Together for Quality Making It Happen: System Fundamentals
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Transcript of Together for Quality Making It Happen: System Fundamentals
1© 2006, Vanderbilt University
Together for QualityMaking It Happen: System Fundamentals
Mark FrisseVanderbilt University
February 7, 2007
This project will result in an automated, inclusive, interoperable, real time HIS and a data driven quality improvement program.
Alabama Medicaid Transformation Grant Application
2© 2006, Vanderbilt University
This presentation
• Is anyone really doing all of this successfully?• What can one learn from other data exchange efforts to
advance the Together for Quality program?• What generic principles can be applied?• Are there examples of “best practices”?• What choices are right for Alabama?• Are there barriers or conflicts associated with each option?
Based on what we know• What is straightforward?• What is challenging?• Where should leadership efforts be focused?
3© 2006, Vanderbilt University
Selected Together for Quality Programs
• Internal integration of HHS systems• Pharmacy management
– Medication history– Prior authorization– Formulary management– Controlled substances
• Clinical programs– High-risk Medicaid patients– Immunizations
• Participants emphasize case managers• Participants include patients, providers….nearly
everyone
Source: Medicaid Transformation Grant Application
4© 2006, Vanderbilt University
Overview
• Statewide electronic health information system
• Links Medicaid, state health agencies, providers, and private payers
• Will provide Medicaid, other HHS agencies, providers, and private payers with secure, real time access to individual health information
– Claims
– immunization records
– prescription data
– laboratory results
Source: Medicaid Transformation Grant Application
5© 2006, Vanderbilt University
Why an interoperable data hub?
• Only a system-wide change can address inadequacies and inconsistencies of patient care
• Establishes a comprehensive quality improvement model for the Alabama Medicaid Program
• Remove duplication• Avoidable emergency room visits• Support creation of a medical home
Source: Medicaid Transformation Grant Application
6© 2006, Vanderbilt University
“Wiring” Healthcare
Hospitals
Primary care physician
Specialty physician
Ambulatory center (e.g.
imaging centers)
Pharmacy
Laboratory
Public health
Current system fragments patient information and creates redundant, inefficient efforts
Future system will consolidate information and provide a foundation for unifying efforts
Hospital
Data Vaults
Health Information Exchange
Network applications
Server
Payers
Labs
Outpatient RX
Physician office
Ambulatory centers Public healthSource: Indiana Health Information Exchange (modified)
Payers
7© 2006, Vanderbilt University
Data Reuse
Data management
Hospital
Data Vaults
Health Information Exchange
Network applications
Server
Payers
Labs
Outpatient RX
Physician office
Ambulatory centers Public health
Data access and use
Hospitals
Physicians
Labs
Publichealth
Payer
• Results delivery• Secure document
transfer• Shared EMR• Credentialing• Eligibility checking
• Results delivery• Secure document
transfer • Shared EMR• CPOE• Credentialing• Eligibility checking
• Results delivery
• Surveillance• Reportable conditions• Results delivery
• Secure document transfer
• De-identified, longitudinal clinical dataResearchers
PayerPayer
Secure Access
Source: Indiana Health Information Exchange
8© 2006, Vanderbilt University
Technical assertions and issues
• A common identifier for Medicaid beneficiaries will be developed
• An overlay that allows agencies to interact at appropriate security levels
• Claims data• Integrated laboratory data from third-party labs• Clinical decision-support tool (pharmacy)• Peer comparisons on patient acuity and outcomes
measures
Source: Medicaid Transformation Grant Application
9© 2006, Vanderbilt University
Sustainability
• A…firm foundation on which to build a permanently funded PDH that will ultimately be supported by primary partners and various funding sources.
• Funding possibilities include both public and private sector funds, membership fees, and access fees from payer groups.
• Identification of additional sources for revenue and the development of a permanent funding plan.
Source: Medicaid Transformation Grant Application
10© 2006, Vanderbilt University
Fundamentals: Patient data hub
Features• Centralized• Medicaid claims
Challenges• Management and oversight• Transparency• Use limitations• Patient involvement• Auditing• Sustainability• Extension – plan and provider “buy-in”
Examples:•Louisiana•TennCare•Indiana•Memphis•New York•Florida
11© 2006, Vanderbilt University
Fundamentals: Reconciliation of HHS Agencies
Features• Efficiency• Multiple uses• Planning• Quality
Issues• Master person index• Access controls• Data mapping• Aggregate data
12© 2006, Vanderbilt University
Fundamentals: Supplemental data
Features• Better immunization records• Controlled substances• Labs – clinical decision support
Issues• Collection of immunization data• Access: controlled substances• Gaining collaboration of clinical labs• Mapping lab results to appropriate patient
13© 2006, Vanderbilt University
Use of data for clinical decision-support
Features• Integration of data for patient care• Profiling• Population care• P4P
Issues• What is covered under HIPAA?• Authorization and authentication• Individual vs. group data• Population data vs. individual use
14© 2006, Vanderbilt University
Interaction with electronic medical records
Features• Practitioners access all data about patient• Data populates hub automatically
Issues• Provider cooperation• Markets – will all “certified” vendors have equal
access?• Vendor integration and cost – who pays?• Data quality and auditing – who is responsible?• Secondary use of data – will it be “sold”?
