Building Health Information Exchanges to Support Accountable Care Organizations and

Medical Homes: Delaware’s Experience

Web SeminarWeb Seminar

June 5, 2013June 5, 2013

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Today’s Event ModeratorToday’s Event Moderator

Gerry Fairbrother, PhDGerry Fairbrother, PhD

Senior ScholarSenior Scholar

AcademyHealth AcademyHealth

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HITECH* Spurred Dramatic HITECH* Spurred Dramatic Growth in TechnologyGrowth in Technology

Increase in electronic health records Increase in electronic health records adoptionadoption

Meaningful Use provisions to promulgate Meaningful Use provisions to promulgate standards and promote qualitystandards and promote quality

Community-wide technology (Beacon Community-wide technology (Beacon Communities Program)Communities Program)

Health Information Exchanges (HIE) at Health Information Exchanges (HIE) at state and regional levelstate and regional level

*Health Information Technology for Economic and Clinical Health*Health Information Technology for Economic and Clinical Health

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Growth in TechnologyGrowth in Technology

Source: Hsiao CJ, Hing E Use and characteristics of electronic health record systems among office-based physician practices: United states, 2001-2012. NCHS data brief no 111. Hyattsville, MD: National Center for Health Statistics. 2012

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Beacon CommunitiesBeacon Communities

University of Hawaii at Hilo

University of Hawaii at Hilo

Southeastern Michigan Health Association

Detroit, MI

Southeastern Michigan Health Association

Detroit, MI

Louisiana Public Health InstituteNew Orleans, LA

Louisiana Public Health InstituteNew Orleans, LA

Delta Health AllianceStoneville, MS

Delta Health AllianceStoneville, MS

Geisinger Clinic Danville, PA

Geisinger Clinic Danville, PA

HealthInsightSalt Lake City, UT

HealthInsightSalt Lake City, UT

Inland Northwest Health Services

Spokane, WA

Inland Northwest Health Services

Spokane, WA

Community Services Council of Tulsa

Tulsa, OK

Community Services Council of Tulsa

Tulsa, OK

Mayo Center Clinic Rochester, MN

Mayo Center Clinic Rochester, MN

Rhode Island Quality InstituteProvidence, RI

Rhode Island Quality InstituteProvidence, RI

HealthBridgeCincinatti, OHHealthBridgeCincinatti, OH

Southern Piedmont Community Care Plan

Concord, NC

Southern Piedmont Community Care Plan

Concord, NC

The Regents of the University of California

San Diego, CA

The Regents of the University of California

San Diego, CA

Western NY Clinical Information Exchange

Buffalo, NY

Western NY Clinical Information Exchange

Buffalo, NY

Rocky Mountain HMOGrand Junction, CO

Rocky Mountain HMOGrand Junction, CO

Eastern Maine Healthcare Systems

Brewer, ME

Eastern Maine Healthcare Systems

Brewer, ME

Indiana HIEIndianapolis, IN

Indiana HIEIndianapolis, IN

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HIEs are KeyHIEs are Key

“…“…Health information exchange (HIE) is a Health information exchange (HIE) is a key driver of efficiency gains…key driver of efficiency gains…

……Therefore, the success of HITECH Therefore, the success of HITECH hinges, in part, on whether we can jump-hinges, in part, on whether we can jump-start HIEs.”start HIEs.”

Adler-Milstein J, DesRoches CM, and Jha AK. Health information exchanges Adler-Milstein J, DesRoches CM, and Jha AK. Health information exchanges among US hospitals. Am J Manag Care. 2011 Nov;17(11):761-8among US hospitals. Am J Manag Care. 2011 Nov;17(11):761-8..

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Coverage and LocusCoverage and Locus

Coverage and locus of Health Information Coverage and locus of Health Information Exchanges (HIEs) varyExchanges (HIEs) varyState (Delaware – linked to other states)State (Delaware – linked to other states)Local and regional (Cincinnati, Ohio; Local and regional (Cincinnati, Ohio; Buffalo, New York; Indiana)Buffalo, New York; Indiana)Market-based (Minnesota, Arizona)Market-based (Minnesota, Arizona)

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Growth of Accountable Care Growth of Accountable Care Organizations and HIEOrganizations and HIE

Accountable Care Organizations (ACOs) need Accountable Care Organizations (ACOs) need population management at system level (data population management at system level (data warehouse, registry function)warehouse, registry function)

Move data from different electronic health Move data from different electronic health record systems to point of carerecord systems to point of care

Some HIEs have adjusted to become Some HIEs have adjusted to become connectors between ACOsconnectors between ACOs

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Important Functionality of HIEImportant Functionality of HIE

Technology to improve quality (data Technology to improve quality (data exchange, alerts, population exchange, alerts, population management)management)

Beyond technology: Need to make Beyond technology: Need to make business case and need for strong business case and need for strong governance structuregovernance structure

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More than TechnologyMore than Technology

““HIE is dependent on government to change HIE is dependent on government to change the way care is paid for…the way care is paid for…

……Things not related to technology need to Things not related to technology need to happen.”happen.”

