Trends in Health Information Exchange and Implications for Public Health
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Transcript of Trends in Health Information Exchange and Implications for Public Health
Trends in Health Information Exchange and Implications for Public Health
June 12, 2013
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The inverse-square law of health information exchange
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HIE is maturing
• Focused on “the noun”• Assumed hierarchy of HIEs
- State- and regional-level HIEs feeding into a National Health Information Network
• Assumed repository-style architectures with rich applications
HIE 1.0 hie 2.0• Focused on “the verb”• No organized hierarchy of HIE
organizations- No “National Network”- State-level HIEs highly varied
and locally driven- Greatest growth in “private HIEs”:
vendor- and ACO-driven• Wide variety of integration approaches
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What is driving this transition?
Limited successes of the prior model
Bottom-up demand -- systems are not interoperable because not enough customers asked for interoperability
• Meaningful Use incentives• Value-based purchasing• Market expectations about standards of care• Younger provider expectations about use of technology• Consumer expectations about use of technology
Supply-side• EHR certification requirements – common denominator important in a
fragmented industry• Technology advancements in cloud services, mobile, broadband, storage,
patient-matching capability, etc
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HIE Building Blocks
Content and vocabulary standardsDocumentation standardizationAnalytics definition synchronization
Interfaces to connecting systemsSecurity and transport standardsPhysician/facility directory
Patient-matchingMedical record indexingConsent managementData access and use contractsClinical portals (patient/provider)
Amount of central orchestration required
Acc
ount
able
car
e ca
pabi
lity
MU
cap
abili
ty
EHR functions
Message & document delivery
Registries & Repositories
Case management and patient access
Measurement & Reporting
Population, Risk, and Financial Management
Enterprise Integration & Management
HIT/HIE Uses Functional requirementsBusiness models
Cross-system query
Business process harmonization
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Data Needs Vary With Business Goals
Independent actors
IDNAccountable care entities
IPA/PHO
Enterprise Integration & Management
• Business integration
Measurement & Reporting
Population, Risk, and Financial Management
Case management, and patient access
Population, Risk, and Financial Management
• Business alignment
• Team-based care• Patient
engagement
EHR functions
Message & document delivery
EHR functions
Message & document delivery
EHR functions
Message & document delivery
EHR functions
Message & document delivery • Become
electronic• Fill in gaps in care
transitions
Registries & Repositories
Cross-system query
Registries & Repositories
Cross-system query
Registries & Repositories
• Performance mgmt
• Population mgmt• Utilization mgmt• Case facilitationCross-system query
Case management & patient access
Case management & patient access
Case management & patient access
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hie 2.0 comes in many shapes and sizes
Transaction-specific national level (e.g., Surescripts)
State-level and regional collaborative HIE organizations
Vendor-specific (e.g., Epic, eClinicalworks)
Point-to-point (e.g., LabCorps, hospital labs)
Enterprise-level HIE organizations (e.g., “private HIEs”)
National level collaborative HIE organizations (e.g., Healtheway)
Level of external coordination needed
Point-to-patient
Level of highest growth
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hie 2.0 comes in many shapes and sizes (2)
• Ability to export and import structured data
• Incorporate in EHR and usable for all EHR analytic and decision support functions
• Ability to export and import clinical documents
• Attach to patient record and viewable
• Ability to provide view into another clinical system at point-of-care
• No exchange of data or documents
Data integration Document integration Visual integration
Growing increasingly common to solve immediate need without interfacing and application workflow redesign
Growing rapidly and likely to increase even more with maturation of directed exchange capabilities
Essentially not happening, except:
• Specific transaction streams such as eRX and labs
• Within EHR network, such as Epic and eCW
• Sophisticated implementations such as Healtheway
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National-level HIOs are most comprehensive HIE implementations, but still quite thin
• Over 20 participants (4 federal) as of September 2011• Over 90,000 transactions conducted• HIE solution based on NHIN standards enabling send/receive and
query/retrieve• DURSA covering complete set of exchange patterns
• Five provider organizations (Geisinger, Kaiser, Mayo, Intermountain, Group Health)
• Complete solution based on NHIN standards enabling send/receive and query/retrieve
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State-level collaborative HIE activity high in certain areas
42 remaining HIE activities had fewer than 1,000 monthly transactions
State HIE Grantee Monthly
transactions Indiana 351,070 Texas 215,005 New York 101,748 Kentucky 92,387 South Carolina 50,515 Delaware 37,245 Oklahoma 32,015 Colorado 22,665 Mississippi 12,909 Nebraska 3,459 Tennessee 3,254 Maryland 3,223 Maine 3,211 New Jersey 1,601 Utah 454 Kansas 302 Minnesota 208 New Mexico 165 Rhode Island 130
