Redwood Health Information Collaborative 2-18-09

1. Redwood Health Information Collaborative2-18-09

2. Session Overview • Health Information Exchange: • Why? What? Who? How? • Challenges Along the Way • Results – Making a Difference

3. Acronyms to Enjoy • RHIO = Regional Health Information Organization • governance model / funding mechanism • HIE = Health Information Exchange • clinical / consumer / claims / public health • NHIE = National Health Information Exchange • (standardized interface, certified • technologies • NHIN: Nationwide Health Information Network • “network of networks” • EHR + PHR + HIE + PHIN + ???

4. 750,000 patients in multi-state region Hospitals: 18 Physicians: 1200 Public Health: 7 regional, 2 state Payor: 25% Medicare 20% Medicaid 18% uninsured 2-20% commercial Small – Med Employers: Eastman Chemical 7500 ETSU – 6500 Hospitals – 5500, 5400 2/3 of patients live in Tennessee 1/3 live in Virginia 5% in other states

5. CareSpark’s Mission Regional Population Has High Disparities of: • CareSpark’s mission is to improve the health • of people in NE Tennessee and SW Virginia through the collaborative use • of health information • Diabetes • Cardiovascular Disease • Hypertension • Lung Disease • Cancer • Premature Mortality CareSpark region has $2,400 higher per capita patient care coststhan other regions of the country

6. Regional Health Status

8. Trend are getting worse

9. Drug Caused Death Rates 2002 - 2003

10. Quality Measures For VACompared With Best Practices 17 Measures 2002 Data

11. Value is Derived from Better Medical Decisions Treatment Diagnostic Redundancy Patient Data Errors Electronic Medical Record Clinical Data Sharing Decision Support Source: SBCCDE, CITL, Gordian Project analysis

12. What Will CareSpark Do? • Outcomes Improvement • Individual health outcomes Population health status • Decision Support • (real-time, at point of care, across all systems) • Patient-specific info (Rx, Dx, Hx) • Clinical Best Practices • PHR / EMR / CCR • Cost-Efficient Use of Resources • Reduced duplication, errors, administrative costs

13. CareSpark’s Strategic Outcomes • Population Health Clinical Premature Mortality Adult Diabetics, Rx filled, vision / foot, HBA1C<7 New Diabetes Cases Lipid Panel LDL < 100 Flu Vaccines for 65+ Pneumo Vax for ages 65+, <2 ER Visits for Health Attack Stroke Therapy Post- MI followup Cancer Screenings (PAP, Mammogram, colorectal) Financial Savings -- ROI • Patient • Clinician • Facilities • Purchaser (health plan, employer, taxpayer, individual)

14. Awareness & Adoption of Best Practices Community Population Health Informaticist Public Health Individual (patient / consumer) Purchaser (Payors / employers) Clinician

15. Community-Wide Collaboration • Active, representative participation, including • Employers: Eastman Chemical Company, CGI, BAE Systems, City of Kingsport, • Payors: Blue Cross Blue Shield of Tennessee, John Deere Health / United Healthcare, Cariten • PHP, Highlands Wellmont Health Network • Hospitals: Mountain States Health Alliance, Wellmont Health System, Johnston Memorial • Hospital, Quillen V.A. Medical Center, Laughlin Memorial • Physician Practices: Holston Medical Group, Highlands Physicians, Health Alliance PHO, • Cardiovascular Associates, ETSU University Physicians, Clinch River Health Services, Frontier Health, • Southwest Virginia Community Care Network, Blue Ridge NeuroScience, C-Health • Health Education: East TN State University School of Medicine / College of Nursing/ College • of Public and Allied Health, University of Appalachia College of Pharmacy, University of Virginia • Public Health:Sullivan and Northeast Regional Health Departments in TN, Cumberland • Plateau and Lenowisco Health Districts in VA, Tennessee Department of Health, Virginia Department • of Health and Human Resources • Community Non-Profits: Kingsport Tomorrow, United Way of • Kingsport, Rotary Club of Kingsport, Kingsport Chamber of Commerce, • Bristol Chamber of Commerce, NETWORKS Sullivan County Partnership • Patient Advocacy Groups: American Cancer Society, • Minority Health Coalition, Mountain Empire Older Citizens • Local Technology Companies: Intellithought, LucentGlow, • Deliberare, Holston Technology, the Creative Trust, ntara

