Trends in Health Information Exchange and Implications for Public Health

1. Trends in Health Information Exchange and Implications for Public Health June 12, 2013

2. The inverse-square law of health information exchange

3. HIE is maturing HIE 1.0 hie 2.0 • Focused on “the noun” • Assumed hierarchy of HIEs • State- and regional-level HIEs feeding into a National Health Information Network • Assumed repository-style architectures with rich applications • Focused on “the verb” • No organized hierarchy of HIE organizations • No “National Network” • State-level HIEs highly varied and locally driven • Greatest growth in “private HIEs”: vendor- and ACO-driven • Wide variety of integration approaches

4. What is driving this transition? • Limited successes of the prior model • Bottom-up demand -- systems are not interoperable because not enough customers asked for interoperability • Meaningful Use incentives • Value-based purchasing • Market expectations about standards of care • Younger provider expectations about use of technology • Consumer expectations about use of technology • Supply-side • EHR certification requirements – common denominator important in a fragmented industry • Technology advancements in cloud services, mobile, broadband, storage, patient-matching capability, etc

5. HIE Building Blocks Business models HIT/HIE Uses Functional requirements Enterprise Integration & Management Business process harmonization Population, Risk, and Financial Management Content and vocabulary standards Documentation standardization Analytics definition synchronization Measurement & Reporting Case management and patient access Patient-matching Medical record indexing Consent management Data access and use contracts Clinical portals (patient/provider) Registries & Repositories MU capability Cross-system query Accountable care capability Interfaces to connecting systems Security and transport standards Physician/facility directory Message & document delivery EHR functions Amount of central orchestration required

6. Data Needs Vary With Business Goals Enterprise Integration & Management • Business integration Population, Risk, and Financial Management Population, Risk, and Financial Management • Business alignment • Team-based care • Patient engagement Measurement & Reporting Case management, and patient access Case management & patient access Case management & patient access Case management & patient access • Performance mgmt • Population mgmt • Utilization mgmt • Case facilitation Registries & Repositories Registries & Repositories Registries & Repositories Cross-system query Cross-system query Cross-system query Message & document delivery Message & document delivery Message & document delivery Message & document delivery • Become electronic • Fill in gaps in care transitions EHR functions EHR functions EHR functions EHR functions Independent actors IPA/PHO Accountable care entities IDN

7. hie 2.0 comes in many shapes and sizes National level collaborative HIE organizations (e.g., Healtheway) State-level and regional collaborative HIE organizations Transaction-specific national level (e.g., Surescripts) Level of external coordination needed Level of highest growth Enterprise-level HIE organizations (e.g., “private HIEs”) Vendor-specific (e.g., Epic, eClinicalworks) Point-to-point (e.g., LabCorps, hospital labs) Point-to-patient

8. hie 2.0 comes in many shapes and sizes (2) Visual integration Data integration Document integration • Ability to export and import structured data • Incorporate in EHR and usable for all EHR analytic and decision support functions • Ability to export and import clinical documents • Attach to patient record and viewable • Ability to provide view into another clinical system at point-of-care • No exchange of data or documents Growing rapidly and likely to increase even more with maturation of directed exchange capabilities Growing increasingly common to solve immediate need without interfacing and application workflow redesign • Essentially not happening, except: • Specific transaction streams such as eRX and labs • Within EHR network, such as Epic and eCW • Sophisticated implementations such as Healtheway

9. National-level HIOs are most comprehensive HIE implementations, but still quite thin • Over 20 participants (4 federal) as of September 2011 • Over 90,000 transactions conducted • HIE solution based on NHIN standards enabling send/receive and query/retrieve • DURSA covering complete set of exchange patterns • Five provider organizations (Geisinger, Kaiser, Mayo, Intermountain, Group Health) • Complete solution based on NHIN standards enabling send/receive and query/retrieve

10. State-level collaborative HIE activity high in certain areas Directed transactions Query transactions 14 million directed exchanges per month 3.2 million directed exchanges per month 42 remaining HIE activities had fewer than 1,000 monthly transactions 200K+ directed exchanges per month 37 remaining HIE activities had no query-based transactions Source: ONC HIE Dashboard

11. EHR vendors with high penetration generating large amount of vendor-specific HIE traffic • Large majority of customers (200+) participating in query-based exchanges • Currently CCD/CDA query-based exchange is ~2.2 million records for ~385K unique patients per month • Volume doubled over previous year • Does not include HL7 directed exchange transactions • 16,743 providers using query-based exchange • ~2.5 million new CCD records made available on query exchange hubs or sent directly to referral providers per month • Processed over 75+ million lab result records in 2012 • ~1.5 million query-based exchanges per month • ~58.5 million directed exchange transactions per month (including HL7 lab result delivery) Source: Epic, eClinicalWorks, Cerner

12. Lab Market Is Highly Fragmented 116,634 physician office laboratories • Fragmentation may be increasing as hospitals increase lab business to offset revenue decreases in other areas • Fragmentation makes it difficult to generate collective action for a national lab network like Surescripts • Meaningful Use is the only industry-wide force driving standardization of lab results delivery • High fragmentation of lab market makes it difficult to measure progress of electronic transactions • ONC is now fielding national lab survey 5,604 commercial labs • Quest: ~30% • LabCorp: ~20% • Only Quest and LabCorp cover the entire US • Next largest, Spectra, covers 1/3 of US counties and county-equivalents 8,807 hospital labs % of labs conducted Source: Quest Diagnostics 2009 Annual Report; CMS CLIA Update July 2012

