MASSACHUSETTS eHEALTH COLLABORATIVE HIT Symposium

1. MASSACHUSETTS eHEALTH COLLABORATIVEHIT Symposium July 2006

2. MASSACHUSETTS COMMUNITY OF E-HEALTH ORGANIZATIONS 1978 1998 2003 2004 • “The Convener” • “The Transactor” • “The Grid” • “The Last Mile” • The convener and educational organization, the business incubator • The transactor of administrative (HIPAA transaction) processes • The grid of state-wide clinical utilities • The last-mile to clinician offices

3. Company launched September 2004 • Non-profit registered in the State of Massachusetts • CEO on board January 2005 • Backed by broad array of 34 MA health care stakeholders MAeHC ROOTS ARE IN MOVEMENT TO IMPROVE QUALITY, SAFETY, EFFICIENCY OF CARE • Universal adoption of electronic health records • MA-SAFE • $50M commitment to heath information infrastructure • Recognition of “systems” problem

4. 34 ORGANIZATIONS REPRESENTED ON MAeHC BOARD • Health plans and payer organizations • Alliance for Health Care Improvement • Blue Cross Blue Shield of Massachusetts • Fallon Community Health Plan • Harvard Pilgrim Health Care • Massachusetts Association of Health Plans • Massachusetts Health Quality Partners • Tufts Associated Health Maintenance Organization • Healthcare purchaser organizations • Associated Industries of Massachusetts • Massachusetts Business Roundtable • Massachusetts Group Insurance Commission • Non-voting members • Center for Medicare & Medicaid Services • Healthcare professional associations • American College of Physicians • Massachusetts League of Community Health Centers • Massachusetts Medical Society • Massachusetts Nurses Association • Consumer, public interest, and labor • Health Care for All • Massachusetts Coalition for the Prevention of Medical Errors • Massachusetts Health Data Consortium • Massachusetts Taxpayers Foundation • Massachusetts Technology Collaborative • MassPRO, Inc. • New England Healthcare Institute • Hospitals and hospital associations • Baystate Health System • Beth Israel Deaconess Medical Center • Boston Medical Center • Caritas Christi • Fallon Clinic, Inc. • Lahey Clinic Medical Center • Massachusetts Hospital Association • Massachusetts Council of Community Hospitals • Partners Healthcare • Tufts-New England Medical Center • University of Massachusetts Memorial Medical Center Governmental agencies • Executive Office of Health and Human Services

5. …incorporated into clinical practice… • …and sustained over time. • Overcome barriers to promote widespread use of EHRs and associated decision support tools • Lack of capital • Misaligned economic incentives • Immature technology standards • Develop operational and financing models to foster and sustain state-wide adoption of such technologies and infrastructures MAeHC VISION • Tools for better, more accessible health care… • Improve quality, safety, and affordability of health care through: • Universal adoption of modern information technology in clinical settings • Access to comprehensive clinical information in real-time at the point-of-care

6. MAEHC MISSION: CLINICAL IT ADOPTION THROUGH COMMUNITY EMPOWERMENT

7. ICCC PSC PSC PSC PILOT PROJECTS HAVE FOUR MAIN PIECES Management & coordination • Joint oversight and decision-making bodies • Multi-stakeholder governance Evaluation • Quality • Cost • Productivity • Etc. • Quality measurement • Pilot evaluation Intra-community connectivity Connectivity • Clinical access to data • Data gathering and aggregation • Communication • Hardware/software • Implementation/tech support • Systems integration • Workflow redesign • Decision support Clinical IT implementation/ support

8. MAeHC PROJECT TIMELINE Activities 2004 2005 2006 2007 2008 ACP-MA summit MAeHC launch Community RFA launch Pilot communities announced EHR vendor RFP EHR vendor finalization Physician recruitment Implementation Evaluation Formal Pilot completion

9. 94% participation 149 158 = EVEN $50M CAN’T GET THE LAST 5% • Main sources of attrition: • Outyear cost • Close to retirement • Too much of a hassle 22 180 9 149 Most didn’t fit MAeHC definition of community

