HIE base.Research.101

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  • 234 known HIE’s
  • The last year has seen many advances in health information exchanges. The eHealth Initiative has identified and collected information on 234 active health information exchange initiatives (HIEs) in the country. Of the 234 known initiatives, 199 groups responded to and qualified for inclusion in the 2010 Annual Survey on Health Information Exchange. This year, there has been significant expansion in the field with the creation of 56 state designated entities (SDE). eHeaIth Initiative made a concerted effort to include these entities in the survey; it should be noted that 48 of the 56 SDEs completed the 2010 survey.
  • The last year has seen many advances in health information exchanges. The eHealth Initiative has identified and collected information on 234 active health information exchange initiatives (HIEs) in the country. Of the 234 known initiatives, 199 groups responded to and qualified for inclusion in the 2010 Annual Survey on Health Information Exchange. This year, there has been significant expansion in the field with the creation of 56 state designated entities (SDE). eHeaIth Initiative made a concerted effort to include these entities in the survey; it should be noted that 48 of the 56 SDEs completed the 2010 survey.
  • The last year has seen many advances in health information exchanges. The eHealth Initiative has identified and collected information on 234 active health information exchange initiatives (HIEs) in the country. Of the 234 known initiatives, 199 groups responded to and qualified for inclusion in the 2010 Annual Survey on Health Information Exchange. This year, there has been significant expansion in the field with the creation of 56 state designated entities (SDE). eHeaIth Initiative made a concerted effort to include these entities in the survey; it should be noted that 48 of the 56 SDEs completed the 2010 survey.
  • The last year has seen many advances in health information exchanges. The eHealth Initiative has identified and collected information on 234 active health information exchange initiatives (HIEs) in the country. Of the 234 known initiatives, 199 groups responded to and qualified for inclusion in the 2010 Annual Survey on Health Information Exchange. This year, there has been significant expansion in the field with the creation of 56 state designated entities (SDE). eHeaIth Initiative made a concerted effort to include these entities in the survey; it should be noted that 48 of the 56 SDEs completed the 2010 survey.
  • Are initiatives allowing patients to opt-in or opt-out?There continues to be a lot of discussion around opt-out/opt-in policies. Ninety-eight initiatives responded that their state allows them to choose either an opt-in or opt-out policy. However, 40 initiatives, 19 of which are state designated entities, responded that they are unaware of state legal requirements that do not allow an opt-out policy. Only 36 initiatives have an opt-in policy where patients must give consent to have their data included. Eighty-one initiatives have an opt-out policy, where patients’ data is automatically included but they can choose to withdraw. Twenty-seven initiatives were unsure of their policy, and 56 chose not to answer. Initiatives overwhelmingly use a global opt-out/opt-in policy with 61 responding this was their policy.
  • Most health information exchange initiatives are leaving it up to points of service to inform patients their health information is accessible through the initiative. Sixty-six respondents said that patients are notified through the Notice of Privacy Practices (NPP) of participating Healthcare providers, with anumber of initiatives (11) writing in a variation of this under Other. Only 18 initiatives notify patients themselves, and 8 said that patients are not notified.
  • Most non-SDE initiatives are operating at a multi-county coverage area. Fifty-five initiatives report covering a multi-county area, while 21 initiatives report covering an entire state. Other coverage areas include: 17 at a multi-state level, 11 at a county level, 7 at a metro level, 5 that do not cover a geographic area, and 6 initiatives that cover another area such as part of a city or county, or are working with a specific population group.
  • The last year has seen many advances in health information exchanges. The eHealth Initiative has identified and collected information on 234 active health information exchange initiatives (HIEs) in the country. Of the 234 known initiatives, 199 groups responded to and qualified for inclusion in the 2010 Annual Survey on Health Information Exchange. This year, there has been significant expansion in the field with the creation of 56 state designated entities (SDE). eHeaIth Initiative made a concerted effort to include these entities in the survey; it should be noted that 48 of the 56 SDEs completed the 2010 survey.
  • Stage 1 Recognition of the need for health informationexchange among multiple stakeholders in your state, region or community. (Public declaration by a coalition or political leader)Stage 2 Getting organized; defining shared vision,goals, and objectives; identifying funding sources, setting up legal and governance structures. (Multiple, inclusive meetings to address needs and frameworks)Stage 3 Transferring vision, goals and objectives totactics and business plan; defining your needs and requirements; securing funding. (Funded organizational efforts under sponsorship)Stage 4 Well under way with implementation –technical,financial and legal. (Pilot project or implementation with multiyear budget identified and tagged for a specific need)Stage 5 Fully operational health informationorganization; transmitting data that is being used by healthcare stakeholders.Stage 6 Fully operational health informationorganization; transmitting data that is being used by healthcare stakeholders and have a sustainable business model.Stage 7 Demonstration of expansion of organization toencompass a broader coalition of stakeholders than present in the initial operational model.
  • Regional Extension Centers (REC) as a catalyst: Cooperation among health information exchange initiatives, regional extension centers, and state designated entities is key to meeting the expedited timelines of implementation required to meet meaningful use rules. Ninety-four initiatives, 34 of which are statedesignated entities, report that they are currently working closely with a regional extension center, and 34 report they will be in the next 6 months. Twelve initiatives report that they have no immediate plans to work with a regional extension center, and 9 initiatives were unsure of who is acting as the regional extension center in their area.
  • Most health information exchange initiatives are leaving it up to points of service to inform patients their health information is accessible through the initiative. Sixty-six respondents said that patients are notified through the Notice of Privacy Practices (NPP) of participating Healthcare providers, with anumber of initiatives (11) writing in a variation of this under Other. Only 18 initiatives notify patients themselves, and 8 said that patients are not notified.
  • Most health information exchange initiatives are leaving it up to points of service to inform patients their health information is accessible through the initiative. Sixty-six respondents said that patients are notified through the Notice of Privacy Practices (NPP) of participating Healthcare providers, with anumber of initiatives (11) writing in a variation of this under Other. Only 18 initiatives notify patients themselves, and 8 said that patients are not notified.
