Evolution of Healthcare Information Exchange: Past and Future Perspectives

1. IABPAD MemphisHEALTHINFORMATIONEXCHANGE- A Public Policy Challenge for Healthcare Professionals and Administrators L. Philip Caillouet PhD FHIMSS Louisiana Center for Health Informatics The University of Louisiana at LafayetteOctober 28, 2011

2. Outline of This Presentation • Introduction • A Brief History of Standards, Networks, CHINs, RHIOs and HIEs • A Vision of the Future • “Top-Down” Goals and Strategies • “Bottom-Up” Inertia • Incomes and Outcomes

3. A Brief History of Standards, Networks, CHINs, RHIOs, and HIEs George Santayana (1863-1952): “Those who cannot remember the past are condemned to repeat it.”

4. A Brief History ... 1987-today • Health Level 7, ASTM E31, IEEE P1157 & P1073, ANSI X12N, NCPDP, WEDI, and other standards development organizations (SDOs) work to link computers in healthcare – at multiple levels of the Open Systems Interconnection (OSI) Model, from “physical” to “application”. 1991 • Institute of Medicine’s “The Computer-based Patient Record (CPR): An Essential Technology for Health Care”. • John A. Hartford Foundation ‘s “Community Health Management Information System, Functional Specifications” (by Benton International). • High Performance Computing and Communication Act of 1991 (“The Gore Bill”) allows NSFNet to connect to commercial networks. 1992 • WEDI’s “Report to the Secretary of U. S. Department of HHS”. • World-Wide Web hypertext linkage capabilities deployed outside of research. • Hewlett-Packard’s Imagine video released as a depiction of a visionary future.

5. A Brief History ... (continued) 1993 • Clinton Administration takes office and “Health Security Act” proposed, with many “Administrative Simplification” provisions to require EDI. • Provider market consolidation accelerates to grab market-share before reforms. 1994 • Singer’s “Community Health Information Networks: Hype or Reality?”. • Wakerly’s “Community Health Information Networks: Creating the Health Care Data Highway”. • Metropolitan Chicago CHIN and other, more successful efforts. • Clinton’s “Health Security Act” defeated; Democrats lose Congress. 1995 • “dot-com” era begins. • Even with federal health care reform unlikely, market consolidation continues. • Emphasis on hospital-centric CHINs for “physician bonding” [“bondage”?]. • Community Medical Network Society (ComNet Society). • 2nd Annual CHIN Summit (Chicago IL). • “Acadiana Hot Link” (Lafayette LA) launched as concept of GLCC;first industry focus to be healthcare; key players to be LGMC, USL, others

6. A Brief History ... (continued) 1996 • ComNet’s 1996 HIN Market Directory lists 522 “CHINs-In-Progress in 1995, including five in Louisiana. • HIPAA passed & signed by Clinton; includes “Administration Simplification” provisions in “Health Security Act”. • “Acadiana Hot Link” gets some buy-in, but never achieves critical mass by the time that GLCC leadership transition is made at the end of year. 1996-2000 • Internet commercialization and “dot-com” opportunities heavily hyped, including healthcare industry applications. • “dot-com” bubble eventually bursts when venture capital sources dry up. 2001-2003 • Bush administration takes office, crossing Gore’s “bridge to new millennium”. • Terrorist attacks force refocus on security and rooting out terror sources. • Bush HHS Secretary Tommy Thompson makes slow but deliberate progress on HIPAA-mandated privacy and security rules, without which CHIN development cannot go forward.

7. A Brief History ... (continued) 2004 • Office of the National Coordinator of Health Information Technology (“ONCHIT” or simply ONC”) created in 2004 within HHS, with David Brailer MD, appointed in 2004 as first ONC director. • Brailer adopts the term “Regional Health Information Organization (RHIO)”; the term “CHIN” goes away virtually overnight, while “Health Information Exchange (HIE)” is used to describe the function of a RHIO. • Eventually, HIE replaces RHIO as the generic name of any organization that performs the HIE function. 2005-2006 • Katrina and Rita devastate the Louisiana and Mississippi Gulf Coast, leading to the Markle Foundation’s “KatrinaHealth.org” project, to “LaHIE-1”, and to the formation of the SGA Gulf Coast HIT Task Force, and ICE-Rx. • Louisiana Recovery Authority (LRA) fails to recommend healthcare reforms. • Louisiana Healthcare Redesign Collaborative (LHRC) proposes “Medical Home” concept heavily dependent on HIT (EHRs & HIE). • Louisiana Health Care Quality Forum (LHCQF) created to extend LHRC work.

