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Community Meeting 2 1 February 2012

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Agenda TopicStart TimeSpeaker 1. Counties to be included in project6:30 pmLyman Dennis 2. HIE: Whats in it for patients? A physicians perspective. 6:40 pmPeter Mathews, MD 3. Vision statements7:05 pmMarty Malin & Tim Wilson 4. What do we want to accomplish?7:15 pmGroup 5. Organization approaches7:30 pmLori Sklar & Carl Thomas 6. What services do HIEs provide?7:40 pmKathy Ficco, Justin Graham, MD Dave Minch 7. Models for funding HIE activities7:55 pmSuzanne Ness 8. Resources available8:05 pmDave Minch 9. Name of Community group?Next meetingGroup 10. Discussion8:10-8:30 pmGroup

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Service Areas for Inclusion Lyman Dennis Organizer & Facilitator

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Approach Looked at Dartmouth Atlas data Uses two Medicare referral types Major cardiovascular surgery Neurosurgery to aggregate 3,436 hospital service areas into 306 hospital referral regions Counties are split Diagram: to nearest county

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Conclusions Sacramento is the center of a separate service area Yolo is closely related to Sacramento for Medicare patients Yolo is part of PHC and is involved in the Medi- Cal systems of care with the other PHC counties Communicare uses Redwood Community Health Network in Sonoma for its eCW EHR Recommendation Omit Sacramento Retain Yolo

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DISCUSSION

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Health Information Exchange Whats in it for Patients? A Physicians Perspective By Dr Peter Mathews Kaiser Permanente Napa 02/01/12

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Definition of Health Information Exchange Secure, Standardized Electronic Transfer of Health Information Among Health Care Organizations (hospitals, office, labs, pharmacies, the patient, SNF,etc) For improving Health (Quality), improving Experience of Care, and reducing Cost

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Key Attributes of High Performing Health Care Organizations Organization wide focus on the needs of the patient Strong organizational and clinical leadership Access to info to support EFFICIENT, COORDINATED CARE Timely access to care Emphasis on Prevention, Wellness and Healthy behaviors

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Enabling New Patient Centric Models of Care Better telephone and e-visits enabled because of presence of clinical information Teledermatology Telemedicine Population management Better preventive care (paps, Mammos, etc) Better chronic disease management (Diabetes) Reduced rate of hospital readmission

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Who Needs the Info The Patient Primary Care Physician Offices Specialist Physician Offices Lab, Pharmacies and Radiology Health Plans Long Term Care Facilities Hospitals/Emergency Departments

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What Information is the most Clinically Important to Exchange? Problems Meds Allergies Immunizations Problem List Screening Advance Directive Recent Discharge Summaries/H&P/Op Note

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Scenario 1 ED to Physician office 60 yo man is seen at Local Emergency department with Chest Pain. Is evaluated there and discharged home. Comes to his doctors office 2 days later. Need for ED Visit record and EKG from the ED

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Scenario 2 Doctors Office to Hospital 88 yo lives at home with is wife. He has previous filled out an Advanced Directive stating he wishes no heroic measures. This is at his doctors office. He collapses at home, is found by a neighbor, and he is intubated and has a prolonged hospitalization

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Scenario 3 Hand off Between primary care and specialty care 45 yo female develops arthritic symptoms. Xray and blood tests for arthritis are done patient is referred to Specialist - Results are not available. Studies are repeated. Patient was allergic to one of the drugs prescribed. Was in family doctors records but patinet forgot to tell this to the specialist.

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Scenario 4 45 year old woman previous had care at the local community clinic and states she had a mammogram in the last year. It turns out its been 3 years. Mammogram not ordered. Patient presents with advanced breast cancer.

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Exchanging Clinical Information Where do we start? What has been our experience in Kaiser Permanente?

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What we did First Lab Medications Radiology online Soon thereafter Allergies Problem List

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Next Discharge Summaries (transcriptions) Next we implemented an Ambulatory Electronic Health Record (Epic) Next we implemented an Inpatient Electronic Health Record (EpicCare Inpatient)

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And the last lap We implemented Secure Messaging to our Members In the last 6 months we turned on Care Epic The ability to View Records on Kaiser Patients from other Kaiser regions (e.g. Southern California) We scan in Advanced Directives

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SNAPSHOT (SUMMARY CLINICAL RECORD)

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Allergies

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Medications

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Status on Preventive Tests (pap smear, mammo, colon ca screening, etc)

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Immunizations

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Lab results (and or trend) note prior Vital Signs (weight, bp)