  • Capitation. Much has been written about capitation, However, one of the promises of creating new incentives for quality and HIT adoption is making it worth providers’ while to invest in EMRs. Any payment technique that creates a fixed budget over a population or a span of care achieves something fee-for-servicedoes not: it allows for a budgetary process with room for capital allocations for reengineering and care improvement, including investments in HIT. Whatever criticisms can be mounted against capitation, one positive aspect has manifested itself in large integrated delivery systems (IDS) and independent practice associations (IPA) that accept global and sub-capitation: they have large capital budgets in which management can make allocations for HIT investment. There are many examples in California, where capitated provider systems have made major investments in EMRs. While this in itself does not bring about interoperability between systems, it does prove that fixed budget payments create both incentives and available capital to invest in HIT.Pay for Performance. Pay-for-performance is riding a wave of increasing preeminence in the ongoing challenges to unlock efficiency gains in US Healthcare. In a recent survey article appearing in the Annals of Internal Medicine (the PWUDS study), the authors of the study question the base of knowledge that is driving the emergence of pay-for-performance in the market. While most studies document an increase in measured indicators of quality when financial incentives are introduced, there is considerable room to question the significance of these findings. The jury may still be out as to whether pay-for-performance programs will bring about the desired change, but one thing is for certain: the widespread and growing adoption of incentive programs has legitimized differential pay; which is to say, purchasers now recognize that not all providers are equal, and are now ready to recognize top performers with top pay. But there is unease about pay-for-performance even among its advocates, and one of the reasons is that most incentives are layered add-ons over a fee-for-service system that still remains unchanged. Wouldn’t it be more effective to go straight to the heart of matter and reform the very basis of fee-for-service reimbursement?Global Fees for Episodes of Care. The American system of reimbursing Healthcare providers renders few rewards for delivering high quality care. It is often the case that improvements on behalf of physicians to re-engineer care can leave them making less money. And it is not just a lack of incentives to improve care that is worrisome; the existing payment system actually entrenches poor quality care. The Institute of Medicine labeled the current payment system “toxic.” That fact,combined with widening knowledge about real gaps between the quality of care provided and what best evidence guidelines would suggest, has spurred activity byhealth plans to make extra money available to providers who meet quality benchmarks. One way to alter the current regime would be to reimburse care not through fragmented unit pricing (fee-for-service) nor through actuarial pricing (capitation), but through production pricing: a fixed budget compensating episodes of care as individual patients experience them and the services required for providers to produce them. Where an episode of care is defined as the complete sequence of interactions between a patient and providers of healthcare services in pursuit of a defined clinical objective over a specified period of time, it may be more sensible to make episodes the natural unit of reimbursement.Taken in that context, then, globally pricing episodes of care create the equivalent of an upfront sticker price on clinically homogenous pathways, whether acute or chronic, so that: (1) patients have a predictable measure of the cost of medical treatments(2) providers have an incentive to organize and re-engineer treatments around clinicallyhomogenous care paths rooted in evidence-based guidelines(3) plans can measure the cost and effectiveness of integrated care teams(4) risk-based contracting avoids the pitfalls of capitation and gradually erodes the predominance of fee-for-service purchasing; and(5) patient choice at the point of service becomes the engine of efficiency instead of the driver of inflation.
  • First, are your revenue projections sound and sustainable?Second, are your expense projections reasonable and can you provide the promised level of service within these expense restrictions?Third, can you hire and retain the quality of staff you need to operate the RHIO within the expense projections?Finally, can you fund your ongoing capital requirements and expansion plans within the net profit margin? If the answer to each of the questions is positive, you are ready to begin building your sustainability model.
  • HIE Lit Review: Prior literature has identified three critical success factors in the broader framework of business models that may be responsible towards a successful HIE. First, studies argue that careful crafting and consideration of the operational, financial and societal returns in the business model will ensure smooth and streamlines processes of the HIE organizational structure (Hayward, Warren and Sykes 2007; Miller and Miller 2007). Second, specifically incorporating a plan for comprehensive evaluation of the return on investments will ensure that the HIE is moving as per original plan to achieve its objectives (Hripcsak et al. 2007). Third, the regulation and financial structure in the healthcare sector also shapes the success or failure of the HIE (Frisse 2005).
  • Maffei et al (2009) “Determining Business Models for Fin Sustainability in RHIOs.” Population Health Management Vol. 12 (5)
  • Based on the experience of 6 years of operation and an on‐going history of service development, launch, and support, IHIE bases its sustainability plans seven basic principles.
  • Based on the experience of 6 years of operation and an on‐going history of service development, launch, and support, IHIE bases its sustainability plans seven basic principles.
  • Based on the experience of 6 years of operation and an on‐going history of service development, launch, and support, IHIE bases its sustainability plans seven basic principles.
  • ARRA - The recently passed stimulus package provides over $20 billion in funding for health IT. These provisions, known collectively as the Health Information Technology for Economic and Clinical Health (HITECH) Act, include $2 billion allocated for ONC and $17.2 billion going to Medicare and Medicaid reimbursement incentives to encourage adoption of EHRs. The incentives for EHR adoption will only be provided over the next five years to those with certified EHRs that include patient demographic and clinical health data, as well as clinical decision support with physician order entry. Eligible professionals must also demonstrate “meaningful use” of the technology. This standard will be determined by the Secretary of HHS and will require the capability for the electronic exchange of health information to improve the quality of care and the ability to submit clinical quality measures. Over time, the incentive for EHR adoption in Medicare will disappear and a penalty will be imposed for those who are not meaningful users of EHRs. Although the bulk of this investment is directed towards promoting the adoption of EHRs, the law also includes a more limited pool of money to support standards and policy development and to provide seed funding to help build infrastructure for data exchange. Funding from HITECH will certainly facilitate electronic exchange of health information—particularly if “meaningful use” is defined in such a way that HIE is an integral component—but it does not establish a solution for the long-term economic sustainability of HIE. Assessments on Insurers-States could impose an assessment on all insurers on a per member basis or a charge per claim. (Federal action might be required to allow states to levy such an assessment on self-funded plans.) This policy lever would eliminate the barrier created by insurers who may be less willing to invest in the infrastructure for HIE that would benefit patients not covered by their plans. General tax revenues-If HIE is considered a public good that accrues benefits to all Americans, an increase in taxes for all citizens might be appropriate. Consumption-based taxes-Taxes could be raised on items like tobacco. Tobacco taxes have been criticized in the past as unreliable sources of long-term funding. Because raising the price of tobacco products is an effective deterrent to new users, revenues diminish over time. While this reduction is a problem for ongoing programs, federal funding for HIE is often viewed as primarily serving a “start up” or “seed money” role, rather than providing an ongoing subsidization by the taxpayers, so this type of tax may be well designed for the policy purpose at hand.
