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Health Information Exchange 101 Problem, Definitions, Value, Policy David C. Kendrick, MD, MPH Asst. Provost for Strategic Planning OUHSC Slide 2 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 Slide 3 Healthcare Reform likely possible Details change daily, but will probably might include Coverage expansion for the uninsured, perhaps through a public plan or premium assistance programs Emphasis on preventive care More prominent role of the Patient Centered Medical Home Emphasis on Healthcare IT Slide 4 2009 State of the States Health Summary Slide 5 Oklahoma is the only state where the death rate has gotten worse.. Some Factors 1.Economic downturn healthy people and jobs left Oklahoma 2.Poverty remained 3.Heart Disease (Diabetes) 4.Cancer 5.Access to Care Age-adjusted Death Rates Past 25 Years Slide 6 2007 COMMONWEALTH FUND Report State Scorecard Summary of Health System Performance Slide 7 Slide 8 What WE CANT Do Grow more doctors quickly Create new hospitals overnight Force patients to: Exercise Stop smoking Lose weight Slide 9 What We Can Do Leverage Technology Complex populations Limited Resources : Create a lean healthcare system Improve Care Coordination Business case for: Funding Efficiency Slide 10 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 Slide 11 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 Slide 12 Where Will there be Savings? Majority: From the Exchange of Clinical Information among care providers Reduction in duplicate Dx procedures Prevention of Medical Error Source: Center for Information Technology Leadership 2005 Slide 13 Current Situation Payers Demographics Medical claims Pharmacy claims Case mgmt records Payers Demographics Medical claims Pharmacy claims Case mgmt records Doctor offices EHR Claims Rx Case mgmt Community outreach Rx Imaging Hospitals (inpt) ER/UC Public Health Other PCPs Specialists Ancillary care PT/OT/Aud/Diet Ancillary care PT/OT/Aud/Diet Labs Manual connection (mail, fax) Electronic connection Safety Net Clinics and community agencies Patient Slide 14 Available at the POS Logically presented Current Medicare patient - 5.6 providers/yr (7.7 providers/yr including 2 PCPs) Community Care Coordination Health Information - Useful Slide 15 Definitions: EMR vs. HIE vs. HIO vs. CCC HIE Slide 16 RHIO Greatest Value Your Data is Local (CCC) Business Model - Self Supporting Stakeholders/Users Quality, Safety & Efficient Delivery Govern, Sets Rules Statewide Network of Networks DisasterBioterrorismPublic Health National (NHIN) Health Information Organization Slide 17 Scale State-wide: A Network of Networks Local governance Common technology Slide 18 Slide 19 Anatomy of a HIE Health Information Exchange Electronic Master Patient Index Population Care AnalyticsPatient PortalPhysician Portal Medical Education Slide 20 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 Slide 21 What is the relationship between Health Information Exchanges and the Patient Centered Medical Home? Organizing the Concepts Patient Centered Medical Home Health Information Exchange Reimbursement Model Patient Centered Medical Home P a t i e n t C e n t e r e d M e d i c a l H o m e P a t i e n t C e n t e r e d M e d i c a l H o m e Patient Centered Medical Home Health Information Exchange Slide 22 Medical Home & HIE Fragmented 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 Slide 23 Medical Home Goals 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 Slide 24 Slide 25 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 Slide 26 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? Slide 27 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 Slide 28 HIE Value Construct Providers Hospitals Pharmacies Radiology Centers Other Providers Public Health Agencies Payers Clinical Laboratories Slide 29 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 Slide 30 What about funding? One time: ARRA stimulus dollars Other grants Ongoing: Business model must be developed ROI by stakeholder will drive the business model Slide 31 ARRA Stimulus Dollars Washington, D.C. Earmarks Federal Agency Grants ONCHIT AHRQ DHS State distributions Heath Dept OHCA Slide 32 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 Slide 33 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 Slide 34 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 Slide 35 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 Slide 36 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