13. Large fraction of lab results delivery still via fax and paper % lab electronic lab results • Progress in electronic results delivery tied to EHR penetration • Interface implementation is significant barrier to progress – lack of standardization and competing priorities • MU Stage 2 may not be enough of a spur to significantly increase electronic delivery from hospitals – does not require electronic delivery and standardization of electronic delivery is menu set item Paper/fax delivery HL7 interfaces ~585 million lab results delivered by Cerner customers per month Source: Cerner Corporation

14. Large fraction of lab results delivery still via fax and paper % lab electronic lab results • athenahealthhas unique data because they track ALL lab result reports delivered to their customers • Small number of labs account for majority of electronic results • Effort required for interface deployment is barrier both on the lab side as well as on EHR vendor side • athenahealthcompleting about 15 new lab interfaces per month • Large practices have higher lab interface rate (68%) than small practices (56%) who get lower priority from labs -- commercial labs do not cover cost of interfaces to small practices • Not interfaced with ~6800 labs • ~3,400 fax • ~3,400 paper, portal, etc HL7 interfaces with ~600 labs Analysis of 29 million lab result records received by athenahealth customers Source: athenahealth

15. Large gap in LOINC-mapping capabilities % LOINC-encoded labs • Vast majority of labs do not send LOINC-encoded results • 1 national lab does, another national lab can but currently does not because has not been asked to • Large commercial labs capable of LOINC-encoding, however, vast majority of hospitals are not and will take significant effort to get them there • MU Stage 2 may not provide enough of a spur given difficulty of effort, allowed variation in state public health requirements, and competing priorities ~599 labs send results with proprietary codes Only 1 lab sends LOINC-encoded results Analysis of 29 million lab result records received by athenahealth customers Source: athenahealth

16. HIE Activity Mushrooming Across the Region VITL NH-HIO North Adams Newburyport NYeC Winchester Beverly Emerson Holyoke Berkshire Health NEHEN Baystate SafeHealth South Shore Sturdy RIQI Cape Cod Health

17. MassHealth DPH Current state of the market favors a network of networks connected via a single statewide open HISP supported by centralized project managementIllustrative example BIDMC Partners NwHIN Berkshire Health System EOHHS NEHEN Direct gateway services PKI/certificate mgmt Web portal Provider/entity directory Audit log Atrius SafeHealth MD MD MD MD MD MD MD Fallon Clinic UMass Memorial MD MD MD

18. Data Aggregation Process Steps Data requirements Clinical sources Transport Management and analysis Reporting and data access H RX Labs Vitals Problems Patient Provider Payer etc H H H MDs MDs MDs MDs Remediation and Improvement • Key questions: • How well-defined are reporting/analysis needs, and corresponding data requirements? Will source-level remediation be required? • How many clinical sources will be included? What is integration strategy and timeline for disparate EHR systems? • Which transport option? What are pros/cons of each? • Are there unique data management and analysis requirements? • Who will be accessing reports and data? Are there unique reporting and/or data access requirements? • How will reporting/analysis integrate with business and care processes?

19. BIDCO QDC Cumulative records 2013 YTD (828,339) • Electronic reporting • MU, PQRS, AQC, etc 576,765 • Data management • Report viewing • Case tracking BIDCO QDC • Data extraction • Queries • Pre-defined data marts 231,218 • Current status: • 5,611,698 care event C32 records • Covers 614,829 unique patients • Covers 2,506 unique providers • Management Info System • User information • Utilization analysis • Other 20,356 Documentation & Extraction Transport Validation & Analysis User Access

20. Cumulative records 2013 YTD (278,587) AHI QDC 31,504 84,507 • Data management • Report viewing • Case tracking Pod 1 50,416 87,934 AHI QDC • Data management • Report viewing • Case tracking Pod 2 13,061 • Current status: • 760,923 care event C32 records • Covers 155,740 unique patients • Covers 300+ unique providers Pod 3 11,165 • Data management • Report viewing • Case tracking Documentation & Extraction Transport Validation & Analysis User Access

21. Current Data Frequency Count AHI BIDCO

22. Implications for Public Health • Heterogeneity will be the hallmark of HIE activity in the coming years • Multi-layered HIE modes seem to be developing as business practices mature • “B2B”-style patterns to move documents around with little to no centralized coordination – Direct and Directed Query • “Supply-chain” style patterns with deep integration among very closely aligned entities seeking centralized orchestration for rich applications to support complex uses • Aggregation at the edge • HIE as conduit for aggregation rather than as repositories themselves • Alignment with Meaningful Use • MU Stage 2 includes higher standards for clinical content • Aligning with and/or “piggy-backing” on MU and ACO capabilities is most likely path to scaleable model for rich, longitudinal data to meet variety of public and population health purposes

23. www.maehc.orgMicky Tripathi, PhD MPPPresident & CEOmtripathi@maehc.org781-434-7906