  • Nonfinancial Assistance. This approach envisions a continued government role in providing technical assistance, education, coordination and dissemination resources. It calls for the continuation, or potential expansion, of existing projects on standards, assimilation of privacy regulation, certification of HIE-related software and other ongoing projects to lessen barriers to HIE participation. Many of these activities are essential to lay the groundwork for the exchange of health information. As such, this approach may be seen as a necessary (although likely insufficient) piece of any effort to promote widespread HIE engagement. Federal Government Focus. This approach calls for modifying legislation and rules governing all federally underwritten Healthcare benefits and services including those led by the Centers for Medicare and Medicaid Services, the Federal Employees Health Benefits Program, the Veterans Health Administration, the Indian Health Service, the Department of Defense and others to reflect the need for greater public and private sector investment in HIE. Key components of this approach include looking at conditions of participation in HIE as a prerequisite for payers and providers to participate in federally underwritten programs and adjustments to reimbursement to payers and providers under federal programs to create new incentives to participate in HIE. State Government Focus. This approach is similar to the federal approach, only it focuses on levers available to state officials. This approach could involve direct subsidies to states to establish HIOs in areas where there are currently limited options for providers and payers seeking to participate in HIE. Given the current financial circumstances of most states, federal grants to states would be required; however, governance and administration of policies developed through these grants could take place on the state level. In addition, states would be able to lead modifications in licensure, malpractice and provider regulation where they have jurisdiction. Key components of this approach could also include modification of state Medicaid plans to establish reimbursement rules to support HIE, new licensure requirements for Healthcare facilities and practitioners, adjustment of malpractice premiums to support HIE, modifications to state employee health benefits plans and other programs and initiatives supported and governed on the state-level. Private Sector Focus. This approach directly subsidizes establishment and participation in HIE by granting tax advantages for HIE-related expenditures by for-profit entities or a combination of tax advantages and direct grants to for-profit and non-profit providers and payers to cover the costs of establishing and participating in HIE. Another way the tax system could promote HIE is by making the existing tax advantage for employer-sponsored insurance contingent on benefit plans engaging in HIE. The approach also includes subsidies for HIOs, such as a guaranteed loan program.
  • Delaware established its system it received $5-million from the state, $2-million from the private sector, and $5-million from the federal AHRQ for start up.At the same time, New York is investing more than $200 million to support health IT adoption and the development of an interoperable health information infrastructure.
  • To understand how information exchange creates value, it is necessary to establish the institutional and market linkages between users and producers of information. On one side of the market exchange, individuals and intermediaries present themselves, as users, in anticipation of enhancing their well-being through an exchange. On the other side, individuals and organizations offer products and services they hope will appeal to users at a profit. It is in this context that the HIE network operates as an intermediary to facilitate mutually beneficial exchange and value creation.
  • Based on the experience of 6 years of operation and an on‐going history of service development, launch, and support, IHIE bases its sustainability plans seven basic principles.
  •  Physician, improvement, efficiency, and outcomes measurement Performance management Program integrity Fraud and Abuse Identification and Prevention Population monitoring and predictive profiling Care Gap Identification Care/Disease Management Population Health Analysis Public Health Monitoring Clinical Research
  • HIE base.Research.101

    1. 1. 1HIE Base ResearchAugust 2010Rex OsbornClinical Informatics SME
    2. 2. 2 RHIO vs HIEA RHIO is an organization whose chief objective is to bring community leaders together from disparate stakeholding interests around a vision of health data interoperability. By arguing that systemic improvements resultfrom fully mobilized patient data, they initiate a process of trust building, whereby stakeholders are broughtinto convergence. As momentum gathers, conversations yield to negotiations, and stakeholding leaders lay thegroundwork for governance, mission statements, business plans, choices of functionalities, privacy and securitypolicies, management teams, financial commitments, and covenants. The result of these hard-won efforts is aRHIO, usually a non-profit organization composed of influential stakeholders bound by covenants and vision.As opposed to economic or technical functions, its chief utility is political, and as such, is the indispensablecatalytic agent of change without which the economic and technical functions of exchange will not come topass.By contrast, Health Information Exchange represents the human capital side of the equation. HIE is whatemerges from the presence of RHIO activities, e.g., social capital giving birth to human capital. Humancapital is the specialized knowledge and skill sets that make exchange possible. It ranges from executive teambusiness acumen to technology platforms. All RHIOs at this point are not only acting as catalytic agents ofsocial capital, but also as incubators for whole new sets of skills and technology applications that constitute themeans of exchange, from data hubs to edge system connectors. This is the aspect of exchange that is sodisruptive — people working within the exchange must acquire novel skills to successfully leverage the newpotential. Management must develop creative services and revenue models to support them, along withinventive applications of traditional finance and accounting disciplines. Technical staffs have to master vendorproducts. They must, in turn, be able to support and teach edge system users how to deploy the newfunctionalities. End users, such as physician offices, need to alter workflows to leverage enhanced informationflows.
    3. 3. 3HIE Exchange EMPI
    4. 4. 4HIE Stakeholders LABORATORIES HEALTHCARE HOSPITALS PAYORS HIE DIAGNOSTIC IMAGINGAMBULATORY EHRs WEB PORTALS MEDICATION INTERMEDIARIES PUBLIC HEALTH OTHER PHRs AGENCIES /HEALTH BANKS
    5. 5. 5 eHealth Initiative (EHI) Report Key HIE Survey Findings:  The value of HIE is not clearly understood by the majority of respondents: 54.9% disagree or strongly disagree with the statement that the value of HIE is clearly understood.  The majority of respondents believe outreach to consumers about the value of EHRs and HIE is not effective: 66.6% disagree or strongly disagree with the statement that current outreach to consumers about the value of EHRs and HIE is effective. There has been an increases in functionality amongst health information exchange initiatives with respect to the meaningful use rules: The top 3 functionalities being provided by the initiatives:  Connectivity to EHRs (67)  Results Delivery (50) The top 3 services offered by the state designated  Health Summaries for continuity of care (49) entities:  Electronic prescribing and refill requests (4) The top 5 types of data exchanged by the initiatives:  Prescription fill status and/or medication fill history (3)  Laboratory Results (68)  Electronic eligibility and claims transactions (3)  Medication Data (63)  Outpatient laboratory results (62)  Allergy Info (61)  ED episodes/discharge summaries (58)Source: 199 of 234 participated in survey/ 48 of 56 SDE’s participated
    6. 6. 6Revenue Sources for Operational HIEs Ongoing Revenue Sources for Operational HIEs Hospitals 27% Physician Practices 20% Payors - Private 15% Labs / Ref Labs 12% Federal Gov’t Grants & Contracts 7% State Gov’t Grants 7% Payors – Medicaid / Medicare 6% Public Health 6% Hospitals Physician Practices Payers - Private Labs / Ref Labs Federal Gov’t Grants & Contracts State Gov’t Grants Payers – Medicaid / Medicare Public Health
    7. 7. 7Funding Sources Top 3 Funding Sources for Operational HIEs  Subscription Fees or Membership Dues to Data Users / Providers - 65%  Transaction Fees Charged to Data Users / Providers – 20%  One-time financial contribution to HIE (Donation) – 12% 18 break- even initiatives Subscription / Membership One-Time Donation Transaction Fees Advertising or Marketing Public Health Utility
