Massachusetts NEHEN Network - DeBor

8/9/2019 Massachusetts NEHEN Network - DeBor

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US-German Summit on Primary Care Greg DeBor, Computer Sciences Corporation 781-890-7446 April 9 , 2010 0

Creating a Medical Networkin Massachusetts

US-German Summit onPrimary Care

Washington, DCApril 9, 2010


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Thesis Sharing Data Improves Patient Care

Interoperable health IT can improve individual patient care in numerous ways,including:1

Complete, accurate, and searchable health information, available at the point of diagnosisand care, allowing for more informed decision making to enhance the quality and reliabilityof health care delivery.

More efficient and convenient delivery of care, without having to wait for the exchange ofrecords or paperwork and without requiring unnecessary or repetitive tests or procedures.

Earlier diagnosis and characterization of disease, with the potential to thereby improveoutcomes and reduce costs.

Reductions in adverse events through an improved understanding of each patientsparticular medical history, potential for drug-drug interactions, or (eventually) enhancedunderstanding of a patient's metabolism or even genetic profile and likelihood of a positive

or potentially harmful response to a course of treatment. Increased efficiencies related to administrative tasks, allowing for more interaction with

and transfer of information to patients, caregivers, and clinical care coordinators, andmonitoring of patient care.

1http://healthit.hhs.gov/, U.S. Department of Health & Human Services, accessed 1/27/2010


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The Current Problem

Unfortunately, data sharing across organizational boundaries is not widelyavailable today for a number of historic reasons

Absence of incentives and return on investment few or fragmented short-term financialincentives (payer-specific pay-for-performance) and virtually no long-term studies orevidence on the value of sharing data

Misaligned incentives perception that value accrues to organizations other than the onesmaking the investment (providers pay for implementation and purchasers and payersgain, or payers make the investment and the patients next payer reaps the benefit, etc.)

Legal liability access to or availability of data generated elsewhere somehow compelsthe receiver to verify it and act on it

Privacy sharing violates patient confidentiality (real or perceived)

Competitive barriers current practice rewards health care organizations for developinglong term patient relationships; many fear making it easier for patients to exercise choiceby opening up their records

Technical limitations absence of standards in the past and, because of all the otherfactors, market solutions have been specialized, ill-adapted, expensive and not very good


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ARRA / HITECH Sets a New Data Sharing Agenda

The American Recovery and Reinvestment Act of 2009 (ARRA, or the Stimulus)(Pub. L. 111-5) enacted February 17, 2009 includes provisions to promote theadoption and meaningful use of interoperable health information technology

Collectively cited as the Health Information Technology for Economic and Clinical HealthAct (HITECH)

Implementation is directed by the Office of the National Coordinator for Health InformationTechnology (ONC) in the Office of the Secretary of the U.S. Department of Health andHuman Services

ONC has adopted a set of five Health Outcomes Policy Priorities that will guidemeaningful use, interoperability and data sharing for the foreseeable future:

Improve quality, safety, efficiency, and reduce health disparities

Engage patients and families Improve care coordination

Improve population and public health

Ensure adequate privacy and security protections for personal health information


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Implementation Challenges for Health IT and InformationExchange

Hospital workflow is complex and difficult to change without unintendedconsequences some of which can be potentially life-threatening

Many settings need many solutions

Hospital is different from ambulatory

PCP vs, specialist (and changing models for primary care)

Needs are often different across specialties and patient demographic groups

Labs, pharmacies, imaging centers, long-term care . . . the list goes on and on

Where to focus point of care, secondary use or both in parallel?

Different dynamics, with much of the attention so far on the former, and on thepatient/provider relationship

There is much to be learned related to access to large volumes of health care data forresearch, comparative effectiveness, etc.

Questions abound surrounding the payers role as the focus is almost exclusivelyon enabling the provider

What is the role of the patient or family?

What role does consumerism play? What tools are and will be available? Will patientsengage in using data to manage their care?