8. A Brief History ... (continued) 2006-2009 • Robert Kolodner MD, replaces Brailer as ONC director in 2006; serves until 2009. • In 2006, the Tax Relief and Health Care Act (TRHCA) established a physician quality reporting initiative (PQRI), including an incentive payment for eligible professionals who satisfactorily report data on quality measures. PQRI is now called the PQR System. • CCHIT begins certifying EHR products, under contract from ONCHIT. 2009 • Obama Administration takes office; months pass before Sebelius joins HHS. • “Stimulus Bill” (American Recovery and Reinvestment Act or ARRA) is passed and signed into law in February 2009. • ARRA contains “the HITECH ACT” which funds Cooperative Agreements with States to create HIEs within each jurisdiction. • LHCQF is named “State-Designated Entity (SDE)” by Louisiana DHH for purposes of ARRA funding. • David Blumenthal MD, replaces Kolodner as ONC director in 2009; serves until 2011.

9. A Brief History ... (continued) 2010 • LHCQF awarded HIE Cooperative Agreement funding, as well as Regional Extension Center funding. • “Healthcare Reform Bill” (Patient Protection and Accountable Care Act or PPACA) is passed and signed into law; Democrats lose House. • Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) EHR Incentive Program “Meaningful Use” Final Rule released. • LHQCF begins to establish relationships with Project Implementation Partners, IT Infrastructure partners, “preferred” EHR vendors, and with HIE developers and platform hosts. • “Acadiana Hot Link” agenda back on the table? 2011 • Farzad Mostashari MD replaces Blumenthal as ONC director in 2011. • LHCQF awards Technical Architecture vendor contract to Orion Health (August). • LHCQF formally launches LaHIE at LaHIMSS Conference (November 3-4).

10. A Vision of the Future Visualize healthcare as having only two underlying processes: a. provision of care b. gathering information to facilitate the provision of care in the future

11. Healthcare Information: Order from Chaos? Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. ASO TPAs Network & Care Mgrs. Credit Bureaus Claims Assistance Financial Services Color Key: Clinical (specific) Clinical (summary) Financial Administrative Patients Insurers

12. Once Upon a Time ... … things were simple ...

13. Healthcare Information: Simple Beginnings The Doctor-Patient Relationship Physicians Patients

14. The Hypothetico-Deductive Approachfrom Biomedical Informatics, Shortliffe & Cimino editors, Springer, 2006.

15. Healthcare Information: Post-World War II Wage & Price Freezes; Government Subsidies Equip. Mfrs. Hospitals Suppliers Employers, Unions, & Assns. Physicians Workers Insurers

16. Healthcare Information: The Great Society Medicare & Medicaid Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians Citizens Insurers

17. Healthcare Information: Corporate Self-Insurance The Bottom Line Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians ASO TPAs Enrollees Insurers

18. Healthcare Information: Rise of the HMO, PPO, & IPA Wellness, Not Illness Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians ASO TPAs Network & Care Mgrs. Members Insurers

19. Healthcare Information: Direct Contracting & Data Services Who Has Data Wins Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians IPAs ASO TPAs Covered Lives Network & Care Mgrs. Insurers

20. Healthcare Information: Cost Sharing Sharing = “You Pay” Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Physicians IPAs ASO TPAs Network & Care Mgrs. Consumers Credit Bureaus Claims Assistance Financial Services Insurers

21. Healthcare Information: Supply-Side Economics Technology & Cash Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. IPAs ASO TPAs Marginal Units Network & Care Mgrs. Credit Bureaus Claims Assistance Financial Services Insurers

22. Healthcare Information: Vertically Integrated Health Systems “Hospitals” to “Systems” Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. IPAs ASO TPAs Network & Care Mgrs. Populations Credit Bureaus Claims Assistance Financial Services Insurers

23. Healthcare Information: A State of Confusion!?! Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. IPAs Us! ASO TPAs Network & Care Mgrs. Credit Bureaus Claims Assistance Financial Services Insurers

24. Will We Live Happily Ever After? Enter Healthcare Reform andHealth Insurance Reform Accountable Care Organizations? Coordinated Care Networks? National Health Information Infrastructure? Meaningful Use? … one more time ...

26. So … Will We Live Happily Ever After? ???

27. “Top-Down” Goals and Strategies “Meaningful Use” or “Meaningless Abuse”?

28. CMS Health Outcomes Policy Priorities • Improve quality, safety, efficiency, and reducing health disparities • Engage patients and families in their health care • Improve care coordination • Ensure adequate privacy and security protections for personal health information • Improve population and public health (Unless an EP, Eligible Hospital or CAH has an exception for all of these objectives and measures they must complete at least one in order to be a meaningful EHR user.)