    8. 8. 8eHealth Initiative (EHI) Dependency on Federal Funding (All Initiatives)  Dependent on Gov’t Funding –35%  Independent Funding – 61%  Not Sure – 7% Not Sure 4% Dependent 35% Independent 61%
    9. 9. 9eHealth Initiative (EHI) Sources of Startup Hospitals State Gov’t Federal Gov’t Grants Payors / Private Physician Practices Medicaid / Philanthropic Sources Medicare Public 5% Health Payors – Medicaid / Medicare Philanthropic 3% Sources Public Health 8% Medical Hospitals 21% Medical Societies Societies 4% Physician Practices 11% State Gov’t 19% Payors / Private 12% Federal Gov’t Grants 17%
    10. 10. 10eHealth Initiative (EHI) Sustainable Model Revenue Sources – Stakeholders paying dues/fees Hospitals Health Plans Community Clinics Independent Labs Primary Care Physicians Mental Health Long-Term Care Ambulatory Surgery Specialty Centers Physicians Ambulatory Surgery Centers 8% Hospitals 8% 19% Specialty Physicians Long-Term Care 9% Health Plans 14% Mental Health 10% Community Clinics Primary Care 12% Physicians 10% Independent Labs 10%
    11. 11. 11eHealth Initiative (EHI) Sustainable Initiative Top Services Connectivity to EHR Alerts to Providers Referrals & Consultations Results (Lab / Dx Study Results) Health Summaries - CCR Clinical Documentation Alerts to Providers Connectivity to EHR eRX D/D D/A 14% 19% Alerts to Providers Drug – Drug & Alerts to Providers Drug – AllergieseRX 11%10% Clinical ReferralsDocumentation 12% 11% Health Results (Lab / Dx Summaries - CCR Study Results) 11% 12%
    12. 12. 12TOP HIE Initiative Challenges1. Sustainability model (over 60%)2. Addressing Government Policy & Mandates (over 60%)3. Defining the value of the HIE (over 50%)4. HIPAA – Privacy, Consent, Confidentiality, Securi ty & Breach policies (over 50%)5. Technical infrastructure; Architecture, Applications & Connectivity6. Governance Issues 7.Legal Issues 8.Cross Referencing Patients 9.Engaging Health Plans (coverage area) 10.Engaging Practicing Clinicians (coverage area) 11.Systems Integration 12.Engaging Laboratories (coverage area)
    13. 13. 13Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use HIE FACTS • 2010 = 234 HIE initiatives • Less than 10% of Hospitals are currently linked to a HIE • There are 73 operational initiatives in 2010 up from 57 in 2009 • Sustainable #’s  107initiatives are operational, not on federal funding, up from funding & have broken even  18 initiatives are not dependent dependent on ―any‖ federal 71 in 2009 through operational revenue • 44 of the 73 operational initiatives have no financial relationship with the entities involved in the initiative ―coopetition‖ • Proven ROI Points: Reduced staff time spent on clerical administration and filing (33 sites) - Reduced staff time spent on handling lab and radiology results (30 sites) - Decreased dollars spent on redundant tests (28 sites)
    14. 14. 14Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use HIE FACTS • 131 of 199 HIE respondents cited addressing government policy mandates as a major challenge NO Fed. Policy Issues 33% Fed. Policy Issues 67%
    15. 15. 15Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTS States and State Designated Entities Patient engagement has increased(SDE) have varying perspectives of dramatically. More organizationstheir purpose. are providing services to patients 40 entities see their role as planning for and providing access to patient health information exchange data through a HIE. 8 entities see their role as building or  44 initiatives allow patients to view maintaining a technical infrastructure their data, up from 3 in 2009 22 entities see their role as supporting a  31 initiatives allow patients to technical infrastructure contribute information on their 2 entities are not directly involved in health status, up from 7 in 2009 building an infrastructure, but in coordinating or creating policy
    16. 16. 16Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTS (HIE MU)There have been increases in functionality amongst HIE initiatives withrespect to the meaningful use rules.o The top 3 functionalities being provided by the initiatives: Connectivity to electronic health records (67) Results Delivery (50) Health Summaries for continuity of care (49)o The top 5 types of data exchanged by the initiatives: It is NOT currently a Laboratory Results (68) MU requirement to Medication Data (63) connect to a HIE Outpatient laboratory results (62) Allergy Info (61) Emergency Department episodes/discharge summaries (58)o The top 3 services offered by the state designated entities: Electronic prescribing and refill requests (4) Prescription fill status and/or medication fill history (3) Electronic eligibility and claims transactions (3)
    17. 17. 17Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTS (HIE MU)HIE HIPAA Consent Approaches: Allowpatients to control the level of access to theirPHI. 61 initiatives have global opt-in/out policies 36 initiatives have organizational opt-in/out policies 34 initiatives have provider opt-in/out policies 14 initiatives have emergency care opt-in/out policies 13 initiatives have individual data element opt- in/out policiesThe goal of the meaningful use rule is to improve the quality and efficiency of patient care by providing incentivesto eligible providers and hospitals to utilize certified EHR technology for the electronic exchange of healthinformation and the reporting of clinical quality measures. HIE initiatives can provide the technologyand support providers and hospitals who want to qualify for meaningful use incentive payments.
    18. 18. 18Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTS Protecting Pt PrivacyWhat types of policies do initiatives use to protectpatient privacy?At a minimum, all initiatives are required to abide by HIPAA standards, but mostorganizations have policies that go beyond HIPAA. Only 36 respondents, 13 of whichare state designated entities, said they have no policies in place or in developmentbeyond HIPAA. There has been a significant increase from 2009 in privacy policies thataddress sharing aggregated data with third parties. Of those that have policies in placeto protect patient privacy beyond HIPAA, the most common include: Patient consent required to share clinical data deemed to be sensitive (e.g., mental health, STD, AIDS) with another provider for treatment purposes (62) Patient consent required to share clinical information with another provider for treatment purposes (opt-in) (61) Patient consent required to share clinical information for healthcare operations purposes (31) Patient consent required to share aggregated or de-identified information for purposes other than treatment, payment, or healthcare operations (31) More stringent restrictions are in place for use and disclosure for research (31) Patient consent required to share information for payment purposes (30)
    19. 19. 19Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTSHealth informationexchanges span all 50states, the District ofColumbia, and the U.S.territories of the VirginIslands, PuertoRico, American Samoa, andthe Northern MarianaIslands, and the island ofGuam. Florida (22), NewYork (20), California(15), North Carolina(13), Washington(11), Michigan (10), andVirginia (10) have thehighest concentration ofinitiatives.
    20. 20. 20Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTSOperational HIE Initiatives in 2010 = 73
    21. 21. 21Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTSStage 1 Recognition of the need forhealth informationexchange among multiple stakeholders in yourstate, region or community. (Public Numbers of HIEs & SDEs & their respective stages…declaration by a coalition or political leader)Stage 2 Getting organized; definingshared vision,goals, and objectives; identifying fundingsources, setting up legal and governancestructures. (Multiple, inclusive meetings toaddress needs and frameworks)Stage 3 Transferring vision, goals andobjectives totactics and business plan; defining your needsand requirements; securing funding. (Fundedorganizational efforts under sponsorship)Stage 4 Well under way withimplementation –technical,financial and legal. (Pilot project orimplementation with multiyear budgetidentified and tagged for a specific need)Stage 5 Fully operational healthinformationorganization; transmitting data that is beingused by healthcare stakeholders.Stage 6 Fully operational healthinformationorganization; transmitting data that is beingused by healthcare stakeholders and have asustainable business model.Stage 7 Demonstration of expansion oforganization toencompass a broader coalition of stakeholdersthan present in the initial operational model.
