connecting payers, providers, and patients a journey of innovation

Connecting Payers, Providers, and PatientsA Journey of Innovation

John D. Halamka MDMay 28, 2012

The Need for Innovation

• Universal adoption of usable electronic health records

• Frictionless Healthcare Information Exchange

• Turning data into information, knowledge and wisdom

• Engaging patients and families in ways that add value

• Protecting privacy

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Universal adoption of usable electronic health records

• Getting the data in• The ideal form factor• Integration with workflow• Leveraging the power of the care

team• Agile continuous improvement of the

products

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Patient Profile Screen

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Problems

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Medications

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Medication History and Reconciliation

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Reports

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1010

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Care Plans

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Frictionless Healthcare Information Exchange

• The “View” Approach• The “Push” Approach• The “Pull” Approach

The Massachusetts Statewide Health Information Exchange

Berkshire Health System

Atrius

NEHEN

SafeHealth

Fallon ClinicUMass Memorial

Statewide HISPSecure Certificate Management

WebPortal

Provider/EntityDirectory

Auditlog

BIDMCPartners

Direct Gateway Services

EOHHS NwHIN

MD

MD

MD

MDMD

MDMD MD

MassHealth DPH

Basic Commonwealth HIE Services

Provider directory

Certificate repository

DIRECT gateway

Web portal mailbox

Repository of physician names, entities, affiliations, and security credentials

Repository of security certificates for authorized users of HIE services

Adaptor that transforms messages from one standard to another without decrypting the message

Secure, encrypted mailbox for users without standards-compliant EHR

“Lookup” services

“Message-handling” services

HIE Services

Users have 2 ways to connect

Provider directory

Certificate repository

DIRECT gateway

Web portal mailbox

HIE ServicesUser types

2 methods of accessing HIE services

EHR connects directly

Browser access to webmail inbox

Physician practice

Hospital

Long-term careOther providersPublic healthHealth plans

Labs and imaging centers

Accelerating Use of HIE

Value of statewide HIE network and services will increase exponentially with the number of users

Removing adoption barriers is key to increasing number of users

– Up-front cost and difficulty of system integration is significant barrier to adoption to most users, especially small practices and safety-net providers

Can address this barrier through a variety of means

•Align all funding streams to maximize opportunities for synergy

•Leverage existing assets

•Build services where the users are

•Lower the cost and ease the difficulty of using the statewide HISP

Roadmap for Statewide HIE Program

•Create infrastructure to facilitate data aggregation/analysis

•Will support Medicaid CDR and quality measure infrastructure

•Will support vocabulary translation services (lab, RX)

Increasing cost and complexity

Facilitate normalization and aggregation

Enable queries for records

Information Highway

•Create infrastructure to enable secure transmission (“directed exchange”) of clinical information

•Will support exchange among clinicians, public health, and stand-alone registries

•Focus on breadth over depth

Analytics and Population Health

•Create infrastructure for cross-institutional queries for and retrieval of patient records

Search and Retrieve

Phase 2

Phase 3

Phase 1

The Reality of Vendor Products

• EHR vendor roundtable held on December 16, 2011 – Over 20 vendors participated in 4-hour session– Mix of ambulatory, hospital, and HIE vendors

• Goal was to understand vendors current and near-future interoperability capabilities and get feedback on MA approach

• Findings– There is wide variation in vendor interoperability capabilities– Few if any vendors have production Direct-enabled systems in

place today– There are no standardized approaches to integration with

centralized provider directories or PKI infrastructure– All of the vendors supported a centrally coordinated approach to

interface development and deployment

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Turning data into information, knowledge and wisdom

• Centralized or distributed databases?• Prospective or retrospective

reporting?• Structured or non-structured data

capture?

BIDPOQDC

A Centralized Database

Distributed Databases

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Distributed Databases

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Prospective Reporting

Retrospective Reporting

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Structured Data Capture

•VITAL SIGNS: Blood pressure 110/70. Height 5 feet 3-1/2 inches, weight 122 pounds, and BMI is 21.5.

•CURRENT MEDICATIONS:1. Docusate sodium 100 mg b.i.d.2. Ferrous sulfate 325 mg b.i.d.3. Magnesium oxide 400 mg b.i.d.4. Aspirin 81 mg daily.5. Plavix 75 mg daily.

