Southwestern VaMedical Technology SummitOct. 2, 2009

Presentation Overview

Background • Coordination of Care for Individuals• Regional Public Health Status Improvement

Current Status • Regional Participation and Capabilities• State-level initiatives• National

Future Plans • Support participants to achieve “Meaningful Use”• Expansion of cooperative efforts• Tracking and reporting of outcomes

Background: Regional Health Improvement

750,000 citizens

(2/3 in Tennessee, 1/3 in Virginia)

Disproportionately High Rates for

•Premature mortality

•Chronic Diseases

•Prescription Drug Overdose Uneven Access to Services

•18 hospitals•1400 physicians•18% uninsured

CareSpark’s Mission: to Improve the Health of People

in northeast Tennessee and southwest Virginia

through the Collaborative Use of Health Information

CareSpark’s Core Strategies

Provide patient information and decision supportat the point-of-

care

Provide patient information and decision supportat the point-of-

care

Align financial incentives for

patients, providers, purchasers

Align financial incentives for

patients, providers, purchasers

Empower patientsto make informed

decisions and healthy choices

Empower patientsto make informed

decisions and healthy choices

Compile and analyze aggregate data for population health improvement

Compile and analyze aggregate data for population health improvement

1.1. 2.2.

3.3. 4.4.

Community-Wide Collaboration

• Employers: Eastman Chemical Company, CGI, BAE Systems, City of Kingsport,

Food City, ntara, the Creative Trust, Steadman Corporate Design,

• Payors: Blue Cross Blue Shield of Tennessee, John Deere Health / United Healthcare, Cariten

PHP, Highlands Wellmont Health Network, CIGNA

• Hospitals: Mountain States Health Alliance, Wellmont Health System, Johnston Memorial

Hospital, Quillen V.A. Medical Center, Laughlin Memorial

• Physician Practices: Holston Medical Group, Highlands Physicians, Health Alliance PHO,

Cardiovascular Associates, ETSU University Physicians, Clinch River Health Services, Frontier Health, Southwest Virginia Community Health System, Mountain Region Family Medicine, Medical Care PLLC

• Health Education: East TN State University School of Medicine / College of Nursing/ College

of Public and Allied Health, University of Appalachia College of Pharmacy, University of Virginia

• Public Health: Sullivan and Northeast Regional Health Departments in TN, Cumberland

Plateau and Lenowisco Health Districts in VA, Tennessee Department of Health, Virginia Department of Health and Human Resources

• Community Non-Profits: Kingsport Tomorrow, United Way of

Kingsport, Rotary Club of Kingsport, Kingsport Chamber of Commerce, Bristol Chamber of Commerce, NETWORKS Sullivan County Partnership

• Patient Advocacy Groups: American Cancer Society,

Minority Health Coalition, Mountain Empire Older Citizens, Savvy Patient

•Technology Companies: ActiveHealth, AllScripts, Anakam, BCTI, Cisco,

CGI, Deliberare, Healthvision, Holston Technology, Initiate Systems, Intellithought, Intel, LucentGlow, OnePartner, Oracle, Wellogic

Key Strategic Decisions

1. Enable voluntary participation by all patients and providers in region

2. Enroll patients through default Passive Enrollment (“opt-out”) with option for Active Enrollment (“opt-in”)

3. Hybrid Model, combining Federated Repositories and Centralized

Repository for limited clinical data- Enabling coordination of care decision support, monitoring and aggregate data analysis

4. Data Access and UsesPatient: view content of records, view access logProvider: payment, treatment, operations Public health: required reporting and authorized queriesPayers: de-identified aggregate dataResearch: IRB-approved studies

5. Fee-Based Revenue Model- Contracts with public agencies, insurers and employers- Transaction fees for data providers (labs, hospitals, large practices)- Contributions (cash and inkind)

6. Commitment to standards (ISO, IHE / HITSP / NHIN, other)

CareSpark Data-Sharing Options

Data Sharing Option Intended Data Use Data Sharing Result

Identified Data Patient Care and Treatment

All data sent to CareSpark will be identified data in order to match patient records from multiple providers. Identified data will be available to authorized providers for access of additional healthcare information about the patient.