37 remaining HIE activities had no query-based transactions
State HIE Grantee Monthly
transactions Indiana 14,532,368 Colorado 5,011,816 New York 3,322,812 Minnesota 1,680,124 Vermont 889,700 Delaware 827,483 Washington 138,422 Michigan 98,976 Maryland 48,655 Ohio 35,359 Rhode Island 29,627 California 28,439 Alaska 3,701 Utah 2,482
3.2 million directed exchanges per month
14 million directed exchanges per month
Directed transactions Query transactions
200K+ directed exchanges per month
Source: ONC HIE Dashboard
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EHR vendors with high penetration generating large amount of vendor-specific HIE traffic
• Large majority of customers (200+) participating in query-based exchanges
• Currently CCD/CDA query-based exchange is ~2.2 million records for ~385K unique patients per month
• Volume doubled over previous year
• Does not include HL7 directed exchange transactions
• 16,743 providers using query-based exchange
• ~2.5 million new CCD records made available on query exchange hubs or sent directly to referral providers per month
• Processed over 75+ million lab result records in 2012
• ~1.5 million query-based exchanges per month
• ~58.5 million directed exchange transactions per month (including HL7 lab result delivery)
Source: Epic, eClinicalWorks, Cerner
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Lab Market Is Highly Fragmented
60%
33%
7% 116,634 physician office laboratories
5,604 commercial labs
8,807 hospital labs
• Quest: ~30%• LabCorp: ~20%• Only Quest and LabCorp cover the
entire US• Next largest, Spectra, covers 1/3 of US
counties and county-equivalents
% of labs conducted
• Fragmentation may be increasing as hospitals increase lab business to offset revenue decreases in other areas
• Fragmentation makes it difficult to generate collective action for a national lab network like Surescripts
• Meaningful Use is the only industry-wide force driving standardization of lab results delivery
• High fragmentation of lab market makes it difficult to measure progress of electronic transactions
• ONC is now fielding national lab survey
Source: Quest Diagnostics 2009 Annual Report; CMS CLIA Update July 2012
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Large fraction of lab results delivery still via fax and paper
10%
90%
HL7 interfaces
Paper/fax delivery
~585 million lab results delivered by Cerner customers per month
• Progress in electronic results delivery tied to EHR penetration
• Interface implementation is significant barrier to progress – lack of standardization and competing priorities
• MU Stage 2 may not be enough of a spur to significantly increase electronic delivery from hospitals – does not require electronic delivery and standardization of electronic delivery is menu set item
% lab electronic lab results
Source: Cerner Corporation
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Large fraction of lab results delivery still via fax and paper
62%
38%
HL7 interfaces with ~600 labs
Not interfaced with ~6800 labs• ~3,400 fax• ~3,400 paper, portal, etc
Analysis of 29 million lab result records received by athenahealth customers
• athenahealth has unique data because they track ALL lab result reports delivered to their customers
• Small number of labs account for majority of electronic results
• Effort required for interface deployment is barrier both on the lab side as well as on EHR vendor side
• athenahealth completing about 15 new lab interfaces per month
• Large practices have higher lab interface rate (68%) than small practices (56%) who get lower priority from labs -- commercial labs do not cover cost of interfaces to small practices
% lab electronic lab results
Source: athenahealth
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Large gap in LOINC-mapping capabilities
24%
76%
Only 1 lab sends LOINC-encoded results
~599 labs send results with proprietary codes
Analysis of 29 million lab result records received by athenahealth customers
• Vast majority of labs do not send LOINC-encoded results
• 1 national lab does, another national lab can but currently does not because has not been asked to
• Large commercial labs capable of LOINC-encoding, however, vast majority of hospitals are not and will take significant effort to get them there
• MU Stage 2 may not provide enough of a spur given difficulty of effort, allowed variation in state public health requirements, and competing priorities
% LOINC-encoded labs
Source: athenahealth
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HIE Activity Mushrooming Across the Region
NEHEN
North Adams
Baystate SafeHealth
Newburyport
RIQI
VITL
NYeCBeverlyWinchester
Holyoke Emerson
Sturdy
BerkshireHealth
South Shore
NH-HIO
Cape Cod Health
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Current state of the market favors a network of networks connected via a single statewide open HISP supported by centralized project management
Illustrative example
Berkshire Health SystemNEHEN
SafeHealthMD
MDMD MD
Fallon Clinic UMass Memorial
PKI/certificate mgmt
Webportal
Provider/entitydirectory
Auditlog
MD MD
MDMD
MD
MD
BIDMCPartners
Direct gateway services
EOHHS NwHIN
MassHealth
DPH
Atrius
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Data Aggregation Process Steps
Clinical sources Transport Management and analysis Reporting and data access
MDs
MDs
MDs
MDs
HHHH
Data requirements
RX
Labs
Vitals
Problems
Patient
Provider
Payer
etc
Remediation and Improvement
Key questions:• How well-defined are reporting/analysis needs, and corresponding data requirements? Will source-
level remediation be required?