16. Stakeholder Advisory Groups Patient Physician Public Health Facilities Purchaser Project Management Office Partner Partner Partner Partner CareSpark RHIO Organizational Structure Board of Directors Nominating Legal Health Information Control Personnel Audit Finance Clinical CareSpark Management Technical Outcomes / Evaluation Population Health workgroup Financial Savings Workgroup Communications

17. CareSpark Board of Directors • Board Membership • Selected as individuals, not organizational rep’s • Expectation: put community good ahead of individual or organizational agenda • Self-perpetuating (nominating process, board members elect successors) • 1-3 year staggered terms, two-term maximum • Balance of leadership experience, necessary skill-sets, network contacts to achieve strategic goals, representative of stakeholder and regional demographic composition Current Members include: CIO of large health system, CEO of independent pharmacy, CEO of behavioral health provider, CEO of hospital-physician network, CFO of large insurer, Health Benefits director for large employer, President of large multi-speciality practice, CEO of community health center, Director of regional public health department, Chief of Staff for local V.A. hospital, Exec Director of regional seniors programs, VP for local university / rural health education

18. 1. 2. 3. 4. CareSpark’s Core Strategies Provide patient informationand decision support on demand at the point-of-care Align financial incentives to assure fair return on investment Empower patientsto make healthychoices & informed decisions Provide selected aggregate datafor population health improvement

19. Tennessee State-level leadership Common Portal • Coordinating organization facilitates rules of engagement: • Data-sharing Agreement • Legal Framework • Standards • Interoperability • Transparency • Value • Quality/Cost H.I.E. EMR / EHR/PHR Implementation Structured Notes & Paper Records Administrative Transactions (claims…) Secure Clinical Messaging (labs, imaging, email…) ePrescribing Roll Out Broadband % of Access, Stakeholders, Automation Framework for Trust and Collaboration

20. Virginia Health IT Framework

21. Virginia RHIO initiatives

22. Key Strategic Decisions • Enable participation by all patients and providers in region • 2. Enroll patients through default Passive Enrollment (“opt-out”) with option for Active Enrollment (“opt-in”) • - Passive or Active enrollment managed through Master Patient Option Preference (MPOP) and Local Patient Option Preference (LPOP) • Hybrid Model, combining Federated Repositories and Centralized Repository for limited clinical data • - Enabling decision support, monitoring and aggregate data analysis where regionally approved • 4. Data Access and Uses • Patient: view content of records, view access log • Provider: payment, treatment, operations • Public health: required reporting and authorized queries • Payers: de-identified aggregate data • Research: IRB-approved studies • Fee-Based Revenue Model • - Contracts with insurers and employers • - Transaction fees for data providers (labs, hospitals, large practices) • - Contributions (cash and inkind) • 6. Commitment to standards (IHE / HITSP, ISO)

23. Convergence of Data Clinical Patient-Centered Care Administrative Billing & Claims Personal Health Record Research Best Practices

24. From Patient Perspective • Perceived Benefits • Convenience • Access to critical information (allergies, rare diseases) • Reduced duplication = reduced cost • ability for proxy to manage care (adults caring for elderly parents from a distance) • Advanced directives • Perceived Risks • Privacy (unauthorized access or release) • Use of data (denial of care, coverage, or employment) • Identity theft • Government as “big brother” • Incorrect matching of records • Incorrect data entry

25. The Importance of Standards • Standards for data content (what are the important pieces of information necessary? Is terminology consistent?) • Standards for data transmission (how is data sent?) • CDA= (clinical document architecture) exchange of fixed, legally defensible document upon request • CCR = (continuity of care record) assembly “on the fly” from discrete data elements in multiple systems • CCD = (continuity of care document) standard document that includes common discrete data elements • Standards for security (access, authorization, audit) • use existing international standards from other industries • Standard policies (who decides what to share, with whom and for what use? • consumer-directed permissions for access to / use • address issues of liability and enforcement • Funding / sustainability (who benefits, so who pays?) • savings accrue mostly to purchasers (insurers, employers, taxpayers, self-pay consumers) • “transparency” for capital and operating costs, ROI, quality outcomes

26. CareSpark RHIO Consortium Partners • National / International: Local / Regional: • ActiveHealth the Creative Trust AllScripts Deliberare • Anakam Holston Technology • Cisco Intellithought • CGI LucentGlow • Dell OnePartner • GE Healthcare • Healthvision / Quovadx State: • Initiate Systems Tennessee • Intel Virginia • Misys • Oracle Federal: • Siemens DHHS / ONC Wellogic Market / thought leaders committed to interoperability, collaboration and results