    22. 22. 22Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTSPhysician Involvement: Seventy-five HIE initiatives said that physicianengagement in the exchange is difficult, while 75 also said engagement was notdifficult. Physician engagement is incredibly important to the success of healthinformation exchange, which makes this an important finding. Respondentscited the following as the main reasons whyphysician engagement is difficult: Lack of understanding of benefits (64) Concern regarding implementation (34) Physicians have limited access to broadband (27) Costs too much to participate (26) Takes too much time to look up (24)
    23. 23. 23Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTSPatient Engagement via HIE: Operational initiatives are offering moreservices to patients than last year. In 2009, only 3 operational initiativesallowed patients to view their health data; now 44 initiatives report thatpatients can review their health data. The number of initiatives that allowpatients to add information on their health status is up from 7 to 31. Thirty-three initiatives now provide electronic communication between patients andcare providers, and 30 initiatives provide patients with access to educationinformation on health and Healthcare. While many initiatives are still notproviding services to patients, there has been a marked improvement in patientservices over the last year. Thirteen operational initiatives currently allowpatients to view and receive data. Eight initiatives allow patients to providedata, and 25 allow them to be involved in governance.
    24. 24. 24Excerpts from - The State of Health Information Exchange in2010: Connecting the Nation to Achieve Meaningful Use FACTSMany exchanges strive to demonstrate that HIE can reduce costs forphysicians, hospitals, payers and patients. Forty-six of the operationalinitiatives havequantified financial savings through surveys, electronic medical records, andother clinical IT systems. Operational initiatives are helping their customersrealize financial savings through the following: Reduced staff time spent on clerical administration and filing (33) Reduced staff time spent on handling lab and radiology results (30) Decreased dollars spent on redundant tests (e.g., laboratory tests, radiology results) (28) Reduced medication errors (16) Decreased cost of care for chronic care patients (16) Reduced staff time spent on handling prescriptions (15)
    25. 25. 25 Meaningful Use & the Value of HIEStage 1 Meaningful Use Core Items Connectivity to EHR (67 sites) Health Summaries (CCR) (49 sites) eRx (37 sites) Alerts Drug to Drug (35 sites) Alerts Drug to Allergy (31 sites) Clinical Decision Support (26 sites)
    26. 26. 26Statistics & HISTORY
    27. 27. 27Background: Funding Data Date Organization Stage Geographical Area Total Funds to Date Primary Source of Revenue Founded Greater Rochester RHIO 5 Rochester, NY 2005 $20,700,000 Government grants Bronx RHIO 5 Bronx, NY 2007 $13,100,000 Government grants MidSouth eHealth Alliance 5 Memphis, TN 2005 $12,500,000 Government grants Big Bend RHIO 6 Tallahassee Region, FL 2005 $10,400,000 Government grants NYCLIX 5 New York, NY 2006 $8,300,000 Federal + community org grants DC RHIO 5 DC 2006 $6,000,000 State grants Hospitals, Foundations, Health CalRHIO (now HIE) 4 CA 2004 $4,610,000 Plans VT ITL 6 VT 2005 $4,200,000 State grants Brooklyn RHIO 5 Brooklyn, NY 2007 $4,000,000 Government grants Keystone HIE 5 Central and Northeastern PA 2005 $3,500,000 Government + private org grants United Health Services 4 Johnson City, NY 2005 $3,500,000 Government grants Secure Med. Rec. Transfer 7 Oklahoma 2005 $3,400,000 Sponsor grants Network Lakelands Rural Health 4 Lakelands, SC 2005 $1,800,000 Government grants Network SAFEHealth 5 Massachusetts 2005 $1,500,000 Federal grants Capital Area RHIO 4 Mid-Michigan 2009 $1,400,000 Government grants CareSpark 5 Appalachia (TN & VA) 2005 $600,000 Government + sponsor grants Tampa Bay RHIO 4 Tampa Bay, FL 2005 $500,000 Government grants
    28. 28. 28# of HIEs & their Stage ofDevelopment according to eHI 57 HIEs were deemed as Operational in 2009 Stages 5-7
    29. 29. 29 Stages of HIE DevelopmentStage Characteristics of HIEStage 1 Recognition of the need for health information exchange among multiple stakeholders in your state, region or community. (Public declaration by a coalition or political leader)Stage 2 Getting organized; defining shared vision, goals, and objectives; identifying funding sources, setting up legal and governance structures. (Multiple, inclusive meetings to address needs and frameworks)Stage 3 Transferring vision, goals and objectives to tactics and business plan; defining your needs and requirements; securing funding. (Funded organizational efforts under sponsorship)Stage 4 Well under way with implementation –technical, financial and legal. (Pilot project or implementation with multiyear budget identified and tagged for a specific need)Stage 5 Fully operational health information organization; transmitting data that is being Operational used by healthcare stakeholders.Stage 6 Fully operational health information organization; transmitting data that is being HIE used by healthcare stakeholders and have a sustainable business model.Stage 7 Demonstration of expansion of organization to encompass a broader coalition of stakeholders than present in the initial operational model.
    30. 30. 30HIE Stages of Maturity (Technology)Level Defining Characteristics Non-electronic data—no use of IT to share information (examples: mail, 1 telephone). Machine transportable data—transmission of non-standardized information via basic IT; information within the document cannot be electronically manipulated 2 (examples: fax or PC-based exchange of scanned documents, pictures, or PDF files). Machine-organiz’able data—transmission of structured messages containing non- standardized data; requires interfaces that can translate incoming data from the sending organization’s vocabulary to the receiving organization’s vocabulary; 3 usually results in imperfect translations because of vocabularies’ incompatible levels of detail (examples: e-mail of free text, or PC-based exchange of files in incompatible/proprietary file formats, HL-7 messages). Machine-interpretable data—transmission of structured messages containing standardized and coded data; idealized state in which all systems exchange 4 information using the same formats and vocabularies (examples: automated exchange of coded results from an external lab into a provider’s EMR, automated exchange of a patient’s ―problem list‖).
    31. 31. 31Economic sustainability is the state of the RHIO / HIE can be maintained at asatisfactory financial and operational level indefinitely.Annual revenues exceed annual expenses and your RHIO has a sufficient return to fundits ongoing capital and operating costs including funded depreciation.In addition, you have developed a business model where you can fund your expansionrequirements in accordance with your strategic plan.