15© 2006, Vanderbilt University
Solution: Stakeholder Council
Oversight• “Architects and engineers”• Critical examination – now – of major aims and concerns• Development of a roadmap consistent with the aims of
state government and its citizens• Clearly-defined tasks for work groups with time lines• Realistic expectations: focus on Medicaid but address
whether or not the same system – alone or as a central hub – will meet the care needs of everyone in Alabama
• You may need sustained and consistent leadership from senior state officials – not just Medicaid
Source: Medicaid Transformation Grant Application
16© 2006, Vanderbilt University
Solution: Work Groups
Policy • Responsible for the very difficult work of reconciling various interests with the
Together for Quality Agenda. Health care is more than Medicaid
Privacy• Its more than HIPAA; it is about public trust (patients, providers)
Clinical• Must focus on a realistic view of care for individuals and populations
Technical• Must focus on technical limitations, realities. Must help State deal with
“Vendor frenzy syndrome.”• You don’t have to build it all or “own” it – e.g., Medication history
Finance• Must view the Hub as a part of the overall care delivery infrastructure and not
only as a separate entity
Source: Medicaid Transformation Grant Application
17© 2006, Vanderbilt University
Today’s decisions influence tomorrow’s markets
• What will be the role of a non-profit organization fostering exchange?
• How do your decisions influence market choice? Do they lead to innovation or monolithic bureaucracy?
• What is the best way to align state, federal, employer incentives
• What is the ideal infrastructure in terms of technology and intermediaries (plans, PBMs)
• What is the measurable “end game”?• What “portfolio of initiatives” should be developed to
focus on the best solutions for your state?
18© 2006, Vanderbilt University
A regional effort in Memphis
Three-county region that includes Memphis TN; Approximately 1 million residentsSerious community health problemsMajor public hospitalMultiple competing providersThis is not a state-wide Medicaid initiative
19© 2006, Vanderbilt University
A regional effort in Memphis
• Based on real patient data, not claims• Governance through a 501(c)(3) corporation• Participation of major hospitals and clinics• Participation of state and local government• Involvement of the business community• University participation
– Tennessee Tech– University of Memphis (pending)– University of Tennessee– Vanderbilt University
• National collaborators• Cost: $12 million over 5 years
20© 2006, Vanderbilt University
Goal: To understand what the market should be
• Legal / policy framework• Public Health (Robert Wood Johnson grant)• E-prescribing (AHRQ contract expansion)• Quality (AHRQ contract expansion)• Community Action (Robert Wood Johnson; Healthy Memphis
Common Table)• Understanding of emergency department use• Extension to safety-net clinics to strengthen “medical home”
concepts• Technology – Vanderbilt technologies, Tennessee Tech• Retail pharmacy (coming soon)• Commercial vendors (coming soon)
21© 2006, Vanderbilt University
The real opportunity: find alternatives to ED care
This individual had over 40 ED visits to multiple emergency departments within a 7-month periods. Options:- more effective treatment in ED- more effective care outside of ED
22© 2006, Vanderbilt University
What we have not resolved
We believe much more work is required:• Public trust• Provider trust• Appropriate use• Transparency• Auditing and reporting• Identity management• Cost-effective integration with all certified clinical
information vendors• Medicaid vs. future medical markets• Population data use vs. individual care
23© 2006, Vanderbilt University
Links:http://www.volunteer-ehealth.orghttp://www.connectingforhealth.org/http://www.mc.vanderbilt.edu/vcbh/ds/0606_privacy/http://www.volunteer-ehealth.org/frisse/http://www.volunteer-ehealth.org/frisse/frisse-policy-confidentiality/http://www.volunteer-ehealth.org/news/info/2006/09/midsouth-ehealth-alliance-data-sharing.php
24© 2006, Vanderbilt University
Additional slides
Screen shots of current systemData are from a fabricated test data set
25© 2006, Vanderbilt University
We can locate records and allow “opt out
26© 2006, Vanderbilt University
We can show encounter data
27© 2006, Vanderbilt University
Our user interface is based on user feedback
28© 2006, Vanderbilt University
We can now display data across institutions
29© 2006, Vanderbilt University
(Million)
Net Financial Benefit ($ Million)
Net Present Value
Assumptions
Includes only hospital ED benefits
No adverse drug event benefits modeled
No population health or practitioner productivity modeled
Based on data obtained on the core healthcare entities
Deployment schedule is limited initially to EDs and Labor & Delivery; years four and five will extend to all healthcare providers
Inflation and volumes remain constant
The costs to move and support the RHIO data center are not included in the five-year forecasts
The RHIO support desk infrastructure is not established
The average cost for a core healthcare entity for implementation and operation activities is $30,000 per year.
The State of Tennessee and the Core Healthcare Entities realize a higher financial gain when you consider the
different stakeholder contributions.
State of Tennessee
Payback Period = 1.7
Return on Investment = 1.95
Core Healthcare Entities
Payback Period = 0.5
Return on Investment = 17.5
Payback Period (years) = 3.3
-$2.2
$4.6$1.9
-$0.3
$3.9
-$2.2
-$2.2
$4.2
$1.8
$3.5
-$3
-$2
-$1
$0
$1
$2
$3
$4
$5
Yr 1 Yr 2 Yr 3 Yr 4 Yr 5
Project Return on Investment = .56
NPV (based only on urban ED) is $4.2 Million