De-Identified Data Anonomized – patient data can never be re-identified

Approved Population Health Improvement activities

Identified data available to CareSpark will be de-identified according to the approved requirements and stored separately.Pseudo-Anonomized –

Patient data can be re-identified, if necessary, but only by the party who provided the pseudo-anonoymized data

Limited Public Health Identified data available to CareSpark will be de-identified with the specified additional fields required for a limited dataset according to the approved requirements and stored separately.

CareSpark’s infrastructure

• We’ve Built a standards-compliant Clinical Document Exchange Network• Exchanges clinical documents between providers• Accepts patient demographic information from

Providers• Controls clinical data in accordance with patient

consent preferences• Supports direct integration and

access through provider EMRs (standard and non-standard)

• Allows access for providers without EMR

• High levels of security

Technical Architecture

Internet

Provider 1

Active Health

Data BaseServer

ApplicationServer

`

MPI ClientFilters and Encryptions

Application Server

Data BaseServer

CareSpark Secure & Redundant

Network A

CareSpark Secure & Redundant

Network B

Note 1: Patient access will be via the internet thorough Https Protocol (SSL)

LoadBalancer

AppFirewall

Note 2: Although not pictured, the Internet connectivity, the Application Firewall and the Load Balancer will all be redundant, to avoid a single point of failure.

See Note 2.

See Note 3

NHIN

Patient`

See Note 1.

Note 3: All non-patient connections to the Internet are secured connections, via SSL.

EMPIFilters and Encriptions

EMPIFilters and Encriptions

Data BaseServer

Data BaseServer

Router

Provider 2`

MPI ClientFilters and Encryptions

` Small Doctors Office

`Provider using

ASP

Application Server

Provider

MPI ClientFilters and Encryption

CareSparkCareSpark

OracleOracle

Health Information Exchange Infrastructure

XDS PatientIdentitySource(MPI)

XDS PatientIdentitySource(MPI)

CloverleafCloverleaf

CT TimeClient

CT TimeClient

ATNA AuditRepositoryATNA AuditRepository

XDSDocumentRepository

XDSDocumentRepository

XDSKey Store

XDSKey Store

InitiateEMPI

InitiateEMPI

PostGreSqlPostGreSql

ATNAWinSysLog

ATNAWinSysLog

Service Providers

DB Server

ConsentRepositoryConsent

RepositoryMPOP

ConsentMPOP

ConsentPatient Identity Feed

Patient Queries

Send Clinical Documents

Query For Clinical Documents

Retrieve Clinical Documents

Subscriber Identity Feed

Clinical Documents

CareSpark ProvidersCareSpark Providers

EMREMR

Patient Managemen

t System

Patient Managemen

t System

ActiveHealthActiveHealth

Subscriber Managemen

t System

Subscriber Managemen

t System

CareEngineCareEngine

XDS PIXServiceXDS PIXService

XDS PDQService

XDS PDQService

XDS RegService

XDS RegService

XDS RepService

XDS RepService

Two-Factor

Authentication

Two-Factor

Authentication

Clinician

Portal

Clinician

Portal

XDSDocumentRegistry

XDSDocumentRegistry

XDSRegistry

NIST

XDSRegistry

NIST

ADTService

ADTService

WellogicWellogic

HealthvisionHealthvision

CGICGI

OnePartner/BCTI

OnePartner/BCTI

AnakamAnakam

Car

eSp

ark

XD

S D

ata

Sto

re

-

F

or P

atie

nt C

are

Jan 06

CareSpark RHIO Timeline

Jun 08 Jan 10Jan 07 Jan 11Jan 09Jan 05

Tn non-profit org chartered

document registry andrepository

Build clinical data repository

Physician Portal,

authentication

Decision Support

delivered electronically

Data-sharing

agreements Claims-based

decision support

Clinical documentExchange

MPI build

begins

Strategic Planning

Revenue-generating

services (med hx, results delivery)