    32. 32. 32Steps to Independence  Considered several alternative methods / approaches for funding your RHIO / HIE.  Investigate various revenue models and consider various options.  Examine several methods of raising your required investment capital.  Develop a financial plan for obtaining the required funds to support your ongoing operations.  Price out your technical infrastructure and understand your organizations staffing requirements.  Convert all of this information into long-term economic sustainability model.
    33. 33. 33Models Simplified • Model 1 – Government-Led Electronic HIE: Direct Government Provision of the Electronic HIE Infrastructure and Oversight of its Use. • Model 2 – Electronic HIE Public Utility with Strong Government Oversight: Public Sector Serves an Oversight Role and Regulates Private-Sector Provision of Electronic HIE. • Model 3 – Private-Sector-Led Electronic HIE with Government Collaboration: Government Collaborates and Advises as a Stakeholder in the Private- Sector Provision of Electronic HIE. Most # of Sustained Entities Model 3
    34. 34. 34HIE Franchising• Successful pioneer HIEs may sell their experience, expertise and technology to other emerging RHIOs who wish to take advantage of an established model. The trade-off is between, on the one hand, costs, ease of implementation, speed of scaling up, and risk sharing, and on the other hand, reduced financial upside, strategic freedom, and brand control.• While franchising may take several forms in mature industries, Business Format Franchising is the most commonly known form and provides the franchisee with a complete business plan for all aspects of operating a business within that system. HIEs may be attracted to the franchise model on the basis of proven, verifiable success, faster time to market, training and know-how, established name, patents, trademarks, copyrights, lower capital requirement and financing conditions, scale through association with existing data and net
    35. 35. 35 Eligible Stage 1 Criteria for Meaningful UseProviders Communicate with Public Health 1) Immunizations 1) Immunizations 2) Syndromic Surveillance 2) Syndromic Surveillance 3) Reportable Disease RHIO / HIE Public Health Improve Population Health Prevention Communicable Disease  Children & Adolescents  Case Investigation  Adults & Seniors  Mitigation Syndromic Surveillance / Early Warning Outcomes  Outbreaks  Monitoring & Evaluation  Disease – natural, emerging, terrorism  Comparative Effectiveness  Food borne Chronic Disease Management (CDM)  Bio-surveillance
    36. 36. 36Reasons Early RHIOs Failed• Lack of buy in due to competing/conflicting organizational interests• Perceived lack of control and trust in the network organizational processes• Lack of clear rules for ownership of data• Lack of financial sustainability• Technological difficulties
    37. 37. 37Sustainable HIE• Sustainable HIE reflects a situation where: the costs and benefits of HIE are constructed so that ongoing HIE operations will be funded based on the value generated from HIE (e.g. transaction fees, subscriptions, 3rd party reimbursements) instead of other sources external to direct value chain (e.g. government grants and subsidies)• Challenges: ▫ Misalignment of benefits and incentives ▫ Broad stakeholder support, competing interests It is possible for any healthcare provider, Healthcare consumer or payer to ▫ Privacy concerns, technical challenges, EHR adoption electronically share individually identifiable ▫ Quantifying benefits information to support efficiency and quality of care in a standards-based format using non-proprietary mechanisms and in a manner compliant with all state and federal security and privacy laws, regulations, and policies* *Source: NORC, 2009
    38. 38. 38Value Creation &Sustainability  The key to RHIO sustainability is to identify sources of value for each stakeholder group, create services to deliver the value, and monetize that value strategically• Necessary conditions • Factors influencing sustainability ▫ EMR adoption ▫ Ability to quantify value ▫ Data availability ▫ Support of key ▫ Presence of competition (other HIEs) stakeholders ▫ Scalable business model leveraging ASP or pay per use ▫ Governance structure model of paying for services provided by vendors ▫ Adequate seed funding ▫ Avoiding fixed costs such as IT employees or investments in IT infrastructure without firm commitments from ▫ Viable business model customers about usage, pricing and revenues ▫ Leverage cost by connecting to physician EMR ▫ Develop clinical drug trials and protocols directly with Pharma ▫ Develop quality and transparency pilots ▫ Develop pay-for-performance initiatives with payers ▫ Develop direct payer-coordinated claims processing efficiency pilot
    39. 39. 39Returns Reported by HIE’s• HIE cost savings were reported by 40 operational initiatives in a range of ways: ▫ Decreased staff time spent on handling lab and radiology results (26 operational initiatives). ▫ Reduced staff time spent on clerical administration and filing (24). ▫ Decreased dollars spent on redundant tests (17). ▫ Decreased cost of care for chronic care patients (11). ▫ Reduced medication errors (10).• Operational initiatives report the following impacts for practices that utilize the exchange: ▫ Improved access to test results and resultant efficiencies on practice (28 operational initiatives). ▫ Improved quality of practice life (i.e., less hassles looking for information, getting home sooner at the end of the day, etc) (24). ▫ Reduced staff time spent on handling lab and radiology results (23). ▫ Reduced staff time spent on clerical administration and filing (22).
    40. 40. 40Services Mix FrequencyCurrent Functionalities for Data Exchange 2008 2009 ChangeResults delivery (e.g. laboratory or diagnostic study results) 31 44 13Connectivity to electronic health records n/a 38 n/aClinical documentation 38 34 -4Alerts to providers 26 31 5Electronic prescribing n/a 26 n/aEnrollment or eligibility checking 29 25 -4Electronic referral processing 17 21 4Consultation/referral 23 20 -3Clinical decision support n/a 19 n/aDisease or chronic care management 19 19 0Quality improvement reporting for clinicians 14 19 5Ambulatory order entry n/a 16 n/aDisease registries 11 16 5Reminders 14 16 2CCR/CCD summary record exchange n/a 15 n/aPublic health: case management 7 13 6Public health: surveillance 9 13 4Quality performance reporting for purchasers or payers 9 12 3Connectivity to personal health records n/a 10 n/a
    41. 41. 41 Est. HIE Services Value Is it already Activity WTP by Quantity performed by Performed by stake- Cost Pricing estimate some other RHIO / HIE? holder entity?Current Services View patient information (demographics) View clinic observations View clinic allergies View clinic diagnoses and procedures View clinic medications View lab results View hospital discharge summaries View hospital radiology reportsPotential Services Service 1 Service 2 Service NSample Benefits Reduction in unnecessary tests and procedures Save time associated with handling chart requests and referrals Reduction in administrative portion of test costs Better health outcomes from rapid identification of pre- existing conditions Improve identification of billable patients Reduce unnecessary ED admissions Other benefits… June, 2010
    42. 42. 42Funding Sources • Grants Maturity • Contracts • Debt • Equity • Regulated funds, such as insurer assessments or municipal bonds • Revenue/Cash Flow from Operations As the HIE matures, sustainability must be based on the quantifiable value being created for participants willing to pay for that value.