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Last Cardiac Studies (EKG as an example)

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Advance Directive

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Scan of Advance Directive

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Kaiser Example of Health Information Exchange (WITHIN Kaiser regions) CARE EPIC Almost the entire record - but VIEW only Following slides How the care team pulls up the record What the record looks like once pulled up

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CARE EPIC (requesting a view only record from another Kaiser region)

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Requesting Record (slide 2)

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Viewing Record

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Viewing Record (part 2)

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Viewing record (part 3)

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Exchange of Clinical Information is Important It promotes Quality Health Care Preventing harm to patient from adverse reactions Preventing over utilization of narcotics Insuring patients are up to date on preventive care and chronic disease lab monitoring

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Reducing Cost It prevents duplication of tests It ensures good communication and coordination of care among different members of the health care team It enables new models of care Teledmedicine, population management,

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Begin at the Beginning Meds Labs Pharmacy Problem List Allergies Then Transcriptions/ ED visits/Discharge summaries - the journey begins!

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DISCUSSION

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Vision Statements H. Martin Malin, PhD, MA, MFT Interim Mental Health Services Act Coordinator Solano County Health and Social Services Tim Wilson, PhD Epidemiologist Yolo County Health Department

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To Improve Individual Health Outcomes in the NE Bay Area Support continuity of care Promote appropriate clinical decision making at the point of service Make information available and useful Improve patient safety Improve and enhance the patient/clinician experience Support achievement of systematic goals such as Clinical analytics, Population health management & Implementation of best practices

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Reduce adverse outcomes and costs associated with Treatment decisions made based on incomplete or patient-recall data when better data is available Lack of patient engagement in their own healthcare due to lack of understanding of key health drivers and test trends

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Provide connector technology that Reliably exchanges Physical health Mental health and Alcohol and substance use information among providers Rapidly provides requested data Anticipates connection with other HIEs regionally and nationally

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DISCUSSION

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What do we want the group to accomplish? Lyman Dennis Organizer & Facilitator

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Why HIE? Rationalize medical care Allow continuity of care across providers Provide more (all) clinical data at point of care Support evidence-based medicine by allowing review of more (all) information about each case Reduce duplicate analytical studies Support ACO reimbursement incentives

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Options for the Community Group 1. Do nothing. Disband. 2. Set up a full HIE organization and business. 3. Set up an organization to contract for HIE services. 4. Set up a collaborative to coordinate the contracting for services.

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1. Do nothing. HIE will develop chaotically and without plan for integration. Analogous to unplanned ER services. Competition for victims or no ambulance when needed. Likely to be More expensive Contain gaps Have unlinked HIE service silos

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2. Build a full HIE organization & business Time is past when a full-service HIE (like Santa Cruz HIE) can gain all the exchange services for a county or group of counties. Already have distinct functions and HIEs operating. Cost of a full HIE organization is relatively high staff, policies & procedures, hardware, software, infrastructure, etc. Not necessary as less-expensive alternatives available.

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3. Set up an organization to contract for HIE services A number of organizations provide HIE services Existing HIEs Vendors Having a Community organization do this allows Negotiation leverage Economies of scale A forum to agree on a common approach A way to coordinate community resources related to HIE

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4. Set up collaborative to coordinate contracting for services Bring community together Develop a coordinated plan Provide some negotiation leverage but not as much as a single entity May have a long-term role or may fade A community voice

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DISCUSSION

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Organization Approaches Carl Thomas, Interim Executive Director, Solano Coalition for Better Health Lori Sklar, Executive Director, Redwood Community Health Network

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Nonprofit Structure Looked at organizational models for other HIEs Nonprofit appears most appropriate for community effort Relatively easy to incorporate Application for not-for-profit status time- consuming but not difficult

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Participation Stakeholders influential in developing community solutions Interest in making data sharing work Allow physicians and other caregivers to see recent care Improve outcomes Enhance patient experience Decrease duplication

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Avoid Pioneering Build on experience of other groups Begin with available documents Dont redevelop successful work of others Utilize best practices Do what is needed to assure success

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DISCUSSION

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HIE Service Offerings By Category Paul Alcala, VP CIO NorthBay Healthcare David Minch, HIPAA/HIE Project Manager John Muir Health Kathy Ficco, Executive Director, St. Joseph Health System Justin Graham, CMIO NorthBay Healthcare Lyman Dennis, Organizer/Facilitator (matrix)