• How many clinical sources will be included? What is integration strategy and timeline for disparate EHR systems?
• Which transport option? What are pros/cons of each?
• Are there unique data management and analysis requirements?
• Who will be accessing reports and data? Are there unique reporting and/or data access requirements?
• How will reporting/analysis integrate with business and care processes?
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BIDCO QDC
BIDCOQDC
Electronic reporting• MU, PQRS, AQC, etc
Data management• Report viewing• Case tracking
Data extraction• Queries• Pre-defined data marts
Documentation & Extraction
Transport Validation & Analysis
User Access
Management Info System• User information• Utilization analysis• Other
Current status:• 5,611,698 care event C32 records• Covers 614,829 unique patients• Covers 2,506 unique providers
576,765
Cumulative records 2013 YTD (828,339)
231,218
20,356
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AHI QDC
AHIQDC
Data management• Report viewing• Case tracking
Documentation & Extraction
Transport Validation & Analysis
User Access
Current status:• 760,923 care event C32 records• Covers 155,740 unique patients• Covers 300+ unique providers
Pod 1
Data management• Report viewing• Case tracking
Pod 2
Data management• Report viewing• Case tracking
Pod 3
31,504
Cumulative records 2013 YTD (278,587)
50,416
87,934
13,061
84,507
11,165
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Current Data Frequency Count
Problem
s
Proced
ures
Total R
esult
s
Medica
tions
Immun
izatio
nsVita
ls0
10,000,000
20,000,000
30,000,000
40,000,000
7,336,740 1,817,738
34,671,028
7,639,148 2,366,770
26,239,285
Total Clinical Element Counts
Problem
s
Proced
ures
Total R
esult
s
Medica
tions
Immun
izatio
nsVita
ls0
2,000,0004,000,0006,000,0008,000,000
1,217,776 366,286
8,261,178
1,595,983 581,209
5,983,886
Unique Clinical Element Counts
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
26,189,415
7,251,404
44,036,490
25,315,817
400,37115,051,849
Total Clinical Element Counts
Problem
s
Proced
ures
Result
s
Medica
tions
Immun
izatio
nsVita
ls0
10,000,000
20,000,000
30,000,000
6,729,434 5,854,982
25,951,710
5,854,982 311,2448,356,400
Unique Clinical Element Counts
BIDCOAHI
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Implications for Public Health
Heterogeneity will be the hallmark of HIE activity in the coming years
Multi-layered HIE modes seem to be developing as business practices mature• “B2B”-style patterns to move documents around with little to no centralized coordination
– Direct and Directed Query• “Supply-chain” style patterns with deep integration among very closely aligned entities
seeking centralized orchestration for rich applications to support complex uses
Aggregation at the edge• HIE as conduit for aggregation rather than as repositories themselves
Alignment with Meaningful Use• MU Stage 2 includes higher standards for clinical content• Aligning with and/or “piggy-backing” on MU and ACO capabilities is most likely path to
scaleable model for rich, longitudinal data to meet variety of public and population health purposes
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www.maehc.org
Micky Tripathi, PhD MPPPresident & CEO