    43. 43. 43Economics • Until revenues = operating costs the HIE will require funding $Funding Operating costsRevenues Time Today Break even Future
    44. 44. 44 Revenue Models DefinitionMembership/Subscription Members pay a set subscription fee for participation, typically based on size (e.g. bedHIE Revenue Models size, revenues). Subscription fee benefit is that for one price, participants can utilize without counting costs of transactions. RHIOs should pay close attention in developing pricing scheme to ensure costs and margin are covered.Transaction Fees Participants pay a fee per transaction (e.g. for every result delivered). Transaction fees are best when tied to direct sources of value, e.g. the receipt of electronic test results that otherwise would have quantifiable handling costs. Transaction fees should be avoided in instances where the fee disincentivizes data contributions to RHIO.Hybrid Model A common approach, in a hybrid model, certain services are included in a subscription mechanism with other services or transactions fee-based. Those data transactions which directly contribute to the value of the RHIO, such as data feeds from labs, such as clinical results, are usually in the form of subscriptionSales of goods or services Revenue from selling goods, information or services. E.g implementation services, selling cleansed data. This source of revenue is typically ancillary to core services.Value Exchange Agreement between stakeholders (typically payers) to pay HIE for value generated based on an agreed upon economic model. Based on premise of “shared savings”. In April 2009, United Healthcare became the first U.S. commercial health plan to agree to pay for HIE services for their members in California. The administration costs of value exchange can be high and it has an additional level of complexity. Other sources revenue: online training programs, transcription services, clinical research trials, disease management pilots.
    45. 45. 45Benchmark Data MHIN HealthBridge DHIN $8,000 - $500,000 annual Tiered Subscription for DE statute requires private sector subscriptions, ancillary services unlimited data most services. matching funds fromBusiness Model (interface deployment, quality, Transaction fees for select stakeholders. Working on a EHRs) services. ―sustainable model‖. Founded 1998 1997 1997 Funding $200K from 6 hospitals and $1.75M loan $12M laboratory Origination Results reporting, ―print Clinical messaging and portal. Results delivery (EHR direct, efficiency‖, community repository Sends information including lab clinical inbox, direct to fax), data sourcing data, radiology/ADT Patient search function Services information, demographics, admissions notices, discharge summaries, transfer notices. Commercial Services (100%) Commercial Services (100%) Federal (1/3), State (1/3),Funding Current Customers (1/3) Physicians 1,000 4,400 ~ 7 hospitals, 80+ total 29 hospitals, 5500 physician 3 health systems, adding 4th, organizations users, 17 local health 800,000 patient records Hospitals departments, 700 physician offices and clinics Accelerating the pace of benefit, Push system value, Stakeholder All the players at the table, Strong broad and supportive constituency Support government support, limitedKeys to success , adding data sources. geography
    46. 46. 46 Estimating Revenue Potential Org Type # Orgs Services Valued Mean Total Subscriptio Subscriptio n Fee n Fees Mean Trx Fees Total Trx Fees Potential Other Total Revenue Services Revenue HospitalsMedical ClinicsPhysician OfficesSkilled Nursing Facilities Laboratories Pharmacies Health Plans Medicaid Public Health June, 2010
    47. 47. 47Conclusions onSustainability• Sustainability requires concerted broad public and private stakeholders support• Business case of respective services for each stakeholder will determine appropriate pricing• Interim funding will be required until sufficient operating revenues can be achieved• Must understand which services are valued and deliver those services in an appropriate way that fits with workflow• Ultimately, payment mechanisms must incentivize participation in coordinated care and HIE use
    48. 48. 48Sources of Funding –Grants & Govt funds are deemedas seed / start-up money
    49. 49. 49Sustainable Principlesfrom Indiana HIE  Build a nexus around key payer and provider organizations to secure private funding  Provide a clear value proposition to participants  Structure the deal intelligently to anticipate challenges and change
    50. 50. 50IHIE
    51. 51. 51IHIE SustainabilityPrinciples  Principle 1: HIE is a Business  Principle 2: The Leveraging of High‐cost, High‐value Assets  Principle 3: No Loss Leaders  Principle 4: Independent, Local Sustainability  Principle 5: Natural Monopoly  Principle 6: The Need for Scale  Principle 7: Avoidance of Grants for Operational Cost
    52. 52. 52HIE is a businessP1 & P2HIE is a business and as with all businesses, creating a sustainable HIErequires: offering services that the market wants… at a price the market will bear… doing so in such a way that revenue exceeds expenses. services delivered by the HIE must be at a level that healthcare organizations have come to expect from their suppliers.Once dollars have been invested in the creation of HIE infrastructure, it isessential to leverage and reuse those assets to deliver as much and as manyservices as is necessary to achieve sustainability.  the services an HIE is able to provide to the market must be capable of producing sufficient revenue to cover expenses  due to the cost of the infrastructure that is required, offering multiple services to various market stakeholders is conducive to sustainability.
    53. 53. 53Leverage ExperienceHIE assets are interdependent and, oncecreated, can be leveraged to deliveradditional services.
    54. 54. 54No Loss Leaders Loss leaders are goods or services ―sold at a loss‖ to create profit through other, related goods or services In the business of HIE, avoid loss leader services that promise to amass data or infrastructure to support a future sustainable service.  The HIE policy and business model landscape is evolving too rapidly  The risk that the future services might never be possible is too great and should not be factored into sustainability plans  Examples include many ―secondary use‖ concepts (e.g. information for pharma research)
    55. 55. 55Natural Monopolies • HIEs are natural monopolies. ▫ the total cost of producing HIE services for a given market is lower if there is just a single producer than if there are several competing producers. ▫ There is a large cost for the necessary infrastructure (which is a fixed cost), making the creation of a redundant infrastructure wasteful and detrimental to the economy as a whole.
    56. 56. 56Avoidance of Grants • Grants are indispensable sources of start‐up funds for HIEs or individual services, but should not be counted on to cover operational costs beyond a ramp up stage. • Once fully operational, HIE services must be able to generate revenue equal to or in excess of expenses such that grants (or other non‐operating revenue sources) are not necessary to cover operational costs.
    57. 57. 57IHIE Sustainability Stuff an Services on Stuff an HIE could which you HIE could do to can base a do that Help save sustainable someone The HIE will pay for healthcare system
    58. 58. 58 Sources of Funding – Gov’t Focus• The American Recovery and Reinvestment Act (ARRA) of 2009• Assessments on insurers• General tax revenues• Consumption-based taxes While some of these revenue sources only supply short term investments (e.g., HITECH, consumption-based taxes), others have the potential to provide funding for HIE over the long term. Also, to the extent that direct funding may be inadequate to cover the start-up expenses for establishing mechanisms for HIE, loans and other forms of financing may also be required. - SERVICES
    59. 59. 59 Participation / Stakeholder ValueA common thread running through many of theseapproaches is the need to establish operational criteriafor what constitutes engaging in HIE for eachstakeholder. These criteria would be necessary inlegislation or regulations to determine (depending onwhich options are implemented)Which Stakeholder is eligible for incentive payments; meet participation requirements; or qualify for loans, grants and tax incentives.