10. Patient population (000) 488 43 95 350 DIVERSE ARRAY OF SETTINGS …in almost 200 offices. Almost 450 physicians… …who care for ~500K patients… Offices Physicians 177 65 445 25 Large Med 85 41 295 111 Specialists Small PCPs Brockton N. Adams Brockton N. Adams Brockton N. Adams Newburyport All Newburyport All Newburyport All

11. HIGHLAND PRIMARY CARE KICK-OFF Docs link up to new record styleBy Jennifer Heldt PowellTuesday, March 14, 2006 The end of the paper trailBy Ulrika G. Gerth/ ugerth@cnc.comFriday, March 17, 2006 Setting a new record: Local doctors pilot electronic patient history system By Stephanie Chelf Staff Writer

12. PHYSICIANS “GOING LIVE”, BY COMMUNITY 9 7 5 19 21 33 25 24 27 67 121 9 64 1 7 1 441 # MDs North Adams (55) Newburyport (81) Brockton (305) 2006 2007

13. MA-SHARE Intra-community connectivity Inter-community connectivity THE GRID AND THE LAST MILE

14. THE NEXT PHASE: CONNECTING PHYSICIANS Patient permission Privacy and security Clinical utility Sustainability Health Information Exchange

15. Physician portal • Patient-centric clinical summary • Medications • Labs • Allergies • Problems • Other • eReferrals • Secure-messaging between care-givers • Tracks and matches outbound/inbound referrals, and outbound/inbound consult reports ehr ehr ehr eCR eRef ehr Patient portal ePatient ehr • Patient-specific functions • Appointment requests • e-visits • Clinical summary • Other NORTH ADAMS HEALTH INFORMATION EXCHANGE HIS

19. Low Physician adoption Business sustainability threshhold Clinical usefulness Patient opt-ins DRIVERS OF BUSINESS SUSTAINABILITY High Low High Clinical data fields in eHealth Summary Structured, codified data Unstructured, text Medications Labs Problems Allergies Medical/family history Notes

20. PRIVACY APPROACH SUMMARY (I) • MAeHC and communities need to decide what patient notification or consent we will require for data exchange in community pilots • Not required for stand-alone EHRs • Will be required for data exchange across legal entities • Data exchange already happens today • Current exchanges happen by fax, phone, mail, email, and remote access • Community network could change the scale but probably not scope of that exchange (ie, same type of information will be exchanged but more often) • With no “person-in-the-loop”, electronic data access may seem more risky, whether it is or not

21. PRIVACY APPROACH SUMMARY (II) • Even though we’re just changing the transport vehicle, we can’t rely on existing notifications and consents to cover exchange over the new network • MAeHC commitment to transparency will necessitate some form of patient notification or consent about new network • Furthermore, we can’t assume that current entities have gotten patient consent that conforms with MA consent laws– very likely that many have not • Notification about the network is not enough – MA law argues for some form of affirmative consent BEFORE disclosing data across legal entities • HIPAA Notice of Privacy Practices does NOT count for MA consent • MA consent requires affirmative consent for disclosure of clinical information, and a second affirmative consent for disclosure of sensitive information • Question before us now is how to get patient consent in a way that is ethically and legally robust and operationally sound

22. Publish Community Network Name-location index published for entities who have gotten consent Consent Jane Jones eCommunity Record June 9, 2006 Visit history xxx xxx Active problem list xxx Dr. Jane Brody Current medications xxx Seacoast Cardio Current allergies xxx Dr. Jane Brody Recent laboratory results xxx AJ Hospital Recent radiology results xxx AJ Hospital Other xxx XXX Patient chooses which entity’s records to make available to network Physician views data prior to or during patient visit 3 Retrieve 4 2 N Y Y Y Y 1 Visit Patient visits clinical entity for care and is provided option at first visit to opt-in all clinical data from EACH entity ENTITY-BY-ENTITY OPT-IN (REPOSITORY MODEL) Jane Jones Jane Jones

23. EVALUATION PROGRAM WILL SUPPORT THREE KEY PILOT PROGRAM OBJECTIVES Adoption • What are the most significant adoption barriers? • What are the best ways to overcome them? • What are the costs (direct and indirect) of adoption of IT? • What are the benefits? • How are the costs and benefits distributed across payers, providers, government, patients, ancillaries, etc? • How much money will be required to implement statewide? Value • What is general framework of incentives to implement and sustain the model? • What are the most effective management strategies for implementing and sustaining in communities? • What are the most effective organization models and tactics for implementing and sustaining statewide? Replication Efficacy vs Effectiveness

