Health Information Exchange 101 Problem, Definitions, Value, Policy

1. Health Information Exchange 101Problem, Definitions, Value, Policy David C. Kendrick, MD, MPH Asst. Provost for Strategic Planning OUHSC

2. National perspective • At >17% of GDP, healthcare costs - out of control • Value delivered is limited– US ranks below most industrialized nations on quality metrics, despite spending more • Healthcare IT - part of the solution – prioritized and funded • American Recovery and Reinvestment Act • Patient Centered Medical Home gaining as the delivery model of choice

3. Healthcare Reform likely possible • Details change daily, but will probably might include • Coverage expansion for the uninsured, perhaps through a public plan or premium assistance programs • Emphasis on preventive care • More prominent role of the Patient Centered Medical Home • Emphasis on Healthcare IT

4. 2009 State of the State’s Health Summary

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

6. 2007 COMMONWEALTH FUND ReportState Scorecard Summary of Health System Performance

8. What WE CAN’T Do • “Grow” more doctors quickly • Create new hospitals overnight • Force patients to: • Exercise • Stop smoking • Lose weight

9. What We Can Do Leverage Technology • Complex populations • Limited Resources: • Create a lean healthcare system • Improve Care Coordination • Business case for: • Funding • Efficiency

10. Where to Focus? • Electronic Medical Records (EMRs) important, but . . . • Health Information Exchanges (HIEs) • immediate benefit and greater cost savings • Community-wide care coordination (CCC) • more benefit and cost savings

11. Physician Organization in Relation to Quality and Efficiency of CareThe Commonwealth Fund, April 2008 Evidence Increasingly shows that improved “systemness” drives quality and efficiency System: a group of independent but interrelated elements Designed to work as a coherent entity

12. Where Will there beSavings? Majority: From the Exchange of Clinical Information among care providers Reduction in duplicate Dx procedures Prevention of Medical Error Source: Center for Information Technology Leadership 2005

13. 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

14. Health Information - Useful Available at the POS Logically presented Current Medicare patient - 5.6 providers/yr (7.7 providers/yr including 2 PCPs) Community Care Coordination

15. Definitions: EMR vs. HIE vs. HIO vs. CCC HIE

16. Health Information Organization RHIO Greatest Value Your Data is Local (CCC) Business Model - Self Supporting Stakeholders/Users Quality, Safety & Efficient Delivery Govern, Sets Rules Statewide Network of Networks Disaster Bioterrorism Public Health National (NHIN)

17. Scale State-wide: A Network of Networks • Local governance • Common technology

19. Anatomy of a HIE Patient Portal Physician Portal Population Care Analytics Health Information Exchange Medical Education Electronic Master Patient Index

20. Anatomy: Detailed Version • HIE - Central Data Repository for a core set of clinical variables • eMPI - Master Patient Index tracks unique patients and ensures data integrity • Community Order Entry/Physician Portal- Centralized system coordinating orders, referrals, consultations, radiology and diagnostic tests, PT/OT, etc. • Decision analytics - Tools and algorithms for patient identification, prioritizing patients for interventions, prioritizing appropriate interventions each patient • Patient Portal - gives patients access to their own community health records, ability to communicate with their providers: • eVisits, Schedule requests, Refill requests, Patient educational materials, Self-care logs (BP, BS, asthma, etc.), Health Risk Assessments (Depression screen, Cardiac risk), Review records shared across the community • Comprehensive clinical education support • Trainee portfolios, Evaluations, Delivery of relevant didactic educational materials

21. Organizing the Concepts • What is the relationship between Health Information Exchanges and the Patient Centered Medical Home? Patient Centered Medical Home Patient Centered Medical Home Patient Centered Medical Home Patient Centered Medical Home Patient Centered Medical Home Patient Centered Medical Home Reimbursement Model Health Information Exchange Health Information Exchange

22. Medical Home & HIE Fragmented Care More patients Complex populations 1in 4 - Behavioral Health Diagnosis (Duals Drive cost ) Medicaid 46% Medicare 24% Investing in the Aftermath vs Ahead of the curve Resource Drain from Missed Early Opportunities

23. Medical HomeGoals Integrated Systems More Efficient Use of Resources Identify & Prioritize patients for Intervention (ahead of the curve) Link Providers - Coordinate Care Raise Quality - Evidence Based Guidelines Identify Quality issues & Make Rapid Changes

25. Have we given this any thought? • 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

26. 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 and specifically for the Tulsa region?

27. 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

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

29. 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

30. What about funding? • One time: • ARRA stimulus dollars • Other grants • Ongoing: • Business model must be developed • ROI by stakeholder will drive the business model

31. ARRA Stimulus Dollars Washington, D.C. Earmarks Federal Agency Grants State distributions ONCHIT Heath Dept AHRQ OHCA DHS

32. Opportunity: Stimulus Package • Federal Agencies offering • $20B for healthcare IT, $3B short term and $300M immediately • $1B for comparative effectiveness research • $1.5B for community health centers • Much will be distributed through grant process • Will be highly competitive • Many other communities have been in this game for years • Our communities must • Be unified behind a well-developed plan of action • We must build the coalition now Greater Tulsa Health Access Network

33. From the final ARRA:In order to be eligible for Stimulus Grants • Must be a qualified State-designated entity • Designated by State as eligible to receive awards • Non-profit entity • Clear objectives to use Healthcare information technology to improve care quality and efficiency through secure data exchange • Adopt non-discrimination and conflict of interest policies • Broad stakeholder representation on governing board

34. CMS really wants EMR and HIE adoption . . . † *Assume N=1,500 MDs, DOs, PAs, and NPs and 7 hospitals see Medicare patients †Penalties for non-adoption not yet elaborated, but assume mirror bonuses

35. From the final ARRA:Regional organization must include • Providers, including those focused on low-income and underserved • Health plans • Patient and consumer organizations • HIT vendors • Healthcare purchasers and employers • Public health agencies • Universities • Clinical researchers • Other staff who use HIT

36. 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