Blumenthal, David. Interview by Ravi Parikh for Medgadget. Blumenthal, David. Interview by Ravi Parikh for Medgadget. September 10, 2012.September 10, 2012.

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Now We Will Hear FromNow We Will Hear From

Representatives of two different HIEsRepresentatives of two different HIEs

How they are organizedHow they are organized

Challenges and lessons learnedChallenges and lessons learned

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PresenterPresenter

Jan Lee, MDJan Lee, MD

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Executive DirectorExecutive DirectorDelaware Health Information NetworkDelaware Health Information Network

Delaware Health Information Delaware Health Information Network (DHIN)Network (DHIN)

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Getting StartedGetting Started

Governance, many stakeholdersGovernance, many stakeholders Policies and proceduresPolicies and procedures Security and Trust FrameworkSecurity and Trust Framework Consent model: opt-in versus opt-outConsent model: opt-in versus opt-out Data model: federated versus consolidated Data model: federated versus consolidated

or hybridor hybrid Environmental scan: electronic health Environmental scan: electronic health

records versus paper, statewide availability records versus paper, statewide availability of broadbandof broadband

Market survey: what exchange services Market survey: what exchange services would providers value and actually use?would providers value and actually use?

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Community Health RecordCommunity Health Record Delaware Health Information Network (DHIN)’s Delaware Health Information Network (DHIN)’s

core servicecore service Federated Data Repository ArchitectureFederated Data Repository Architecture Clinical data sent into DHIN hosting center from Clinical data sent into DHIN hosting center from

many sources: labs, pathology, radiology, many sources: labs, pathology, radiology, hospital admission, discharge and transfer hospital admission, discharge and transfer (ADTs), transcribed reports, medication history (ADTs), transcribed reports, medication history (subscription service)(subscription service)

DHIN delivers results to ordering provider…and DHIN delivers results to ordering provider…and aggregates into a longitudinal aggregates into a longitudinal Community Health Community Health Record Record

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Community Health RecordCommunity Health Record

Information accessed in several ways:Information accessed in several ways:Directly populate a practice electronic medical record Directly populate a practice electronic medical record through interfacethrough interfaceAuto-print for inclusion in a paper record systemAuto-print for inclusion in a paper record systemView over a web portal (ProAccess)View over a web portal (ProAccess)Incorporate into a patient-controlled personal health Incorporate into a patient-controlled personal health recordrecord

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Provider Adoption of DHINProvider Adoption of DHIN

Provider adoption as a percent of Delaware healthcare Provider adoption as a percent of Delaware healthcare ordering providers (December 2012)ordering providers (December 2012)

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Current Membership in DHINCurrent Membership in DHIN

As of May 2013As of May 2013Acute care hospitals and Federally Qualified Acute care hospitals and Federally Qualified Health Centers (100%)Health Centers (100%)Providers (98%)Providers (98%)Skilled nursing (100%); assisted living (77%)Skilled nursing (100%); assisted living (77%)Labs (99%) and radiology groups (97%)Labs (99%) and radiology groups (97%)Health home, hospice and pharmacyHealth home, hospice and pharmacyDivision of Public Health, health plans, other Division of Public Health, health plans, other HIEsHIEs

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BenefitsBenefits

Hospitals, labs and other data senders: OverHospitals, labs and other data senders: Over $2 million $2 million

cost saving from results delivery cost saving from results delivery

Providers/practices with electronic health records Providers/practices with electronic health records

Payers/health plans: Estimated 30-33% reduction in Payers/health plans: Estimated 30-33% reduction in

redundant ordering of high cost labs and radiology redundant ordering of high cost labs and radiology

studies over 2 yearsstudies over 2 years

Public health: Real world outbreak of swine flu detected Public health: Real world outbreak of swine flu detected

in near real timein near real time

Patients: Many “stories” but no metricsPatients: Many “stories” but no metrics

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What’s Next?What’s Next?