Its easy to lose the patient focus when considering all of the effort providers require


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Feb 2009ARRA / HITECH becomes

US law, introducingincentives for meaningful

use of EHRs and healthinformation exchange (HIE)

Medical Network History in Massachusetts

Jun 1996HIPAA becomesUS law, requiring

standardizedelectronic

transactionprocessing forclaims, etc.;

PartnersHealthCare

begins to focuson administrativesimplification asmore feasible

productivity toolthan electronic

exchange of laband pharmacy

orders

Sep 1998Payer / provider

connectivity

solution isincorporated asNew England

Healthcare EDINetwork(NEHEN)

1997 2009 20101998 2007 20081999 2005 20062003 20042001 200220001996

October 2003NEHEN meets federal

HIPAA compliance deadlinefor 23 organizations,representing over 40hospitals and 5,000

physicians

Jan 2003Mass. state govt. begins

restructuring of health andhuman services agencies withcommon IT systems and portal

Feb 1997

Two payers and twoother hospital

organizations joinPartners in developingconnectivity solution,

managed by CSC

Jun 2003MA-SHARE forms asclinical counterpart to

NEHEN, initially focusedon emergency medicine

Oct 2005 Jan 2007

MA-SHARE / CSC leaddevelopment of initial federal

NHIN prototype (linking toIndiana and California)

1999 - 2003NEHEN experiencessteady growth as

HIPAA complianceand productivity

solution

Jan 2005CSC assumes program

management of MA-SHARE andarranges Markle Foundationfunding for development of

Record Locator Service

Dec 2004Massachusetts

eHealth Collaborative

forms to provideEHRs to community-based physicians andcollect measurementdata in Quality Data

Center

Jul 2009

MA-SHARE andNEHEN merge,

retaining NEHENname and CSC asprogram manager

Apr 2009Universal health

insurance becomesMassachusetts law,creating insurance

exchange(Connector)

Feb 2010Health reformbecomes USlaw; HITECH

funding beginsflowing to USstates

2006-2008NEHEN payers funddevelopment of all-payer NEHENNetportal for smaller

providers

Aug 2008EHRs and health

information networkmandated by

Massachusetts law

Dec 2008Payers and providers (as EMHI)fund alignment of NEHEN and

MA-SHARE plans with state and

federal direction


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NEHENs Evolution and Growth

1998 2003 2004 2006 2007 - 2008 2009 2010

Payer / provider

direct connect

Developed payer /

provider HIPAAtransaction sets

BCBSMA and MassHealth join Large group practices join Geographic expansion beyond

metropolitan Boston

MassHealth NewMMIS

requires significantchanges to NEHEN forMedicaid

5010 compliance focus Interest in advanced eligibility

features and other use cases

Hosted portal and

shared

infrastructure

Payers commit to portaldevelopment and initialsupport for small providers

Completed NEHENNetand all-payer portal

NEHEN Hub to lowercost / complexity ofconnectivity

Portal rollout and growth Interest in sharing infrastructure

across clinical andadministrative, small and largeproviders

Clinical HIE MA-SHARE formed as

independent initiative

MedsInfo-ED pilot

Connecting for Health RecordLocator Service grant andprototype

Rx Gateway launched ONC NHIN contract

ONC NHIN prototype

completed Adopted push model

and Push Pilot BIDMC Childrens

Northeast

EMHI sponsors interoperability

planning and endorses NEHEN Meaningful use focus

Clinical summaries Labs and public health Quality reporting E-prescribing

Other

developments

Met October 2003HIPAA compliancedeadline

CSC invited to take over MA-SHARE program management

Significant grant funding(Markle, ONC, CMS/AHRQ)

State passes Chapter305, calling for EHRsand HIE (MeHI and HITCouncil form)

ARRA/HITECH promisesmeaningful use incentive

funding for HIE MA-SHARE and NEHEN merge

Customers 23 35 39 41

Hospitals 46 55 59 61

Users ~1,300 ~1,500 ~1,800 ~2,000+

Classic providers ~12,000 ~16,000 ~18,000 ~20,000

Small providers ~750 ~1,200

Transactions ~24 million / year ~40 million / year ~60 million / year 100 million + / year



Exchange Partner

Conceptual Architecture and Workflow

Provider

Directory /

Routing

Internet

/ Network

Treatment events (visits,tests, discharges, etc.) trigger

patient data being published orpushed from one or moresource systems for exchange

Published

Patient

Data

Data is translated to CCD standard

Message is addressed using prov ider directory

Message is logged and retained for tracking by sender

Source ProviderSource EMRs

and Clinical

Systems

Secondary

Local

System

Exchange

Infrastructure(can be local

to each partner orcentrally hosted)