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Unstructured Data Capture

•MEDICATIONS:1.He currently takes 3% hypertonic saline

nebs twice daily.2.Pulmozyme 2.5 mg nebs twice daily.3.He takes Bactrim 5 mL twice daily every

Friday, Saturday, Sunday for PCP prophylaxis.

4.He takes Zithromax 2.5 mL once daily every Friday, Saturday, Sunday for neutrophil modulation.

5.He takes Zyvox 600 mg one tablet twice daily but is stopping on 9/12.

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The Role of Natural Language Processing and other evolving

tools

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Engaging Patients and Families

• Tethered and non-tethered personal health records

• Home care devices• Creating value - Open Notes, Passport

to Trust

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Protecting Privacy

• The challenge of BYOD• Protecting data at the server and the

client• Respecting patient privacy

preferences

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The Anonymizer

Name: Rob SmithDOB: 6/7/1972

cd5dced41028cb7ea51d52a888089d7300c9782a552a2d09b1b85e0d0db52ef37f2b6e48ea7d042bbe85e46ef2107da4

Anonymizer

Rob

Smith

6/7/1972

Robert

7/6/1972

1972

0d06b31faa7c44682d770706640465d2B5e341a4b0cdf0e8de7b6f957818d746bd0ec72f2424729efa7baac9a636970a

Variants

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M. Randal SmithDOB: 06/07/74713 731 5577

Mark Randy SmithDOB: 06/07/74123 Main Street713 731 5577 Lab

Results

Outcomes

Record #A-701

Record #B-9103

ObservationsRe-Constructed Identities

FEATURES:Mark Randy Smith,

M. Randal Smith123 Main Street

713 731 5577DOB 06/07/74

Sensors

Patient Identifiers Are First Anonymized

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LabResults

Outcomes

Record #A-701

Record #B-9103

Cd5dced41028cb …00c9782a552a2 …7f2b6e48ea7d0 ……

0d06b31faa7c…B5e341a4b0c…00c9782a552……

Patient Identifiers Are First Anonymized

ObservationsRe-Constructed Identities

FEATURES:Mark Randy Smith,

M. Randal Smith123 Main Street

713 731 5577DOB 06/07/74

Sensors

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Cd5dced41028cb …00c9782a552a2 …7f2b6e48ea7d0 ……

0d06b31faa7c…B5e341a4b0c…00c9782a552……

Identity Resolution Occurring Post Anonymization

LabResults

Outcomes

Record #A-701

Record #B-9103

ObservationsRe-Constructed Identities

Sensors

FEATURES:Mark Randy Smith,

M. Randal Smith123 Main Street

713 731 5577DOB 06/07/74

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FEATURES:Mark Randy Smith,

M. Randal Smith123 Main Street

713 731 5577DOB 06/07/74

Cd5dced41028cb …00c9782a552a2 …7f2b6e48ea7d0 ……

0d06b31faa7c…B5e341a4b0c…00c9782a552……

Patient Linkage Data is Not Stored in Clear Text

LabResults

Outcomes

ObservationsRe-Constructed Identities

Sensors

Record #A-701

Record #B-9103

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FEATURES:Cd5dced41028cb7ea51

…00c9782a552a2d09b1b

…7f2b6e48ea7d042bbe8

……

Cd5dced41028cb …00c9782a552a2 …7f2b6e48ea7d0 ……

0d06b31faa7c…B5e341a4b0c…00c9782a552……

Patient Linkage Data is Stored Anonymized

LabResults

Outcomes

ObservationsRe-Constructed Identities

Sensors

Record #A-701

Record #B-9103

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Record #A-701Matches

Record #B-9103

Discovery

M. Randal SmithDOB: 06/07/74713 731 5577

Mark Randy SmithDOB: 06/07/74123 Main Street713 731 5577 Lab

Results

Outcomes

Record #A-701

Record #B-9103

Observations Sensors

Policy Controls

Policy Controls

Maximizing Discovery - Minimizing Disclosure!

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The Challenges We Face

• V = Volatility. The nature and dynamics of change, and the nature and speed of change forces and change catalysts.

• U = Uncertainty. The lack of predictability, the prospects for surprise, and the sense of awareness and understanding of issues and events.

• C = Complexity. The multiplex of forces, the confounding of issues and the chaos and confusion that surround an organization.

• A = Ambiguity. The haziness of reality, the potential for misreads, and the mixed meanings of conditions; cause-and-effect confusion.

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Questions?

http://geekdoctor.blogspot.comjhalamka@caregroup.harvard.edu