27. XDS DocumentRepository CareSpark IHE Architecture CareSpark Data Store Physician Practice 1 Document Repository XDS PatientIdentitySource (MPI) Portal XDS PIXService IHE DocSource/ DocConsumer XDS PDQService Hospital 1 XDS DocumentRegistry CareSpark XDS Data Store - For Patient Care Data Participants Document Repository CT TimeService IHE DocSource/ DocConsumer ATNA Audit Repository XDS Key Store Hospital 1 Phys Portal Data Transformation IHE DocConsumer FILTER Public Health Department 1 Clinical Data Repository - For Public Health Improvement Clinical DataRepository IHE DocSource/ DocConsumer Additional Providers and other data participants Public HealthData Mart De-IdentifiedData Mart Document Repository IHE DocSource/ DocConsumer

28. Technical Architecture

29. Nationwide Health Information Network: “network of networks” NHIN Prototype Demonstration 2006-07 design for exchange between CareSpark, West Virginia, Kentucky providers, federal agencies NHIN Trial Implementation 2008 * Core Services: Consumer permissions Security exchange Standardized interfaces Summary medical record * Medication Management eRx, med history, decision support * Consumer Empowerment personal health record, registration and medication history

30. CareSpark NHIN Architecture CareSpark (Hosted at CGI) Anakam Web Server ESB Web Server Anakam Two FactorAnakam PortalWellogic Two FactorAnakam PHRActiveHealth DB Server MPOP Cloverleaf Data Transformation Oracle MPOPConsent CustomInterfaces SOAP/HTTP NHIN request/response Protocol Transformation XDS DocumentRepository XDS RepService Socket TCP ATNA AuditRepository Message Enhancement Providers ATNAWinSysLog XDS PDQService XDS PatientIdentitySource (MPI) EMPIInitiate Security Validation Flat File Any other inbound/outbound end point XDS PIXService ADTService PostGreSql Routing XDSRegistryNIST XDS DocumentRegistry XDS RegService Web Server Orchestration e-PrescriptionAllScripts VersionControlSubversion XDS Key Store CT TimeClient

31. Technical/Financial Timeline Claims-based Decision support implemented Physician Portal, authentication Real-time Decision support integrated with HIE document registry and Repository Clinical document Exchange Build clinical data repository MPI build Jan 08 Jun 08 Jan 09 Jun 09 Dec 09 Jan 07 Jun 07 Enrollment 250,000 patients Data-sharing agreements Enrollment of 25,000 members Enrollment 35,000 members NHIN Trial Implementation

32. Grassroots Sustainability Strategic Business Planning July 2004 – June 2005 Operating Support April 2008 – June 2009 Infrastructure Development July 2005 – March 2008 $100,000 grant from eHealth Initiative $462,000 match from local partners $250,000 Commonwealth of Virginia $308,000 Accenture NHIN Prototype $1,450,000 Consortium Partners (cash/inkind) $1,000,000 State of Tennessee $750,000 contributions and donations $3,688, 622 NHIN Trial Implementation $150,000 transactional fees for services $450,000 contributions and donations $1,055,225 enrollment of members

33. Revenue Sources July 2005 – Dec 2008 • Employers: • Eastman Chemical Company $ 600,000 • King Pharmaceuticals $ 60,000 • Cariten PHP $ 8,000 • Johnston Memorial Hospital $ 10,000 • Contracts: • State of TN $1,016,900 • Accenture (NHIN prototype) $ 308,000 • Commonwealth of Virginia $ 250,000 • NHIN Trial Implementation $3,988,622 • Consortium Partners $1,250,000 • cash and inkind • Enrollment Fees (CareEngine Services) $ 431,640 • Transaction Fees$ 0 • Total $7,923,162

34. CareSpark Data-Sharing Options

35. Future Initiatives • National – connect with V.A., CDC and personal health records • Tennessee – connect with state agencies (public health immunization registry, Tn eHealth Council efforts) • Virginia – connect with immunization registry, prescription management program • Local / Regional – support aggregation and analysis of data to address public health issues for region (chronic disease, prescription drug overdose)

36. Lessons Learned – Regional HIE • Health care market does not conform to political boundaries • Evolving standards will assure interoperability across jurisdictions and between systems (clinical, payer, public health, personally-controlled, research-oriented) • Leverage existing resources and investment through incremental transition • Build for maximum flexibility to accommodate change (technical, policy, funding, users, evidence-base on outcomes)

37. Better Health for Central Appalachia • www.carespark.com • Liesa Jenkins, Executive Director • 423-963-4970 • ljenkins@carespark.com