Provider

Directory /

Routing

Received

Patient

Data

Message or notification of available data is securely

routed to intended receivers

Message can also be routed as encrypted or securee-mail

Fax

Server

Fax

Message can also be routed as facsimile, directly to faxor through fax server at receiver if logging is required

Message is logged and retained for tracking by receiver

Message is inspected for handling and routinginstructions

Acknowledgement is returned to sender based onagreed process and business rules

Message is available for printing (e.g., for paper chart)

Message is available for online viewing from exchangeinfrastructure or in portal

CCD data is translated to proprietary format for use inreceiving system(s)

Exchange infrastructure can also be leveraged forinternal / local exchange within the provider

CCD Standard

Messages

Receiver EMRs

and Other

Systems

Portal or

Dedicated

Viewer

Mail

Server

Interface Engine,

Portal or

Direct Interface

Interface Engine,

Portal or

Direct InterfacePrinter

Fax

Server



Hosted Portal / HIE Service

Hosted by service provider (MA-SHARE) Provides document / data storage, HTTP viewing for subscribers, and

common provider index for dissemination to local gateway participants

Peer-to-Peer Participant

Local gateway users control integration, etc. Can leverage infrastructure for internal integration Interfaces can be direct or use interface engine or similar tools

Architecture Overview

Local Provider

Directory

Internet /Network

PublishedPatient Data

EMRs and Other

Enterprise

Systems

Secondary

Local

System

E-Mail

Server

CCD Standard

Messages,

e-mail or fax

encapsulation

Interface

Engine

or Portal

HIE Application

Server / Gateway

Fax

Server

Web

Server

Service Subscriber

No infrastructure support requirement just Internet connection, fax ore-mail

Summary /

Results Viewer

Fax

Summary /

Results

ViewerE-Mail

Server

Web

Server

Printer

E-mail, fax or

HTTP encapsulation

Published Patient Data

Community Provider Directory

Peer-to-Peer Participant

EMRs and Other

Enterprise

Systems

Secondary

Local

System

E-Mail

Server

Interface

Engine

or Portal

Fax

Server

Web

Server

PublishedPatient Data

HIE Application

Server / Gateway

Local Provider

Directory

HIE Application

Server / Gateway

CCD Standard Messages,

HTTP encapsulation

Summary /

Results Viewer

External

Networks



Patient visits PCP or specialist andestablishes trusted relationship and

consents for release of data

As a result of a referral,admission, or emergency, patient

registers in hospital

Patient is dischargedfrom hospital

Standard formatdischarge summary orER report is transmitted

to HIE network

HIE service checksprovider directory forrouting instructions

HIE service routesdischarge summary to

PCP, specialist or otherinterested and trusted party(e.g., health insurance case

manager)

Consents andprovider routingpreferences are sent to

HIE service

Patient receives care anddetails are noted in hospital

medical record

Sample Use CaseSend / push / route hospital data to interested parties



Patient visits PCP orspecialist and

establishes trustedrelationship and

consents for release ofdata; consents and

provider routingpreferences are sent to

HIE service

Provider refers patient to aspecialist, hospital or other provider for

consultation or service

Standard formatvisit summary withconsultation notestransmitted to HIE

network

HIE service checks providerdirectory for routing instructionsand sends referral request withpertinent patient information /history, diagnosis and service

requested to consulting

provider; business rules can bestored in HIE service for

elements of real-time decisionsupport

HIE service routes visitsummary to PCP, specialist

or other interested and

trusted party (e.g., healthinsurance case manager)

Patient visits consultingprovider, receives services,

and details are noted in patientchart , electronic medical

record or other result is created(e.g., at lab)

HIE service submitsreferral authorization request

to payer for approval andreferral #

Sample Use CaseSend / push / route data in support of a referral or consultation



Sample Use CaseSend / push / route visit and other data for standardized quality measurement /reporting and public / population health management

Patient visits PCP,

specialist, hospital orother provider andestablishes trusted

relationship andconsents for release of

data

Consents andprovider routing

preferences are sent toHIE service (as required)

Standard format visitsummary or batch with data

for determining quality

metrics is sent to payer,government agency or other

organization based onbusiness rules in HIE

service



Sample Use CaseSend / push / route data for personal health records (PHRs)

Patient visits PCP,

specialist, hospital orother provider andestablishes trusted

relationship andconsents for release of

data

Consents andprovider routing

preferences are sent toHIE service

Standard formatvisit summary

is sent to patientproxy for personalhealth record (e.g.,Google, Microsoft

HealthVault, Dossia,etc.)

