Health Information Exchange 101Problem, Definitions, Value, Policy

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

National perspectiveAt >17% of GDP, healthcare costs - out of controlValue delivered is limited US ranks below most industrialized nations on quality metrics, despite spending more

Healthcare IT - part of the solution prioritized and fundedAmerican Recovery and Reinvestment ActPatient Centered Medical Home gaining as the delivery model of choice

2009 State of the States Health Summary

Oklahoma is the only state where the death rate has gotten worse..Some FactorsEconomic downturn healthy people and jobs left OklahomaPoverty remainedHeart Disease (Diabetes)Cancer Access to CareAge-adjusted Death RatesPast 25 Years

2007 COMMONWEALTH FUND Report State Scorecard Summary of Health System Performance

What WE CANT Do

Grow more doctors quickly Create new hospitals overnight Force patients to:ExerciseStop smokingLose weight

What We Can DoLeverage Technology

Complex populationsLimited Resources:

Create a lean healthcare systemImprove Care CoordinationBusiness 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 CareThe Commonwealth Fund, April 2008Evidence 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 SituationManual connection (mail, fax)Electronic connection

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. CCCHIE

RHIOGreatest Value Your Data is Local (CCC)Business Model - Self SupportingStakeholders/UsersQuality, Safety & Efficient DeliveryGovern, Sets Rules

Statewide Network of NetworksDisasterBioterrorismPublic Health

National (NHIN)Health Information Organization

Scale State-wide: A Network of NetworksLocal governanceCommon technology

Anatomy of a HIEHealth Information Exchange

Anatomy: Detailed VersionHIE - Central Data Repository for a core set of clinical variableseMPI - Master Patient Index tracks unique patients and ensures data integrityCommunity 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 patientPatient 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 communityComprehensive clinical education supportTrainee 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

Medical Home & HIEFragmented CareMore patients Complex populations1in 4 - Behavioral Health Diagnosis(Duals Drive cost )Medicaid 46% Medicare 24%Investing in the Aftermath vs Ahead of the curveResource Drain from Missed Early Opportunities

Medical HomeGoalsIntegrated SystemsMore Efficient Use of ResourcesIdentify & Prioritize patients for Intervention(ahead of the curve)Link Providers - Coordinate CareRaise Quality - Evidence Based GuidelinesIdentify 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 ITPrompted, in part, the creation of the Office of the National Coordinator for Healthcare IT (ONCHIT), the Health IT Czar2006: GKFF commissioned an OK-specific evaluation of the value of HIE

MotivationClinicians 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 1995Medicare patients see an average of 5.6 different providers each year= 5.6 silos of dataWhat is the value of HIE for Oklahoma and specifically for the Tulsa region?

HIE Expert PanelistsDavid Brailer, MD, PhDSanta Barbara County Care Data Exchange, Health Technology CenterWilliam Braithwaite, MD, PhD Independent consultant, Dr HIPAAPaul Carpenter, MDAssociate Professor of Medicine, Endocrinology-Metabolism and Health Informatics Research, Mayo ClinicDaniel Friedman, PhDIndependent public health consultantRobert Miller, PhDAssociate Professor of Health Economics, UCSFArnold Milstein, MD, MPHPacific Business Group on Health, Mercer Consulting, Leapfrog GroupJ Marc Overhage, MD, PhDRegenstrief Institute, Associate Professor of Medicine, Indiana UniversityScott Young, MDSenior Clinical Advisor, Office of Clinical Standards and Quality, CMSKepa Zubeldia, MDPresident and CEO, Claredi Corporation

HIE Value Construct

HIE Value Construct

What about funding?One time:ARRA stimulus dollarsOther grantsOngoing: Business model must be developedROI by stakeholder will drive the business model

ARRA Stimulus Dollars

Opportunity: Stimulus PackageFederal Agencies offering$20B for healthcare IT, $3B short term and $300M immediately$1B for comparative effectiveness research$1.5B for community health centersMuch will be distributed through grant processWill be highly competitiveMany other communities have been in this game for yearsOur communities mustBe unified behind a well-developed plan of actionWe must build the coalition now

Greater Tulsa Health Access Network

From the final ARRA:In order to be eligible for Stimulus GrantsMust be a qualified State-designated entityDesignated by State as eligible to receive awardsNon-profit entityClear objectives to use Healthcare information technology to improve care quality and efficiency through secure data exchangeAdopt non-discrimination and conflict of interest policiesBroad 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 patientsPenalties for non-adoption not yet elaborated, but assume mirror bonuses

Chart1

020102010

19800000020112011

1980000001.83

1980000002.85

17550000020142014

15750000020152015

020162016

-15750000020172017

-17550000020182018

-19800000020192019

-19800000020202020

-19800000020212021

Total for Region

Series 2

Series 3

Year of adoption of EMR and HIE

Dollars

10-year change in Medicare payments to Tulsa providers and hospitals by year of meaningful adoption of EHR and HIE*

Sheet1

Total for RegionSeries 2Series 34500

20100.0

2011$198,000,000

2012$198,000,0001.8318000

2013$198,000,0002.8512000

2014$175,500,0008000

2015$157,500,0004000

20160.02000

2017$(157,500,000)-2000

2018$(175,500,000)-4000

2019$(198,000,000)-8000

2020$(198,000,000)-12000

2021$(198,000,000)-18000

From the final ARRA:Regional organization must includeProviders, including those focused on low-income and underservedHealth plansPatient and consumer organizationsHIT vendorsHealthcare purchasers and employersPublic health agenciesUniversitiesClinical researchersOther staff who use HIT

National: Meaningful Use guidanceIn order to qualify for bonus payments (and avoid penalties)By 2011, the following must be exchanged:Doctors: Problem lists, medication lists, allergies, test resultsHospitals: Discharge summaries, procedures, problem lists, medication lists, allergies, and test resultsBy 2013, the following must be exchanged:Doctors: Share all care transition data across the community electronicallyHospitals: Share all care transition data electronically

*Greater Tulsa Health Access NetworkClinical Task Force Meeting #1*Brailer and Overhage, instrumental in 2 of the regional data sharing initiatives currently running.

Economist, people from public health, the payer side, and informaticists, public policy.Greater Tulsa Health Access NetworkClinical Task Force Meeting #1*Greater Tulsa Health Access NetworkClinical Task Force Meeting #1