Health Information Exchange 101Problem, Definitions, Value, Policy

David C. Kendrick, MD, MPHAsst. Provost for Strategic Planning

OUHSC

National perspective• At >17% of GDP, healthcare costs - out of control• Value delivered is limited– US ranks below

most industrialized nations on quality metrics, despite spending more

• Healthcare IT - part of the solution – prioritized and funded– American Recovery and Reinvestment Act

• Patient Centered Medical Home gaining as the delivery model of choice

2009 State of the State’s Health Summary

Oklahoma is the only state where the death Oklahoma is the only state where the death rate has gotten worse…..rate has gotten worse…..

800

850

900

950

1,000

1,050

1980 1985 1990 1995 2000 2005

Tulsa

US

Some Factors1. Economic downturn

healthy people and jobs left Oklahoma

2. Poverty remained3. Heart Disease –

(Diabetes)4. Cancer 5. Access to Care

Age-adjusted Death Rates

Past 25 Years

OK

2007 COMMONWEALTH FUND ReportState Scorecard Summary of Health System Performance

What WE CAN’T Do

• “Grow” more doctors quickly• Create new hospitals overnight• Force patients to:

–Exercise–Stop smoking–Lose weight

What We Can DoLeverage Technology

• Complex populations• Limited Resources:

–Create a lean healthcare system–Improve Care Coordination–Business case for:

• Funding • Efficiency

Where to Focus?

–Electronic Medical Records (EMRs) important, but . . .

–Health Information Exchanges (HIEs) •immediate benefit and greater cost savings

–Community-wide care coordination (CCC)

•more benefit and cost savings

Physician Organization in Relation to Quality and Efficiency of Care

The Commonwealth Fund, April 2008

Evidence Increasingly shows that improved “systemness” drives

quality and efficiency

System:a group of independent but interrelated elements Designed to work as a coherent entity

Where Will there beSavings?

Majority: From the Exchange of Clinical

Information among care providers

Reduction in duplicate Dx proceduresPrevention of Medical Error

Source:Center for Information Technology Leadership 2005

Current Situation

PayersDemographicsMedical claims

Pharmacy claimsCase mgmt records

Doctor officesEHR

ClaimsRx

Case mgmtCommunity

outreach

Rx

Imaging

Hospitals (inpt)

ER/UC

Public Health

Other PCPs

Specialists

Ancillary carePT/OT/Aud/Diet

Labs

Manual connection (mail, fax)Electronic connection

Safety Net Clinics and community

agencies

Patient

Available at the POSLogically presented

Current

Medicare patient - 5.6 providers/yr(7.7 providers/yr including 2 PCPs)

Community Care Coordination

Health Information - Useful

Definitions: EMR vs. HIE vs. HIO vs. CCC

HIE

RHIO

Greatest Value Your Data is Local (CCC)Business Model - Self Supporting

Stakeholders/UsersQuality, Safety & Efficient Delivery

Govern, Sets Rules

Statewide Network of Networks

Disaster Bioterrorism Public Health

National (NHIN)

Health Information Organization

Scale State-wide: A Network of Networks

•Local governance•Common technology

Anatomy of a HIE

Health Information

ExchangeElectronic Master Patient Index

Population Care Analytics

Patient Portal Physician PortalMedical

Education

Anatomy: Detailed Version• HIE - Central Data Repository for a core set of clinical variables• eMPI - Master Patient Index tracks unique patients and ensures data integrity• Community Order Entry/Physician Portal- Centralized system coordinating

orders, referrals, consultations, radiology and diagnostic tests, PT/OT, etc.• Decision analytics - Tools and algorithms for patient identification, prioritizing

patients for interventions, prioritizing appropriate interventions each patient• Patient Portal - gives patients access to their own community health records,

ability to communicate with their providers:– eVisits, Schedule requests, Refill requests, Patient educational materials, Self-care logs (BP, BS,

asthma, etc.), Health Risk Assessments (Depression screen, Cardiac risk), Review records shared across the community

• Comprehensive clinical education support– Trainee portfolios, Evaluations, Delivery of relevant didactic educational materials

• What is the relationship between Health Information Exchanges and the Patient Centered Medical Home?

Organizing the Concepts

Patient Centered Medical HomeHealth Information

ExchangeReimbursement Model

Patient

Centered

Medical

HomePatie

nt

Centered

Medical

Home

Patient Centered Medical Home

Patient Centered

Medical Home

Patient Centered Medical Home Health Information

Exchange

Medical Home & HIEFragmented Care

More patients Complex populations

1in 4 - Behavioral Health Diagnosis

(Duals Drive cost )

Medicaid 46% Medicare 24%

Investing in the Aftermath vs Ahead of the curve

Resource Drain from Missed Early Opportunities

Medical HomeGoals

Integrated Systems

More Efficient Use of Resources

Identify & Prioritize patients for Intervention

(ahead of the curve)

Link Providers - Coordinate Care

Raise Quality - Evidence Based Guidelines

Identify Quality issues & Make Rapid Changes

Have we given this any thought?

