid Claims-Based Electronic Health Record System Ported Through RHIOs Working with the new Medicaid fiscal agent, EDS, on a pilot project to roll out a claims-based EHR for Medicaid physicians. Medicaid pilot to work with Big Bend RHIO to integrate the claims data feed for display through the Big Bend portal. Plan to roll out the Medicaid EHR through RHIO portals in Summer 2008. Medicaid-EDS Web Application Local RHIO or Direct Medicaid Portal Access Home Office Hospital 28

29. Accessing Medicaid Prescription Data Through Gold Standard • Florida Medicaid eMPOWERx e-prescribing software is available to all Medicaid physicians. • eMPOWERx makes 100 days of a patient’s prescription drug history available to physicians. • eMPOWERx uses clinical pharmacology and report tools that alert the provider to potential drug-drug and drug-allergy interactions. • Providers can write prescriptions from a desktop computer to any pharmacy for dispensing and adjudication. • The Florida Center is working with Gold Standard and Medicaid to make eMPOWERxmedication history available to Medicaid physicians through RHIO portals.

30. Florida Medicaid Wireless Handheld PDA Project Approach

31. Outcomes of the Medicaid e-Prescribing Pilot Project Using PDAs • Prescribers who used eMPOWERx write 25% fewer prescriptions than physicians not using the system. • Prescribers who use eMPOWERx save Medicaid an average of $48 more per month per patient on prescription claims. • Florida Medicaid reports $1.8 - $2 million in monthly savings from electronic prescribing. • During 2006, eMPOWERx users received more than 5,000 drug interaction alerts each week, more than 1,000 of which were of high or very high severity. • Physicians wrote an average of 4,115 electronic prescriptions per month.

32. eMPOWERx Usage Statistics, July 2006 to September 2007

33. Average Monthly Cost Savings per Patient in Medicaid Wireless PDA Program

34. AHCA’s Electronic Prescribing Clearinghouse Home Page http://www.fhin.net/eprescribe

35. 29% 70% 1% 2. or & or Cursive Phone Fax (Cursive/Typed) eRx 1. vs. Typed Physician Evaluates Patient & Prescribes Drug 3. Pharmacist review prescription and routes it to the patient’s insurer. Manual Entry By Pharmacist 5. Script to Patient Benefit Manager for Adjudication 4. Payment is collected and Medication is dispensed to the patient Rx Approval Patient Benefit Manager Approves Script ePrescribing Today MJJ - 2007

36. Florida 2007 Electronic Prescribing Report • E-prescribing was on the increase in Florida in 2007, but fewer than 1% of prescriptions were electronic. • During 2007 the number of physicians e-prescribing increased by 80%. • There was a 199% increase in the number of electronic prescriptions in 2007. • Across the state, 63% of all pharmacies in the state are actively receiving e-prescriptions. • New prescriptions make up the greatest number of prescriptions in 2007, at about 47.2%. • The Tampa-St. Petersburg MSA accounts for the largest number of electronic transactions of all types related to electronic prescribing, with 850,619 in 2007.

37. Number of Physicians Actively E-prescribing and Number of New Prescriptions and Refills

38. E-prescribing Transactions in Florida Broken Down by Transaction Type

39. Ongoing Strategies for Fostering Statewide Health Information Exchange in Florida Continue the FHIN Grants Program and foster the development of Regional Health Information Organizations (RHIOs) across Florida. Seek alternate, additional funding sources to ensure the viability of RHIOs currently in operation and to develop sustainability models for their continued success. Work with the RHIOs to establish a statewide, interoperable health information network. Work with the Health Information Exchange Coordinating Committee for state level leadership. Work with the Health Information Security and Privacy Collaboration to reduce barriers to HIE. 39

40. Christopher B. Sullivan, Ph.D. Agency for Health Care Administration Florida Center for Health Information and Policy Analysis Office of Health Information Technology 2727 Mahan Drive Tallahassee, FL 32308 sullivac@ahca.myflorida.com 850-414-5421