nevada oct 24, 2008. session overview health information exchange: why? what? who? how? challenges...
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NevadaOct 24, 2008
Session Overview
Health Information Exchange: Why? What? Who? How?
Challenges Along the Way
Results – Making a Difference
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 + ???
750,000 patients in multi-state region
2/3 of patients live in Tennessee
1/3 live in Virginia
5% in other states
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
CareSpark’s Mission
CareSpark’s mission is to improve the health
of people in NE Tennessee and SW Virginia
through the collaborative use
of health information
Regional Population Has High Disparities of:
• 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
Regional Health Status
Trend are getting worse
Drug Caused Death Rates 2002 - 2003
Quality Measures For VACompared With Best Practices
0
20
40
60
80
100
120
Pe
rce
nt
Go
als
Me
t
VA
Best Other
2002 Data
17 Measures
Source: SBCCDE, CITL, Gordian Project analysis
Redundancy
Treatment
Errors
Diagnostic
Electronic Medical Record
Clinical Data Sharing
Decision Support
Value is Derived from Better Medical Decisions
Patient Data
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
CareSpark’s Strategic Outcomes
Population Health ClinicalPremature Mortality Adult Diabetics, Rx filled, vision / foot, HBA1C<7
New Diabetes CasesLipid Panel LDL < 100Flu Vaccines for 65+ Pneumo Vax for ages 65+, <2ER Visits for Health Attack Stroke TherapyPost- MI followup Cancer Screenings (PAP, Mammogram, colorectal)
Financial Savings -- ROI• Patient• Clinician• Facilities• Purchaser (health plan, employer, taxpayer, individual)
Awareness & Adoption of Best Practices
Public Health
ClinicianPurchaser
(Payors / employers)
Individual
(patient / consumer)
Population Health Informaticist
Community
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
Board of Directors
CareSpark ManagementClinical
Outcomes / Evaluation Population Health workgroup Financial Savings Workgroup
Technical
Finance
CareSpark RHIO Organizational Structure
Communications
Nominating Legal AuditPersonnel
Patient Physician Public Health PurchaserFacilitiesStakeholder Advisory Groups
Project Management Office
Partner Partner Partner Partner
Health Information Control
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
CareSpark’s Core Strategies
Provide patient informationand decision support on
demand at the point-of-care
Provide patient informationand decision support on
demand at the point-of-care
Align financial incentives to assure
fair return on investment
Align financial incentives to assure
fair return on investment
Empower patientsto make healthy
choices & informed decisions
Empower patientsto make healthy
choices & informed decisions
Provide selected aggregate datafor population
health improvement
Provide selected aggregate datafor population
health improvement
1.1. 2.2.
3.3. 4.4.
Coordinating organization facilitates rules of engagement: • Data-sharing Agreement • Legal Framework• Standards• Interoperability• Transparency• Value• Quality/Cost
Framework for Trust and Collaboration
Broadband % of Access, Stakeholders, Automation
EMR / EHR/PHR Implementation
Structured Notes & Paper Records
Administrative Transactions (claims…)
ePrescribing Roll Out
Secure Clinical Messaging (labs, imaging, email…)
H.I.E.
Co
mm
on
Po
rtal
Tennessee State-level leadership
Virginia Health IT Framework
Virginia RHIO initiatives
Key Strategic Decisions
1. 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)
3. 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 UsesPatient: view content of records, view access logProvider: payment, treatment, operations Public health: required reporting and authorized queriesPayers: de-identified aggregate dataResearch: IRB-approved studies
5. 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)
Convergence of Data
Administrative
Billing & Claims
Clinical
Personal Health Record
Research
Best Practices
Patient-Centered
Care
From Patient Perspective
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
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
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 requestCCR = (continuity of care record) assembly “on the fly” from discrete data elements in multiple systemsCCD = (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 / useaddress 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
CareSpark RHIO Consortium Partners
National / International: Local / Regional:ActiveHealth the Creative
Trust AllScripts DeliberareAnakam Holston
TechnologyCisco IntellithoughtCGI LucentGlowDell OnePartnerGE HealthcareHealthvision / Quovadx State:Initiate Systems TennesseeIntel Virginia MisysOracle Federal:Siemens DHHS / ONCWellogic
Market / thought leaders committed to interoperability, collaboration and results
CareSpark IHE Architecture
Data P
articipan
ts
CareSpark Data StoreCareSpark Data Store
XDSDocumentRegistry
XDSDocumentRegistry
XDS PatientIdentitySource(MPI)
XDS PatientIdentitySource(MPI)
PortalPortal
Hospital 1 Phys PortalHospital 1 Phys Portal
IHE DocConsumer
IHE DocConsumer
Hospital 1Hospital 1
IHE DocSource/ DocConsumer
IHE DocSource/ DocConsumer
Physician Practice 1Physician Practice 1
IHE DocSource/ DocConsumer
IHE DocSource/ DocConsumer
Document RepositoryDocument Repository
Document RepositoryDocument Repository
FILTERFILTER
Clinical DataRepository
Clinical DataRepository
Public HealthData Mart
Public HealthData Mart
De-IdentifiedData Mart
De-IdentifiedData Mart
Car
eSp
ark
XD
S D
ata
Sto
re
-
F
or P
atie
nt C
are
Cli
nic
al D
ata
R
epo
sito
ry
-
F
or
Pub
lic H
ealth
Im
prov
emen
t
XDS PIXServiceXDS PIXService
CT TimeServiceCT TimeService
XDS PDQService
XDS PDQService
ATNA AuditRepositoryATNA AuditRepository
XDSDocumentRepository
XDSDocumentRepository
XDSKey Store
XDSKey Store
Public Health Department 1Public Health Department 1
Additional Providers and other data participantsAdditional Providers and other data participants
IHE DocSource/ DocConsumer
IHE DocSource/ DocConsumer
IHE DocSource/ DocConsumer
IHE DocSource/ DocConsumer
Document RepositoryDocument Repository
Data
Transformation
Data
Transformation
Technical Architecture
Internet
Provider 1
Active Health
Data BaseServer
ApplicationServer
`
MPI ClientFilters and Encryptions
Application Server
Data BaseServer
CareSpark Secure & Redundant
Network A
CareSpark Secure & Redundant
Network B
Note 1: Patient access will be via the internet thorough Https Protocol (SSL)
LoadBalancer
AppFirewall
Note 2: Although not pictured, the Internet connectivity, the Application Firewall and the Load Balancer will all be redundant, to avoid a single point of failure.