Current ServicesCurrent ServicesResults deliveryResults deliveryDiscovery tools: record locator service Discovery tools: record locator service (RLS), common master person index (CMPI)(RLS), common master person index (CMPI)Public health reporting: syndromic Public health reporting: syndromic surveillance, reportable labs, immunization surveillance, reportable labs, immunization updateupdateElectronic health records (EHR) interfacesElectronic health records (EHR) interfaces

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Under Development/PlanningUnder Development/Planning

Event notification serviceEvent notification service Immunization queryImmunization query Image viewingImage viewing Consumer engagementConsumer engagement Connect with other HIEs, federal exchange partners Connect with other HIEs, federal exchange partners

via eHealth Exchangevia eHealth Exchange Integrate newborn screeningIntegrate newborn screening Connect with Delaware prescription monitoring Connect with Delaware prescription monitoring

programprogram Incorporate continuity of care documents into the Incorporate continuity of care documents into the

community health recordcommunity health record

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……and Next?and Next?

New data types for the Community Health RecordNew data types for the Community Health RecordAmbulatoryAmbulatoryMedical DeviceMedical DeviceMedication HistoryMedication HistoryClaimsClaims

Analytic ToolsAnalytic ToolsClinical Quality MeasuresClinical Quality MeasuresBusiness IntelligenceBusiness IntelligencePopulation HealthPopulation Health

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Lessons LearnedLessons Learned

Consensus building is slow but essentialConsensus building is slow but essential Begin with the willingBegin with the willing Find out what your market values and will use; do Find out what your market values and will use; do

that that extremelyextremely well well Use a small number of highly valued services to Use a small number of highly valued services to

drive adoption and utilizationdrive adoption and utilization Provide value for everyone; not just the technology Provide value for everyone; not just the technology

eliteelite Measure, measure, measure! Measure, measure, measure! Know the business Know the business

case for participationcase for participation Success begets successSuccess begets success

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Overcoming BarriersOvercoming Barriers

TechnologyTechnology TrustTrust Natural reluctance to changeNatural reluctance to change Late adopters versus early adoptersLate adopters versus early adopters Meet them where they are; not where you wish Meet them where they are; not where you wish

they werethey were Business model for an HIE whose members are Business model for an HIE whose members are

business competitorsbusiness competitors

If it were easy, anyone could do it!If it were easy, anyone could do it!

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RespondentRespondent

Jennifer Fritz, MPHJennifer Fritz, MPH

Deputy Director, Health Information Exchange

Office of Health Information Technology

Minnesota Department of Health

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Minnesota (MN) HistoryMinnesota (MN) History

Policy Levers encouraging HIE*Policy Levers encouraging HIE*MN e-Health Initiative (2004)MN e-Health Initiative (2004)MN Health Records Act (privacy law) re-codified to MN Health Records Act (privacy law) re-codified to enable HIE, still stricter than most statesenable HIE, still stricter than most states

**Before Health Information Technology for Economic and Before Health Information Technology for Economic and Clinical Health (HITECH)Clinical Health (HITECH)

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HIE Governance Structure HIE Governance Structure

Post-HITECHPost-HITECHHIE Oversight Law (2010)HIE Oversight Law (2010)MN e-Prescribing mandate (2011)MN e-Prescribing mandate (2011)State-Certified HIE Service Providers (4 as of May State-Certified HIE Service Providers (4 as of May 2013)2013)Interoperable electronic health record mandate (2015)Interoperable electronic health record mandate (2015)

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State Certification and Oversight State Certification and Oversight

Establishes oversight by Commissioner of Health Establishes oversight by Commissioner of Health to protect the public interest on matters pertaining to protect the public interest on matters pertaining to health information exchangeto health information exchange

Requires State Certificate of Authority to operate Requires State Certificate of Authority to operate Health Information Organizations (HIO) and Health Health Information Organizations (HIO) and Health Data Intermediaries (HDI)Data Intermediaries (HDI)

Allows market-based approach for provision of HIE Allows market-based approach for provision of HIE services; multiple HIE service providers (HIO/HDI) services; multiple HIE service providers (HIO/HDI) may be certified and operate in the statemay be certified and operate in the state

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Statewide Health Information Exchange

eHealth Exchange

Other eHealth ExchangeNodes

HIO #1

HospitalsPrivate

Practices

Other settings

Minnesota Approach: One HIE

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Statewide Health Information Exchange

HIO #1 HIO #2

HospitalsPrivate

Practices

Hospitals PrivatePractices

Other settings

Other settings

Minnesota Approach: Two HIEs

eHealth Exchange

Other eHealth ExchangeNodes

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Statewide Health Information Exchange