Immunizationregistry

Funding Sources – Planning Phase

BlueCross BlueShield of Tennessee $162,125Foundation for eHealth Initiatives $100,000

(Office for Advancement of Telehealth, HRSA, DHHS)AllScripts HealthCare Solutions $ 25,000John Deere Health $ 41,500Eastman Chemical Company $ 50,000Mountain States Health Alliance $ 50,000Wellmont Health System $ 50,000Novartis Pharmaceuticals Corporation $ 15,000Frontier Health $ 10,000Health Alliance PHO $ 10,000Highlands Physicians Inc. $ 10,000Holston Medical Group $ 10,000United Way of Greater Kingsport $ 10,000Rotary Club of Kingsport $ 10,000East TN State University / Medical Education Assistance Corp. $ 5,000Laughlin Memorial Hospital $ 2,500Johnston Memorial Hospital $ 2,500Kingsport Tomorrow $ 1,500Cardiovascular Associates $ 250

Total funds contributed: $562,875

Revenue Sources July 2005 – July 2009

Local Support $4,185,120 Employer contributions: $ 678,000State grants / contracts $1,600,000Technology Partners $2,250,000CareEngine enrollment fees $1,257,120

State contracts $1,669,600Tennessee $1,369,600Virginia $ 250,000

Federal contracts $4,917,098NHIN Prototype $ 308,000NHIN Trial Implementation $3,609,125

NHIN Option year 1 $ 999,973

Total Funding: $10,771, 818

Participation and Capabilities

July 2009 July 2010 July 2011

Patients 175,000 2,500,000 5,000,000

Data Sources

5 25 100

Clinician users

75 500 3000

Record types

LabsMedsAllergiesRadiology reportsDiagnosisImmunizations

ClaimsDischarge summariesAuthorizationse-PrescriptionsSecure messagingReal-time decision support

Patient accessBiosurveillance

CareSpark’s Strategic Objectives

Population Health ClinicalPremature Mortality Adult Diabetics, Rx filled, vision / foot, HBA1C<7

New Diabetes CasesLipid Panel LDL < 100Flu Vaccines for 65+ Pneumo Vax for ages 65+, <2ER Visits for Health Attack Stroke TherapyPost- MI followup Cancer Screenings (PAP, Mammogram, colorectal)Deaths from Rx Overdose Pain Medication

Financial Savings -- ROI• Patient• Clinician• Facilities• Purchaser (health plan, employer, taxpayer, individual)

Convergence of Interests

Administrative

Billing & Claims

Clinical

Consumer / Personal

Health Record

Research

Best Practices

Patient-Centered

Care

Technical InfrastructureFinancial Incentives

Privacy & Confidentiality

Governance and Policy

Patient-Centered

Care

Nationwide Health Information Network: “network of networks”

NHIN Prototype Demonstration 2006-07

design for exchange between

CareSpark, West Virginia, Kentucky providers

NHIN Trial Implementation 2008

* Core Services:

Consumer permissions

Security exchange

Standardized interfaces

Summary medical record

* Medication Management

eRx, med history, decision

support

* Consumer Empowerment

personal health record, registration

and medication history

Health Information Exchange in Tennessee

Tennessee Roadmap for Health IT

Tennessee eHealth Council: seed funds for RHIO’s, grants for eRx, broadband

Coordinating organization facilitates rules of engagement: • Data-sharing Agreement • Legal Framework• Standards• Interoperability• Transparency• Value• Quality/Cost

Framework for trust and collaboration

Broadband % of Access, Stakeholders, Automation

EMR / EHR/PHR implementation

Structured notes & paper records

Administrative transactions (claims…)

E-prescribing roll out

Secure clinical messaging (labs, imaging, email….)

H.I.E.