• 2004: Harvard Center for IT Leadership published a report on the value of health information exchange• $77B in annual savings through Health IT• Prompted, in part, the creation of the Office of

the National Coordinator for Healthcare IT (ONCHIT), the Health IT “Czar”

• 2006: GKFF commissioned an OK-specific evaluation of the value of HIE

Motivation

• Clinicians have incomplete knowledge of their patients – Relevant patient data not available in 81% of

ambulatory visits Tang 1994 – 18% of medical errors that lead to ADEs due to

missing patient information. Leape JAMA 1995

• Medicare patients see an average of 5.6 different providers each year= 5.6 silos of data

• What is the value of HIE for Oklahoma and specifically for the Tulsa region?

HIE Expert Panelists• David Brailer, MD, PhD

– Santa Barbara County Care Data Exchange, Health Technology Center• William Braithwaite, MD, PhD

– Independent consultant, “Dr HIPAA”• Paul Carpenter, MD

– Associate Professor of Medicine, Endocrinology-Metabolism and Health Informatics Research, Mayo Clinic

• Daniel Friedman, PhD– Independent public health consultant

• Robert Miller, PhD– Associate Professor of Health Economics, UCSF

• Arnold Milstein, MD, MPH– Pacific Business Group on Health, Mercer Consulting, Leapfrog Group

• J Marc Overhage, MD, PhD– Regenstrief Institute, Associate Professor of Medicine, Indiana University

• Scott Young, MD– Senior Clinical Advisor, Office of Clinical Standards and Quality, CMS

• Kepa Zubeldia, MD– President and CEO, Claredi Corporation

HIE Value Construct

Providers Hospitals

Pharmacies

Radiology Centers

Other Providers

Public Health Agencies

Payers

Clinical Laboratories

HIE Value Construct

Providers Hospitals

Pharmacies

Radiology Centers

Other Providers

Public Health Agencies

Payers

Clinical Laboratories

Avoided redundant tests, Electronic test ordering and results

delivery

Avoided ADEs, drug utilization savings,

automated transaction sets

Avoided redundant imaging, Electronic imaging ordering

and results delivery

Electronic Rx, refills, interaction checking,

adherence data

Electronic submission of

reportable conditions and vital

statistics

Electronic referrals, consultation letter

delivery, chart requests

What about funding?

• One time:– ARRA stimulus dollars– Other grants

• Ongoing: – Business model must be developed– ROI by stakeholder will drive the business model

ARRA Stimulus Dollars

Washington, D.C.

Earmarks Federal Agency Grants

ONCHIT

AHRQ

DHS

State distributions

Heath Dept

OHCA

Opportunity: Stimulus Package• Federal Agencies offering

– $20B for healthcare IT, $3B short term and $300M immediately

– $1B for comparative effectiveness research– $1.5B for community health centers

• Much will be distributed through grant process• Will be highly competitive• Many other communities have been in this game for years

• Our communities must– Be unified behind a well-developed plan of action– We must build the coalition now

Greater Tulsa Health Access Network

From the final ARRA:In order to be eligible for Stimulus Grants

• Must be a qualified State-designated entity– Designated by State as eligible to receive awards– Non-profit entity– Clear objectives to use Healthcare information

technology to improve care quality and efficiency through secure data exchange

– Adopt non-discrimination and conflict of interest policies

– Broad stakeholder representation on governing board

CMS really wants EMR and HIE adoption . . .

*Assume N=1,500 MDs, DOs, PAs, and NPs and 7 hospitals see Medicare patients†Penalties for non-adoption not yet elaborated, but assume mirror bonuses

†

From the final ARRA:Regional organization must include

• Providers, including those focused on low-income and underserved

• Health plans• Patient and consumer organizations• HIT vendors• Healthcare purchasers and employers• Public health agencies• Universities• Clinical researchers• Other staff who use HIT

National: Meaningful Use guidance

• In order to qualify for bonus payments (and avoid penalties)– By 2011, the following must be exchanged:

• Doctors: Problem lists, medication lists, allergies, test results

• Hospitals: Discharge summaries, procedures, problem lists, medication lists, allergies, and test results

– By 2013, the following must be exchanged:• Doctors: Share all care transition data across the

community electronically• Hospitals: Share all care transition data electronically