24. Return on investment(ROI) WHAT IS ROI?Physician Office Example Easier to measure Harder to measure • Cost saving • Time saving • Revenue increase • Physician/staff satisfaction • Quality of care • Error rate • Patient satisfaction • Liability exposure Benefits = Costs Easier to measure Harder to measure • Investment cost • Investment time • Ongoing cost • Revenue loss • Physician/staff dissatisfaction • Quality of care • Error rate • Patient satisfaction • Liability exposure

25. MAeHC QUALITY DATA WAREHOUSE CLINICAL MEASURES FOR PHYSICIAN PERFORMANCE AQA Recommended Starter Set • 1. Breast Cancer Screening • 2. Colorectal Cancer Screening • 3. Cervical Cancer Screening • 4. Tobacco Use # • 5. Advising Smokers to Quit • 6. Influenza Vaccination • 7. Pneumonia Vaccination • 8. Drug Therapy for Lowering LDL Cholesterol# • 9. Beta-Blocker Treatment after Heart Attack • 10. Beta-Blocker Therapy – Post MI • 11. ACE Inhibitor /ARB Therapy# • 12. LVF Assessment# • 13. HbA1C Management • 14. HbA1C Management Control • 15. Blood Pressure Management# • 16. Lipid Measurement • 17. LDL Cholesterol Level (<130mg/dL) • 18. Eye Exam • 19. Use of Appropriate Medications for People w/ Asthma • 20. Asthma: Pharmacologic Therapy# • 21. Antidepressant Medication Management • 22. Antidepressant Medication Management • 23. Screening for Human Immunodeficiency Virus# • 24. Anti-D Immune Globulin# • 25. Appropriate Treatment for Children with Upper • 26. Appropriate Testing for Children with Pharyngitis

26. WHY DON’T WE JUST LET THE MARKET TAKE CARE OF THIS? • Current system pays for quantity, not quality • Physicians not trained or compensated to reduce fragmentation of care • Few if any incentives to reduce inefficiency, which rations care away from the under-served • No obvious place for consumers to voice their concerns about quality, safety, and protection of privacy • We have a societal interest in how implementation happens • Bad systems and/or bad implementations offer little, if any, value • Collective action and public goods barriers will prevent effective interoperability • “In the long run, we’re all dead....”

27. LEVELS OF HEALTH INFORMATION EXCHANGE No PC/information technology Fax/Email Structured messages, non-standard content/data Structured messages, standardized content/data

28. Technical coordination • Policy coordination • Process coordination • Community coordination 76% 5% 19% Fax/email Structured messages Standardized content TECHNICAL STANDARDIZATION IS ONLY THE BEGINNING... Percent Source: Center for Information Technology Leadership, MAeHC calculations

29. EARLY LESSONS LEARNED... • This can get done on a large scale, and it can get done collaboratively • Building the program is more difficult than originally anticipated • Fixed cost that we can leverage going forward • The market is shifting – getting attention of vendors somewhat harder than before • Affordability isn’t the only barrier to physician adoption • Starting the conversation creates a community – already seeing synergies • Where are we offering greatest value? • Funding • Practice catalyst – facilitators/navigators • Community catalyst – wholesale vs retail • Forcing HIE

30. ...SUGGEST SOME LESSONS ABOUT HOW TO EXTEND THE MODEL IN THE FUTURE • Community is an effective level of organization (“wholesale vs retail”) • Self-defined, cohesive. • Accept accountability for its members, apply peer pressure, and appeal to local pride • Efficient to serve logistically • Natural unit for establishing health information exchange • Central coordination and active intervention are key success factors • Reduced costs for hardware, software, implementation • Dramatic reduction in failure rate • Speedier rollout and recovery of physician productivity • Application of best practices to realize the systems’ potential • The Golden Rule applies (“whoever has the gold makes the rules”) • Direct funding increases compliance with best practices, including standardization, structured data capture • Minimizes “paving over the cow-paths” • Enables community-wide benefit of HIE

31. www.maehc.orgMicky Tripathi, PhD MPPPresident & CEOmtripathi@maehc.org781-434-7905