Co

mm

on

Po

rtal

Virginia RHIO initiatives

Virginia Health IT Council

Health Information Exchange

Stages of Evolution

Pre-operational

1: Recognize need

2. Organizing and planning

3. Securing resources

4. Developing and implementing

Operational

5. Transmitting data

6. Sustainable business model

7. Expanding participation

In August 2008, 57 report being operational, 88 pre-operational

HIT-Enabled Health ReformAchieving Meaningful Use

2009 2011 2013 2015

HIT-Enabled Health Reform

HITECH PoliciesProtect

privacy and security,

2011 Meaningful Use Criteria

(Capture/share data

electronically) 2013 Meaningful Use Criteria

(Advanced care processes with

decision support, patient access)

2015 Meaningful Use Criteria (Improved Outcomes)

23

24

Overview of Federal HIT Programs

States

Providers

Fed

eral

Gov

ernm

ent C

oord

inat

ion

State Grants - ONC

MU Incentive Payments - CMS

Health Center/Health Center Controlled Networks Funds - HRSA

Medicaid HIE Administrative Funding - CMS

Extension Centers - ONC

State & Regional Demonstrations -AHRQ P

rom

otin

g H

IEP

rom

otin

g M

U o

f E

HR

Tec

hnol

ogy

NHIN - ONC

Standards/Certification - ONC

Medicaid Technical Assistance -AHRQ

Federal Stimulus Funds

HITECH legislation in February 2009• Increased privacy and security requirements• Funding for health information exchange (State

HIE Cooperatives)• Funding for National Research Center

(“comparative effectiveness”) and Regional Health IT Extension Centers

• Funding for Healthcare Workforce Development• Incentives for adoption and “meaningful

use” of health information technology

+ + +EMR eRx

HIE Quality Reporting

Patient Access =

$$$$$$$$

2011-2015

State HIE Cooperatives

Health Improvement Partnership of Tennessee (HIP-TN) not-for-profit entity formed to facilitate and oversee application and distribution of ARRA funds

workgroups: Technical, Privacy & Security, Clinical,Governance / Policy, Financial Sustainability

Board members from this region: Doug Varney, David Sensibaugh

Virginia Health IT Interoperability Commission established under Virginia Department of Health by executive order

priorities to be addressed: childhood immunizations, infant mortality

Local appointee: Liesa Jenkins

Regional Health IT Extension Centers

Virginia: statewide collaboration with regional variation, led by

Va Health Quality Center

Tennessee: statewide proposal submitted by QSource, contracting with

regional partners for delivery of services

Letters of intent submitted Sept. 8Full proposals due Oct. 16, if requested

Future Plans for CareSpark

Local

Increased participation: Enhanced capabilities Sustainability

Providers Secure messaging for users Fees for services

Patients Clinical data repository Regional Extension Centers

Knoxville / Danville Population Health Improvement

Virginia

Public health Other

Immunization telemedicine

Rx Monitoring HIT Commission

VHEN

Tennessee

Public health Other

Immunization HIP-TN

Rx Monitoring

National

NHIN Gateway Other

Federal agencies (VA, SSA) Benchmarking

Other HIE’s (NC, KY, WV) Sharing best practices

Next Steps for YOU

1. Begin planning for EMR Assess your organization’s business requirements, including functionality, cost,

privacy and security protection Evaluate, select certified, standards-based solution, contract, train users and

implement (assistance from Regional Health IT Extension Center or other) Consider modularity for future needs: eRx, decision support, analytics and reporting,

patient access

2. Participate in Health Information Exchange Enter into Data-sharing agreements Access broadband services and network(s) Train users Inform patients Shared costs for infrastructure and services

3. Monitor your results Measure your own results (efficiency, cost, patient outcomes) Report outcomes to access incentives payments Benchmark with peers, share best practices Participate in research to improve effectiveness

4. Take pride in your success!

Better Health for Central Appalachia

www.carespark.com

Liesa Jenkins, Executive Director423-963-4970

ljenkins@carespark.com