Health Information Exchange 101Problem, Definitions, Value, Policy
David C. Kendrick, MD, MPHAsst. Provost for Strategic Planning
OUHSC
National perspective• At >17% of GDP, healthcare costs - out of control• Value delivered is limited– US ranks below
most industrialized nations on quality metrics, despite spending more
• Healthcare IT - part of the solution – prioritized and funded– American Recovery and Reinvestment Act
• Patient Centered Medical Home gaining as the delivery model of choice
2009 State of the State’s Health Summary
Oklahoma is the only state where the death Oklahoma is the only state where the death rate has gotten worse…..rate has gotten worse…..
800
850
900
950
1,000
1,050
1980 1985 1990 1995 2000 2005
Tulsa
US
Some Factors1. Economic downturn
healthy people and jobs left Oklahoma
2. Poverty remained3. Heart Disease –
(Diabetes)4. Cancer 5. Access to Care
Age-adjusted Death Rates
Past 25 Years
OK
2007 COMMONWEALTH FUND ReportState Scorecard Summary of Health System Performance
What WE CAN’T Do
• “Grow” more doctors quickly• Create new hospitals overnight• Force patients to:
–Exercise–Stop smoking–Lose weight
What We Can DoLeverage Technology
• Complex populations• Limited Resources:
–Create a lean healthcare system–Improve Care Coordination–Business 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 Care
The Commonwealth Fund, April 2008
Evidence 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 Situation
PayersDemographicsMedical claims
Pharmacy claimsCase mgmt records
Doctor officesEHR
ClaimsRx
Case mgmtCommunity
outreach
Rx
Imaging
Hospitals (inpt)
ER/UC
Public Health
Other PCPs
Specialists
Ancillary carePT/OT/Aud/Diet
Labs
Manual connection (mail, fax)Electronic connection
Safety Net Clinics and community
agencies
Patient
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. CCC
HIE
RHIO
Greatest Value Your Data is Local (CCC)Business Model - Self Supporting
Stakeholders/UsersQuality, Safety & Efficient Delivery
Govern, Sets Rules
Statewide Network of Networks
Disaster Bioterrorism Public Health
National (NHIN)
Health Information Organization
Scale State-wide: A Network of Networks
•Local governance•Common technology
Anatomy of a HIE
Health Information
ExchangeElectronic Master Patient Index
Population Care Analytics
Patient Portal Physician PortalMedical
Education
Anatomy: Detailed Version• HIE - Central Data Repository for a core set of clinical variables• eMPI - Master Patient Index tracks unique patients and ensures data integrity• Community 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 patient• Patient 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 community
• Comprehensive clinical education support– Trainee 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
Patient Centered Medical HomeHealth Information
ExchangeReimbursement Model
Patient
Centered
Medical
HomePatie
nt
Centered
Medical
Home
Patient Centered Medical Home
Patient Centered
Medical Home
Patient Centered Medical Home Health Information
Exchange
Medical Home & HIEFragmented Care
More patients Complex populations
1in 4 - Behavioral Health Diagnosis
(Duals Drive cost )
Medicaid 46% Medicare 24%
Investing in the Aftermath vs Ahead of the curve
Resource Drain from Missed Early Opportunities
Medical HomeGoals
Integrated Systems
More Efficient Use of Resources
Identify & Prioritize patients for Intervention
(ahead of the curve)
Link Providers - Coordinate Care
Raise Quality - Evidence Based Guidelines
Identify 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 IT• Prompted, in part, the creation of the Office of
the National Coordinator for Healthcare IT (ONCHIT), the Health IT “Czar”
• 2006: GKFF commissioned an OK-specific evaluation of the value of HIE
Motivation
• Clinicians 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 1995
• Medicare patients see an average of 5.6 different providers each year= 5.6 silos of data
• What is the value of HIE for Oklahoma and specifically for the Tulsa region?
HIE Expert Panelists• David Brailer, MD, PhD
– Santa Barbara County Care Data Exchange, Health Technology Center• William Braithwaite, MD, PhD
– Independent consultant, “Dr HIPAA”• Paul Carpenter, MD
– Associate Professor of Medicine, Endocrinology-Metabolism and Health Informatics Research, Mayo Clinic
• Daniel Friedman, PhD– Independent public health consultant
• Robert Miller, PhD– Associate Professor of Health Economics, UCSF
• Arnold Milstein, MD, MPH– Pacific Business Group on Health, Mercer Consulting, Leapfrog Group
• J Marc Overhage, MD, PhD– Regenstrief Institute, Associate Professor of Medicine, Indiana University
• Scott Young, MD– Senior Clinical Advisor, Office of Clinical Standards and Quality, CMS
• Kepa Zubeldia, MD– President and CEO, Claredi Corporation
HIE Value Construct
Providers Hospitals
Pharmacies
Radiology Centers
Other Providers
Public Health Agencies
Payers
Clinical Laboratories
HIE Value Construct
Providers Hospitals
Pharmacies
Radiology Centers
Other Providers
Public Health Agencies
Payers
Clinical Laboratories
Avoided redundant tests, Electronic test ordering and results
delivery
Avoided ADEs, drug utilization savings,
automated transaction sets
Avoided redundant imaging, Electronic imaging ordering
and results delivery
Electronic Rx, refills, interaction checking,
adherence data
Electronic submission of
reportable conditions and vital
statistics
Electronic referrals, consultation letter
delivery, chart requests
What about funding?
• One time:– ARRA stimulus dollars– Other grants
• Ongoing: – Business model must be developed– ROI by stakeholder will drive the business model
ARRA Stimulus Dollars
Washington, D.C.
Earmarks Federal Agency Grants
ONCHIT
AHRQ
DHS
State distributions
Heath Dept
OHCA
Opportunity: Stimulus Package• Federal Agencies offering
– $20B for healthcare IT, $3B short term and $300M immediately
– $1B for comparative effectiveness research– $1.5B for community health centers
• Much will be distributed through grant process• Will be highly competitive• Many other communities have been in this game for years
• Our communities must– Be unified behind a well-developed plan of action– We must build the coalition now
Greater Tulsa Health Access Network
From the final ARRA:In order to be eligible for Stimulus Grants
• Must be a qualified State-designated entity– Designated by State as eligible to receive awards– Non-profit entity– Clear objectives to use Healthcare information
technology to improve care quality and efficiency through secure data exchange
– Adopt non-discrimination and conflict of interest policies
– Broad 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 patients†Penalties for non-adoption not yet elaborated, but assume mirror bonuses
†
From the final ARRA:Regional organization must include
• Providers, including those focused on low-income and underserved
• Health plans• Patient and consumer organizations• HIT vendors• Healthcare purchasers and employers• Public health agencies• Universities• Clinical researchers• Other staff who use HIT
National: Meaningful Use guidance
• In order to qualify for bonus payments (and avoid penalties)– By 2011, the following must be exchanged:
• Doctors: Problem lists, medication lists, allergies, test results
• Hospitals: Discharge summaries, procedures, problem lists, medication lists, allergies, and test results
– By 2013, the following must be exchanged:• Doctors: Share all care transition data across the
community electronically• Hospitals: Share all care transition data electronically