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Basic Core Services: Foundational Services: Master Patient Index Record Locator Provider Directory Entity Directory (Hospitals, Med Groups, etc.) User Directory Other Directories (Clinics, Public Services, Registries, non-participant message destinations, etc.) Authentication / Authorization Methods ATNA Standard Transaction and Use Logs Transaction Services (Hospital & Ambulatory): Inbound Interfaces EHR HIE Outbound Interfaces HIE EHR Application Services: Consent Management (Opt-In, Opt-Out) Secure Clinician-Clinician Messaging / Referrals Gateways (NwHIN, other local HIEs, State HIEs, Direct HISP, Immunization Registry, Public Health) Portal to view the Community Record Results Distribution

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Specialty Premium Services: Physician EMR-Lite Full EMR with HIE or contracted Installation / Support Other Physician Products (eRx, practice management, home device monitoring) Personal Health Record (PHR) Dictation Services Disease Registries Public Health and Immunization Reporting and Inquiry Advance Directives Group Purchasing

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Clinical Data & Workflow: Clinical Information Diagnosis / Problem List Allergies Laboratory Values Radiology Transcription Discharge Summary Visit Summary Immunization Medication Summary Workflow Referrals Authorizations Encounters (ED, Ambulatory, Inpatient) Transition of Care support Home Health Reporting Image & other Dx Reporting

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Data Warehouse & Analytics: Clinical Management Clinical Quality Reporting Clinical Disease Registries Chronic Disease Management and Reporting Immunization Registries Syndromic Surveillance Reporting and Monitoring Clinical Decision Support Management Analytics Insurance Claims Analytics Regional Population Analytics Clinical Trials Data Base Public Health Case Mgmt ACO Metrics

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Data Accessibility: Patient Community Record Hospitals / Acute Care Ambulatory / Outpatient Clinics Home Health / Rehab SNF / Long Term Care Care Continuum Merged Encounter Data Financial and Administrative Services: Claims Processing to Payers Eligibility Verifications Remittance Advice Processing Physician Credentialing Services Billing Services Attachments

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HIE Services Defined by Participants

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DISCUSSION

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Models for Funding HIE Activities Suzanne Ness Regional Vice President Hospital Council of Northern & Central California

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Funding of Interest? Beginning as a collaborative, not a formal startup HIE Long organizational road to be a full HIE & not necessary Better to Contract for services or Coordinate provider services so community exchange makes sense

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Funding Models (for Full HIEs) HealthBridge, Cincinnati Founded in 1997 with $1.75M in unsecured loans Two health plans/five hospitals -- $250k each All loans repaid, continuous operation14 years Sustainable w/o grants (5-8% annual return; only 3% from grants)

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Funding Models (full HIEs) - 2 Santa Cruz HIE Founded in 1995 by Physicians Medical Group of Santa Cruz, Dominican Hospital and Unilab (now Quest) as a for-profit. $300k to $500k from each partner, given to Axolotl to develop software Founder users paid subscription from day one Driven by physicians Redwood MedNet, Western Health Information Network (nee Long Beach Network for Health) Grant funded startup and early operation Cal eConnect providing matching expansion funds Still grant dependent but moving to user funding

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Funding Options Grants not sustainable permanently (CareSpark in Tenn expired when grants ran out.) Transaction-based fees discourage use of services Subscriptions HealthBridge, Santa Cruz HIE, Utah Health Information Network

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Examples of Subscription Charges Per MD per month: core services, with additional cost for EHR lite. Hospitals: by bed or occupancy, per month charge Community clinics: a single MD rate, per location Free clinics: free Home health: annual cost based on revenue Ambulatory surgery: based on number of MDs Long-term care/post acute: annual based on number of beds Independent labs: per ordering provider per month, per lab (Quest, LabCorp, others) Pharmacy: per year, per location

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Specialty Premium Services: Physician EMR-Lite Full EMR with HIE or contracted Installation / Support Other Physician Products (eRx, practice management, home device monitoring) Personal Health Record (PHR) Dictation Services Disease Registries Public Health and Immunization Reporting and Inquiry Advance Directives Group Purchasing

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DISCUSSION

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Resources David Minch HIPAA/HIE Project Manager John Muir Health

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Resources Sources From other HIEs (on HIE web sites and in contributed documents) HIMSS HIE Guides & Toolkit eHI (eHealth Initiative) Markle Connecting for Health NeHC University Vendors webinars and supplied docs NwHIN DURSA

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DISCUSSION

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Name of Community Group Next Meeting

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Suggested Homework for Coordinating Committee Group

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Homework Mission, organization and budget for -- Contracting organization Collaborative organization Next meeting: discussion of alternatives and implications