    60. 60. 60 Financial ApproachesLeverages Public Policy for Sustainability
    61. 61. 61 Integrating ApproachesLeverages Public Policy for Sustainability
    62. 62. 62Summarizing Trade-offs
    63. 63. 63Integrating Across Approaches
    64. 64. 64 Promoting HIE 1 of 2Governance Entities: States could support the development of sustainable state-level HIE governance entities or of regional orother forms of HIOs through various financial mechanisms such as appropriations (i.e. budgetary spending), grant and contractfunding, and agency operational funding.26 Such an effort may have an initial emphasis on ensuring that providers and insurersinvolved in Medicaid and state employee health benefits plans have access to a mechanism for exchanging health information.Public Utility Model: States could use grants to establish HIOs that are heavily regulated private entities where supply isguaranteed and prices are structured following a public utility model.Private Matching Funds: States could leverage federal funds by requesting that governmental funding be matched by similarcontributions from the private sector. This could help stimulate initial buy-in from large Healthcare stakeholders who wouldsubstantially benefit from predominately state-sponsored HIE. As the regulators of health insurers, states could assess health insurersa set amount per member or transaction—an approach being used in Vermont. (However, an Employee Retirement Income SecurityAct (ERISA) exemption might be required to allow those assessments to extend to self-insured plans.)Carrots and Sticks for State Insurers and Providers: Consistent with the discussion of the FEHBP in the federal approach,states could develop a series of carrots (reimbursement, start-up funding) and sticks (participation requirements) to providers orinsurers who take part in providing health benefits for state employees.Licensure and Accreditation: Engagement in HIE could be integrated into the licensing and accrediting of Healthcare facilitiesand states could support the development of accreditation standards and processes for HIOs. Additionally, education designed tohelp providers use HIE to improve the quality and efficiency of care could be developed and could count towards continuingeducation requirements for physicians, pharmacists and other providers.
    65. 65. 65 Promoting HIE 1 of 2Health Planning: Assessing the ability of a provider to engage in HIE could be incorporated into health planning efforts. Forexample, if a hospital decides to upgrade its health information technology system, it could be required to demonstrate plans toengage in state-level HIE as part of an application for a certificate of need (CON). (This strategy has been adopted by the State of NewYork.)Direct Funding: States could pass along direct funding to providers, for example by distributing grants or loans or implementingtax incentives, to support start-up expenses of providers who could demonstrate a plan to integrate HIE into their workflow toimprove the quality of care. Direct financial support might be particularly important to subsidize public health reporting and HIE forsafety net organizations—two areas that are unlikely to be initiated by market demand.Technical Assistance: States could ensure the availability of technical assistance to help providers effectively engage in and sustainHIE through either the direct provision of such assistance or by entering into contracts with third party vendors and generating avolume discount that could be passed on to providers. These state TA efforts could complement the assistance incorporated inHITECH.Malpractice Insurance Premiums: States could work with malpractice insurers to encourage them to reduce premiums forentities who engage in HIE. (Some medical malpractice companies do reduce premiums for HIE; however expanding the numberwho do so, or making those premium reductions more sizable, may prove challenging if there is insufficient actuarial data to supportthese reductions. A potential role for state or federal governments would be to conduct research to demonstrate the associationbetween patient safety and participation in HIE.) Another strategy, which could break down an even greater barrier for providers, isenacting state law to indemnify providers who follow set privacy and security guidelines against liability for damages (or create a statefund to cover those damages) resulting from breeches in security or other risks that providers who take reasonable precautions maybe exposed to by engaging in HIE.
    66. 66. 66 Original 10 Gov’t Funded RHIO1) Colorado Health Information Exchange2) Indiana Health Information Exchange3) Maryland D/C Collaborative for Health Information Technology4) MA-SHARE/MedsInfo-ED ePrescribing Initiative5) Santa Barbara County Care Data Exchange (CA)6) HealthBridge (OH)7) Taconic Health Information Network and Community (NY)8) Tri-Cities TN-VA Care Data Exchange9) Whatcom County Health Information Exchange (WA)10) Wisconsin Health Information Exchange.
    67. 67. 67 Examples of ValueValue Creation at the Point of Information Exchange A HIE is an operational entity that facilitates efficient exchange between providers of Healthcare services. In the process, it creates value by extending participants’ capacity to extract value from the coordinated collection of data relevant to more efficient delivery and consumption of Healthcare services.New England Healthcare EDI Network has reduced the costs of administrativedata transactions from $5.00 to $0.25, bringing transaction costs down from$12.5 million a month to $625,000.
    68. 68. 68 Advance Exchange Value Redefine the role of HIEs as clinical data and information intermediaries (infomediaries) by expanding their customer base Re-conceive the role of RHIOs not as local non-profits that build everything de novo, but as social capital generators that build the necessary trust relationships needed for health information exchange Reform the reimbursement system so that incentives for adopting health information technology and HIE in particular, reduce or eliminate current financial and institutional barriers While the last of these requires the actions of policy makers
    69. 69. 69Operational HIE
    70. 70. 70Start-up / Financial
    71. 71. 71Transactions w/ ValueHospitals Public Health Clinical Messaging  Needs Assessment Medication Reconciliation  Surveillance Shared EMR / EHR  Reportable Conditions Credentialing  Results Delivery Eligibility Checking  Syndromic Reporting Referral mgt PayorsPhysicians  Clinical Quality Measurement Results Delivery  Claims Adjudication Secure Document Transfer  Secure Document Transfer Shared EMR / EHR Clinical Decision Support Researchers Credentialing  De-identified, longitudinal clinical Eligibility Checking data Referral mgt PatientsLABS  Personal Health Record (PHR) Clinical Messaging Orders
    72. 72. 72Ingenix Route toHIE Financial Independency• Empower consumers. Patients receive coordinated care, actionable information, and answers to make informed, value-based decisions based on comprehensive, standardized information.• Empower providers. Streamlined administrative functions, comprehensive clinical insight and answers right at providers’ desktops will allow more time for treating patients according to evidence-based medicine (EBM), in addition to eliminating duplication and reducing risk in treatment.• Enable state and federal governments. Providing access to data will allow states and the federal government to better target underserved and at-risk populations with preventative measures, inform best practices, and provide public health and bioterrorism monitoring.• Engage payers. Reduced costs, greater value, and decreased complexity will help payers better control administrative expense and improve operational efficiencies.• Provide opportunity for existing clearinghouses/gateways to realign in a changing market. Although the new model redirects spend from current clearinghouses/gateways to HIEs, it also creates opportunity for the development of new services and innovations for companies that choose to pursue that path.
    73. 73. 73Governing HIE Entity An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards. These organizations may be regionally focused, represent multi-provider organizations such as hospital systems and integrated delivery systems, or include horizontal networks of providers such as health center networks.

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