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Leveraging Payer Datato Jumpstart RHIOs

David St.ClairChairman & CEOMEDecision, Inc.

March 7, 2005

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Agenda

• Our Vantage Point• The RHIO Market• Leveraging Payer Data• Collaborative Care Management

MEDecision’s Vantage Point

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MEDecision’s Position• We are the software leader in Collaborative Care Management.

– Collaborative Care Management enables all members of a Patient’s Care Team to share information about the Patient’s history and status, combined with clinical “best practice”, to improve the quality of care and outcomes.

– MEDecision focuses on health care Payers and the emerging Regional Health Information Organizations (RHIOs) as principal customers.

– MEDecision’s Integrated Medical Management (IMM) solution set is the most comprehensive, functionally integrated and adaptable suite of products in production today.

• We create “Actionable Intelligence” for the health care system.– MEDecision provides authorized stakeholders with access to the new

Payer-based Health Record (PBHR) in a flexible and responsive care management environment to accelerate decisions, automate processes and adjudicate clinical requests on the spot.

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MEDecision’s Position

• Today, we have a more than 60 Payer customers nationally, managing care for 42 million people.– 15% of top 433 MCOs, 1 out of every 6 insured Americans;– 21 of the BlueCross BlueShield Plans;– Significant pockets of managed Medicaid business;

• Collaborative Care Management is most likely in markets with progressive Payers that represent a significant portion of each physician’s practice.– We have market-dominant Payers in more than 30 markets.

• The bridge from the Payer space has been iEXCHANGE® Web. – In production or being implemented in half of the markets.

MEDecision’s Position

iEXCHANGE MarketsiEXCHANGE Penetration

The RHIO Market

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The RHIO Market

• Hundreds of initiatives springing up nationally.– Predominantly well-intentioned, but under-funded…– Lots of excitement, but having difficulty focusing…

• Challenges are daunting for every group.– “Without proven models, how can we raise money?” – “What services and capabilities should the network provide?”– “What technologies should we assemble, and how can we support them?”– “How can we minimize or eliminate first-mover disadvantages?”

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The RHIO Market

• High-level Steps to Start a RHIO– Create a Collaborative environment for constituents.– Set Reasonable expectations and schedules.

» Plan for the Success of early adopters and investors.» Link the “Investment-Value-Investment-Value-Investment-Value” chain.» Prepare the ground for future growth.

– Enroll the regional market leaders as Leaders.» Innovation requires a “leap of faith” mentality, but with very small cliffs!» Be willing to praise commitment publicly – it’s an early ROI for Leaders!

– Take Action!» Small trust-building steps today are much more valuable than bigger successes years

from now, and early, small mistakes will likely not be fatal!» Remember the concept: “Speed to Value”

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The RHIO Market

• What is the “First-Mover Disadvantage”?– The Network Effect: the value of a network grows exponentially as the

number of nodes increases.– Therefore, the early adopters risk receiving no real value for their connections

to a RHIO, as no other user likely has data to share about their patients…

So, what should be the first step?

Leveraging Payer Data

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Patient Data Sources

Lab Care MgmtClaimsPharmacy

• Today, a tremendous amount of Payer data is available for clinical summarization and analysis.

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Patient Data Sources

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• However, other electronic data about Patients are distributed inmultiple repositories.

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Patient Data Sources

PHREMR

PBHR

• Three primary systems are used to integrate and store Patient Data.

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Patient Data Sources

PHREMR

PBHR

Electronic Health Record

“EHR”

• Our challenge is to intelligently “weave” these primary sources of Patient data together.

EHR = PBHR + EMR + PHR!

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“RHIO”

“EHR”

Uses for Woven Record

Consumer Decision Support

Clinician Decision Support

Care Management Support

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Uses for Woven Record

• The EHR becomes the source data for:– Patient-centric Risk Assessment & Predictive Modeling.– Comparison to Evidence-based Medicine treatment plans and identification of

“Treatment Opportunities.”– Populating care management systems in Payer, Provider and Disease

Management organizations.– Public Health and Surveillance programs.– Clinical research with unidentified records and data.

• The PBHR is the first step to the EHR, and it’s moving into production in Provider settings today!– Has years of experience in Disease Management organizations.

Collaborative Care Management

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The Emerging Opportunity• The market for Electronic Health Records (EHR) is exploding, and

Payers can become “infomediaries” to help create Regional data exchanges.– 2nd generation analytics to create the Payer-Based Health Record through a

“data weaving” process;– Evidence-Based Medicine and predictive modeling capabilities to identify

Treatment Opportunities (“gaps in care”) in Patient Clinical Summaries;– Multi-Payer connectivity solutions and a Service Oriented Architecture to

efficiently deliver Payers’ data to the point of care.• The goal is to fully integrate all care management functions across

the entirety of the “Care Team.”– Payers, Disease Management vendors and multiple Providers.

ASP/RHIO

xEHR

The Future of the PBHR

Users of Clinical Data Sources of Clinical Data

MIDRiEXCHANGE Web

PBHR/PCS

PRAV

xEHR

xEHR

xEHR

xEHRs

xEHRs

xEHRs

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DM Services Company

Collaborative Disease Mgmt.

Payer Systems

ASP/RHIO

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DM Services Company

Collaborative Care Mgmt.

Customer Systems

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iEXCHANGE® Web

Questions?

Thank You!