See Note 2.
See Note 3
NHIN
Patient`
See Note 1.
Note 3: All non-patient connections to the Internet are secured connections, via SSL.
EMPIFilters and Encriptions
EMPIFilters and Encriptions
Data BaseServer
Data BaseServer
Router
Provider 2`
MPI ClientFilters and Encryptions
` Small Doctors Office
`Provider using
ASP
Application Server
Provider
MPI ClientFilters and Encryption
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
CareSpark NHIN Architecture
CareSpark(Hosted at CGI)CareSpark(Hosted at CGI)
OracleOracle
XDS PatientIdentitySource(MPI)
XDS PatientIdentitySource(MPI)
PortalWellogic
PortalWellogic
CloverleafCloverleaf
XDS PIXServiceXDS PIXService
CT TimeClient
CT TimeClient
ATNA AuditRepositoryATNA AuditRepository
XDSDocumentRepository
XDSDocumentRepository
XDSKey Store
XDSKey Store
XDS PDQService
XDS PDQService
XDS RegService
XDS RegService
XDS RepService
XDS RepService
Two FactorAnakam
Two FactorAnakam
EMPIInitiate
EMPIInitiate
PostGreSqlPostGreSql
XDSDocumentRegistry
XDSDocumentRegistry
XDSRegistry
NIST
XDSRegistry
NIST
ATNAWinSysLog
ATNAWinSysLog
ADTService
ADTService
Web Server
DB Server
VersionControl
Subversion
VersionControl
Subversion
MPOPMPOP
MPOPConsentMPOP
ConsentCustom
InterfacesCustom
Interfaces
Anakam
ESBESB
NHIN request/response
Providers
Any other inbound/outbound end point
Socket TCP
SOAP/HTTP
Flat File
Data
Transformation
Data
Transformation
Protocol
Transformation
Protocol
Transformation
Message
Enhancement
Message
Enhancement
Security
Validation
Security
Validation
RoutingRouting
OrchestrationOrchestration
Anakam
Two FactorAnakam
Two FactorAnakam
Web Server
PHRActiveHealth
PHRActiveHealth
Web Server
e-PrescriptionAllScripts
e-PrescriptionAllScripts
Jun 07
Technical/Financial Timeline
Jun 08 Jun 09Jan 08 Dec 09Jan 09Jan 07
Enrollment of 25,000members
MPI build
document registry andRepository
Build clinical data repository
Physician Portal,
authentication
Real-time Decision support integrated
with HIE
Data-sharing
agreements
Enrollment 250,000 patients
Claims-based Decision support
implemented
Enrollment 35,000
members
Clinical documentExchange
NHIN Trial Implementatio
n
Operating Operating SupportSupport
April 2008 – June 2009April 2008 – June 2009
Operating Operating SupportSupport
April 2008 – June 2009April 2008 – June 2009
Infrastructure Infrastructure DevelopmentDevelopment
July 2005 – March 2008July 2005 – March 2008
Infrastructure Infrastructure DevelopmentDevelopment
July 2005 – March 2008July 2005 – March 2008
Strategic Business Strategic Business PlanningPlanning
July 2004 – June 2005July 2004 – June 2005
Strategic Business Strategic Business PlanningPlanning
July 2004 – June 2005July 2004 – June 2005
Grassroots Sustainability
$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
Revenue Sources July 2005 – Dec 2008
Employers:Eastman Chemical Company $ 600,000King Pharmaceuticals $ 60,000Cariten PHP $ 8,000Johnston Memorial Hospital $ 10,000
Contracts:State of TN $1,016,900Accenture (NHIN prototype) $ 308,000Commonwealth of Virginia $ 250,000NHIN 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
CareSpark Data-Sharing Options
Data Sharing Option Intended Data Use Data Sharing Result
Identified Data Patient Care and Treatment
All data sent to CareSpark will be identified data in order to match patient records from multiple providers. Identified data will be available to authorized providers for access of additional healthcare information about the patient.
De-Identified Data Anonomized – patient data can never be re-identified
Approved Population Health Improvement activities
Identified data available to CareSpark will be de-identified according to the approved requirements and stored separately.Pseudo-Anonomized –
Patient data can be re-identified, if necessary, but only by the party who provided the pseudo-anonoymized data
Limited Public Health Identified data available to CareSpark will be de-identified with the specified additional fields required for a limited dataset according to the approved requirements and stored separately.
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)
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)
Better Health for Central Appalachia
www.carespark.com
Liesa Jenkins, Executive Director423-963-4970