29. Health Outcomes Policy Priorities and Stage 1 Meaningful Use Objectives [Core Set (CS) and Menu Set (MS)] I. Improving quality, safety, efficiency, and reducing health disparities CS1. Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines CS2. Implement drug-drug and drug-allergy interaction checks CS3. Generate and transmit permissible prescriptions electronically (eRx) [N/A for EHs/CAHs] CS4. Record demographics (preferred language, gender, race, ethnicity, date of birth) CS5. Maintain an up-to-date problem list of current and active diagnoses CS6. Maintain active medication list CS7. Maintain active medication allergy list CS8. Record and chart changes in vital signs: Height, Weight, Blood pressure, Calculate and display BMI, Plot and display growth charts forchildren 2-20 years, including BMI CS9. Record smoking status for patients 13 years old or older CS10. Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance that rule CS11. Report ambulatory clinical quality measures to CMS or the States MS1. Implement drug-formulary checks MS2. Record advance directives for patients 65 years or older [N/A for EPs] MS3. Incorporate clinical lab-test results into certified EHR technology as structured data MS4. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach MS5. Send reminders to patients per patient preference for preventive/ follow up care [N/A for EHs/CAHs]

30. Health Outcomes Policy Priorities and Stage 1 Meaningful Use Objectives [Core Set (CS) and Menu Set (MS)] II. Engage patients and families in their health care CS12. Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), upon request CS13. Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request [N/A for EPs] CS14. Provide clinical summaries for patients for each office visit [N/A for EHs/CAHs] MS6. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within four business days of the information being available to the EP [N/A for EHs/CAHs] MS7. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate

31. Health Outcomes Policy Priorities and Stage 1 Meaningful Use Objectives [Core Set (CS) and Menu Set (MS)] III. Improve care coordination CS15. Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically MS8. The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation MS9. The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary of care record for each transition of care or referral

32. Health Outcomes Policy Priorities and Stage 1 Meaningful Use Objectives [Core Set (CS) and Menu Set (MS)] IV. Ensure adequate privacy and security protections for personal health information CS16. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities

33. Health Outcomes Policy Priorities and Stage 1 Meaningful Use Objectives [Core Set (CS) and Menu Set (MS)] V. Improve population and public health (Unless an EP, eligible hospital or CAH has an exception for all of these objectives and measures they must complete at least one in order to be a meaningful EHR user.) MS10. Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice MS11. Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice MS12. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice

34. Reality: “Bottom-Up” Inertia Isaac Newton – First Law of Motion: “Every body persists in its state of being at rest or of moving uniformly straight forward, except insofar as it is compelled to change its state by force impressed.”

35. No Substitutefor Bottom-up Commitment • CHINs and RHIOs have failed in the past to be sustainable after seed money runs out because of flawed “value propositions” or “business cases”. • Organizers can fall prey to making good-faith assumptions (e.g., “if we build it, they will come”) when a top-down only approach is taken. • HIEs stand better chance of success with today’s technology compared to that of the 1990s, but only if the “business case” can deliver timely ROI to the participating users and to the community at large.

36. Value Proposition • It is not sufficient for an HIE to be an overall good idea, but rather a “value proposition” must be clear at the atomic level – i.e., for each and every “use-case” – or else participation will be rejected. • Benefits – both quantifiable and qualitative ROI • Beneficiaries – may not be the same as the investors

37. Use-Case Scenarios • Use-Case Scenarios for ambulatory care • Pre-Arrival • Point of Arrival • Point of Care • Point of Departure • Post-Departure • Use-Case Scenarios for acute care • Use-Case Scenarios for disaster evacuations

38. Ambulatory CareUse-Case Scenarios

39. Ambulatory CareUse-Case Scenarios(continued)

41. 3. Benefits fromUse-Case Scenarios(continued)

43. Incomes and Outcomes Active Support, Acquiescence, Passive Resistance, Active Resistance, Leave Taking

44. “You can lead a horse to water … • ONCHIT and CMS public policy makers have done a laudatory job of specifying in considerable detail their expectations for HIE participation. • One reason for their success is the input sought from and provided by the American Health Information Community (AHIC) from 2005 through 2008 and subsequently by the federal HIT Policy Committee and its various workgroups.

45. … but you can’t make him drink.” • It remains to be seen, however, as to whether large numbers of healthcare professionals and institutions succeed in achieving status as “meaningful users” of HIT. • As Dunham suggests, the reaction of potential users will range across the full spectrum from active support, through acquiescence, through passive or active resistance, to leave taking.

46. Do Outcomes Depend on Incomes? • Perhaps sustainability will only be possible if enough users recognize that as “carrots become sticks” their future incomes will in fact be directly related to achievement of the policy outcomes. • To date, there is no “pain.” • On a positive note, community pride may also carry the day in some locales.

47. Closing the Deal – in Lafayette LA • To succeed in Louisiana, HIE must succeed in Lafayette -- one of a very few cities in the U. S. where local government owns and operates an extensive fiber loop, and where technology is a point of community pride! • In Lafayette, the mantra is …“The feds have set a high bar for EHR and HIE participation, but it's the feds’ bar not ours.” • Lafayette’s approach is ...“Set your own expectations; then work hard to exceed those!”

48. Questions, Comments,or Suggestions? <caillouet@louisiana.edu> Learn more at http://lchi.louisiana.edu