Patient andauthorized parties

can access personalhealth record

through PHR proxyservice provider


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Physician / clinicianuses software of his orher choice to create anelectronic prescription

E-Prescribing

System

Electronic prescription is transported toHIE service for submission and tracking (viaput / push or get / pull, based on business

rules)

HIE service submits eligibility verif ication topayer for pharmacy benefit eligibility and any

other available data

Payer

Pharmacy Intermediary

(SureScripts-RxHub) /

Pharmacy Benefit

Manager

HIE service submitselectronic prescription / claim

to pharmacy processingaggregator / intermediary ordirectly to pharmacy benefit

manager (PBM) for formularycompliance, etc.

Mail Order /

Retail

Pharmacy

Pharmacy processingaggregator / intermediary

sends electronic prescriptionfill order to mail order or

retail pharmacy

Pharmacy processingaggregator / intermediary

sends acknowledgement toHIE service

HIE service sendsacknowledgement and otherprescription data back to E-

Prescribing System ordirectly to prescribing

physician / clinician (via e-

mail, fax or standard formatmessage)

Sample Use CaseRoute electronic prescriptions


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Patient uses medicationsdispensed at retail or mail order

pharmacy, or purchased over thecounter (OTC)

As a result of a referral,admission, or emergency,patient registers in hospital

Medication history requestis sent to HIE; HIE retrievesretail and mail order history

from national network and anyother available history fromother participating sources

(payers, PBMs, otherhospitals, etc.)

Medication list isvalidated with patient,

incorporating OTC, herbalsupplements, etc.

Inpatient prescriptionorders are created based

on treatment plan andhome listIf patient is discharged, new

discharge prescriptions are writtenand submitted to HIE service forrouting to external pharmacy for

fulfillment

If patient is transferred,reconciled medication list isrouted to next provider of

care via HIE service HIE service routes reconciledmedication list to interested and

trusted party (e.g., PCP)

Sample Use CaseRetrieve and reconcile medication history


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Sample Use CaseAdjudicate and manage claims and/or patient responsibility in near real time

Patient visit orencounter resultsin medical claim

being created inprovider billing

system

Claim is transported to HIE service forsubmission and tracking (via put / push or get /

pull, based on business rules)

HIE service submits eligibilityverification to primary and secondary

payers identified in claim

HIE service transports claim to responsible partyidentified via clearinghouse or other intermediary asspecified in business rules / payer address table;

secondary claim created as necessary

HIE service submits claim statusinquiry based on business rules

HIE service matches solicited and unsolicited inquiryresponses (including payer scrubber reports) to claim,

identifying those requiring further editing

HIE service collects electronic remittances and matches toclaims, on a solicited and automatic basis

Claim detail and statusavailable for viewing in HIE

service; business users view andedit claims as necessary tocorrect insurance and other

information, with original andcorrected images of claim stored

and clearly identified, allowingedited claims to be and sorted

and grouped according tobusiness rules

HIE service triggers workflow related to denial management and secondary claimsubmission, based on business rules and claim conditions

Business users able to use HIE service to perform drill-down analysis and report on claims,claim status and claims management metrics and performance

BillingSystem

Payer /Fiduciary /

Clearinghouse

Payer /Fiduciary /

Clearinghouse


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Smaller Providers /Other Portal or EMR

Lite Subscribers View data for patient

care, etc., onhosted portal

PHR and OtherVendors

Collecting data

for patientsand families

Pharmacies / PBMs Processing

prescriptions andproviding

medication data

to other parties

Payers Collecting quality

and other data

Target HIE CapabilitiesConceptual view and data flow

Hospital / Health

System / Labs /

Large Provider Providing / consuming

clinical summariesand other data forpatient care

Data Routers /

Aggregators

Collecting andprocessing

data for otherparties

CMS / OtherFederal Agencies

Collecting qualityand other data

State Public Health Collecting vital statistics,syndromicsurveillance andimmunizationdata