HIO #1 HIO #2

Shared HIE Services Directory Services Consumer Preference

Management

Health DataIntermediary

HospitalsPrivate

Practices

Hospitals PrivatePractices

Health DataIntermediary

Direct Exchange

Other settings

Other settings

Minnesota Approach: Multiple HIEs

Other eHealth ExchangeNodes

eHealth Exchange

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Market-Based ApproachMarket-Based Approach Versus Single HIE Versus Single HIE

ProsProsAllows for private sector investments and innovationAllows for private sector investments and innovationMore adaptable to changes in technology trends or requirements (e.g., More adaptable to changes in technology trends or requirements (e.g., meaningful use)meaningful use)Gives providers multiple options for HIE servicesGives providers multiple options for HIE services

ConsConsCan create confusion in the marketplaceCan create confusion in the marketplaceInteroperability requirementsInteroperability requirementsMany aspects to monitor (technology, policy/legal, changes in national trends)Many aspects to monitor (technology, policy/legal, changes in national trends)

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Accountable Care and HIEAccountable Care and HIE

Adult day servicesAdult day services Behavioral healthBehavioral health Birth centersBirth centers Chiropractic officesChiropractic offices Clinics: primary care and Clinics: primary care and

specialty carespecialty care Complementary/ Complementary/

integrative careintegrative care Dental practicesDental practices Surgical centersSurgical centers

Government agencies Government agencies (state, county, city)(state, county, city)

Habilitation therapyHabilitation therapy Home careHome care HospiceHospice HospitalsHospitals LaboratoriesLaboratories Long-term careLong-term care PharmaciesPharmacies

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Future of HIE in Minnesota

Interoperability: Need for shared services Interoperability: Need for shared services and agreements between multiple and agreements between multiple entities, including common standardsentities, including common standards

Continued certification of entities Continued certification of entities providing HIE services and monitoring of providing HIE services and monitoring of HIE marketplaceHIE marketplace

Potential updates in laws pertaining to Potential updates in laws pertaining to HIE HIE

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Future of HIE in Minnesota

Provider education and technical assistance Provider education and technical assistance on HIE optionson HIE options

Privacy and security to increase provider Privacy and security to increase provider adoption of HIEadoption of HIE

Interstate/national connectivityInterstate/national connectivity Movement from basic HIE (e.g., direct Movement from basic HIE (e.g., direct

secure messaging) towards advanced HIE secure messaging) towards advanced HIE (e.g., analytics, greater automation, and (e.g., analytics, greater automation, and population management)population management)

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Reflections on Delaware’s Reflections on Delaware’s Lessons LearnedLessons Learned

Consensus: Difficult but essential for Consensus: Difficult but essential for sustainability sustainability

Start small with those motivated and those that Start small with those motivated and those that have a specific use case that can be met by HIE have a specific use case that can be met by HIE

Provide a range of HIE options for different HIE Provide a range of HIE options for different HIE needs (basic to advanced)needs (basic to advanced)

Demonstrating Return on Investment (ROI) and Demonstrating Return on Investment (ROI) and Value on Investment (VOI) is critical; harder to Value on Investment (VOI) is critical; harder to do when there are multiple HIE options do when there are multiple HIE options availableavailable

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Reflections on Reflections on Delaware’s BarriersDelaware’s Barriers

Monitoring and adapting technology according Monitoring and adapting technology according to changes in medical practiceto changes in medical practice

Scalable trust Scalable trust is emerging as a need for HIE is emerging as a need for HIE sustainabilitysustainability

Natural reluctance to change: Importance of Natural reluctance to change: Importance of HIE solutions that are in the provider workflow HIE solutions that are in the provider workflow at the point of careat the point of care

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Reflections on Reflections on Delaware’s BarriersDelaware’s Barriers

Early adopters can be champions to othersEarly adopters can be champions to others

Meet them where they are, not where you Meet them where they are, not where you wish they were wish they were

Business model for an HIE whose members Business model for an HIE whose members are business competitors: Need to are business competitors: Need to overcome for accountable careovercome for accountable care

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Final ObservationsFinal Observations Many type of entities provide HIE services; Many type of entities provide HIE services;

interoperability is a challengeinteroperability is a challenge Sustainability requires a sound business model Sustainability requires a sound business model

and identification of value added servicesand identification of value added services Low provider adoption is linked to low Low provider adoption is linked to low

meaningful use requirementsmeaningful use requirements Don’t underestimate non-traditional settingsDon’t underestimate non-traditional settings Accountable care requires easily sharing Accountable care requires easily sharing

clinical data; HIE need to adapt to shifts in clinical data; HIE need to adapt to shifts in market demandsmarket demands

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