Medicaid / Other

State Agencies Providing / collecting

quality andother data

Municipal Health

Departments Collecting disparity

and syndromicsurveillance

data

HIE Hosting infrastructure,

community servicesand portal /viewer(s)

Supported message / data types CCD-based

Clinical summaries at visit,discharge, transfer Procedure, problems, meds,

allergies, test results

Quality data Filtered or based on above

Immunization reporting Biosurveillance / reportable

diseases Filtered or based on above

Lab results Embedded in clinical summary

NCPDP-based Prescription fills / refills Meds. history / formulary (limited)

ANSI X12-based

All existing administrative txns.= Developed / supported in MA


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Privacy and Security

CoreHIE

Services

Core Technical and Operational HIE Services

Insurance Eligibilityand Claims

EHR Lite

ePrescribingLab Orders and

Results

Quality ReportingPublic Health

ReportingMedication History

Visit Summary Coordination of Care

Payors LabsPBMs PharmaciesPublic Health CMS (QualityReporting)

Hospitals with EHRProviders

Meaningful

UseTrading

Partners

HIE Edge Service

Practices with EHR Physician without EHR


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Optional Services Based on Todays Requirements andCapabilities

OptionalHIE

Services

Claim Status,

Remittance

Consent

Management Clinical Messaging

Secure MessageRouting

ProviderAuthentication

Participant Directory

Master Patient Index /

Patient Matching

Hospitals with EHR Practices with EHRProviders

Physician without EHR


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Other US and International Approaches

U.S. states of interest

California Failed efforts Santa Barbara Care DataExchange ($20M+) and CalRHIO

Florida

Fragmented market solutions with separatepayer and state overlays

Indiana

Sophisticated and custom-built; unique basedon 35+ years of foundation and grant funding(Regenstrief Institute)

New York

Widespread, implemented at local level,seeking a balance of public/privatecollaboration

Ohio

Sophisticated market-based solutions inCleveland and Cincinnati, not coordinated

Utah and Delaware

Effective state-mandated networks, butconcentrated and unique demographics

International experience

Denmark 5M pop., socialized Common purpose-built system deployed atthe county level

Hospital-centric, with extensive sharing withina local region

Netherlands 16M pop., public/private

Landelijik SchakelPunt (National Switch

Point) focus on data sharing and RecordLocator Service (RLS)

Smart card for physician / user authentication

Public initiative not integrated with private

United Kingdom 60M pop., nationalized

20 billion National Health Service project

National Spine: Messaging, Authentication,Demographics, Summary Care RecordSecondary Uses Service

EHRs implemented locally

Integrated Care Records Service (Primary,Community, Mental Health, Acute)

Picture Archive and Communications Service


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Conclusions

As 2010 begins, health care leaders in the U.S. in particular need to recognize

that the data sharing landscape is emerging but unsettled and pay attention to: New regulations and standards

Vendor strategies and plans core EHR, systems integration and specialized

State and local health information initiatives (public / private)

IT incentive programs from Medicare, state Medicaid and private payers (P4P)

Choose a strategy for data sharing matched to business plans

Aggressive maximizing benefits based on external incentives, efficiencies, revenuegains and patient goals; choose commercial solutions carefully

Steady progress stay abreast of others, look to act collaboratively and avoid penalties

Conservative at minimum, avoid penalties, which could be stiff or hospitals in particular

Consider two forms of risk

Inaction may lead to foregone incentives and inability to access implementation resources Precipitous action may result in choosing solutions that arent ready for prime time

Places to start

Cost avoidance areas where current costs can be lowered with IT solutions

Most leaders will need to make sure their organizations can walk before they run, but theyneed to get started now!


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US German Summit on Primary Care Greg DeBor Computer Sciences Corporation 781 890 7446 April 9 2010 21

Contact Info

Greg DeBorClient Partner, Health ServicesComputer Sciences Corporation266 Second AvenueWaltham, MA 02451

781-290-1308

[email protected]

www.csc.com/health_serviceswww.csc.com/de

www.nehen.orgwww.nehennet.org

Massachusetts NEHEN Network - DeBor

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