Health Information Exchange


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Delivered by Craig Brammer at CITIH 2011. Focus on discussion of regional and national initiatives and opportunities for regional partners to leverage them for driving healthcare improvements, public health and research.

This session will provide a broad perspective on the many initiatives related to HIT. Experts from the regional and national level will discuss data models, privacy concerns and adoption strategies from their different perspectives. Also addressed will be planning for NHIN direct adoption as a complimentary strategic to full HIEs.

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Health Information Exchange

  1. 1. Health IT and Health System ReformThe Ohio State University Center for IT Innovations in HealthcareApril 2011Craig BrammerOffice of the National Coordinator for Health Information
  2. 2. Agenda g 1. 1 Uniting the Tribes of Health System Improvement 2. HITECH Status Report 3. Uniting the Tribes in 17 US Markets: The Beacon  Communities 4. Health IT as Infrastructure for Accountability 2
  3. 3. Agenda g 1. 1 Uniting the Tribes of Health System Improvement 2. HITECH Status Report 3. Uniting the Tribes in 17 US Markets: The Beacon  Communities 4. Health IT as Infrastructure for Accountability 3
  4. 4. 4
  5. 5. The “Tribes” of  Health System Improvement:  A Multiplicity of Approaches, Strategies and A Multiplicity of Approaches  Strategies and Tools 1. The Quality Improvement Crusaders 2. The Payment Reformers 3. 3 The Consumer Energizers 4. The Health IT Champions McKethan AN, Brammer CB. Uniting the Tribes of Health System Improvement. The American Journal of Managed Care. 2010;16:SP13-SP18. 5
  6. 6. Tribe 1:  The Quality Improvement Crusaders y pAPPROACH:  Scientific evaluation methods and management techniques to achieve better patient outcomesData analysis and performance measurement - Provider feedback processes  evidence informed guidelines Provider feedback processes, evidence‐informed guidelinesManagement techniques - L Lean manufacturing, continuous quality improvement   f t i   ti   lit  i tLearning and “best practices” - e.g., avoiding complications in the ICU, reducing hospital  d l h d h l readmissions, improving care transitions, reducing infection and  surgical‐complication rates, etc. 6
  7. 7. Tribe 2:  The Payment Reformers yAPPROACH:  Alternatives to volume‐based payments to support systematic improvements in care and opportunities for slower spending growthPerformance Incentives - P4P, high‐performance networks, never eventsPayments promoting provider alignment and care coordination - ACOs, medical homes, bundled payments, readmission penalties 7
  8. 8. Tribe 3:  The Consumer Energizers gAPPROACH:  Information and appropriate incentives to help consumers improve their own health, save money, and achieve better outcomesValue‐based insurance design - Red ced copa s for effecti e treatments  incenti es for seeking  Reduced copays for effective treatments, incentives for seeking  care from high‐performance providers/networksConsumer directed health plans - HSAs and high deductable health plansConsumer information to support health decision makingC  i f ti  t   t h lth d i i   ki - Shared decision making/informed patient choice, “motivational  technologies” to support behavior modificationTransparency of cost and quality information 8
  9. 9. Tribe 4:  The Health IT Champions (aka, Wireheads) pAPPROACH:  Electronic infrastructure to support administrative simplification, error avoidance, cost containment and improved outcomesElectronic health record adoption and information exchange - Standards and interoperabilit  pri ac  & sec rit  MU incenti es Standards and interoperability, privacy & security, MU incentivesTools to support clinicians in delivering high value care - Cli i l d i i   Clinical decision support, performance feedback, ePrescribing   f  f db k   P ibiTools to support consumers in receiving high value care - Personal health records, mHealth applications, eVisitsTools to support purchasers in rewarding high value care - Data aggregation and performance measurement 9
  10. 10. Tribal Approaches to Health System Reform pp y Quality improvement activities are often unsustainable due to  volume‐based payment methods volume based payment methods Payment reforms are ineffective if unaccompanied by changes in  provider practices and consumer behavior Uncoordinated care subjects even highly engaged and informed  p patients to fragmented care g Higher spending on technology with uncertain benefits is  worrisome Yet…tribal approaches to health system reform are ubiquitous  10
  11. 11. Segmentary Lineage and Health System Reform g y g y In his 1940 book about the Nuer people in  southern Sudan, British anthropologist E. E.  Evans‐Pritchard coined the term “segmentary lineage” to describe how members of a society live  in a web of nested identities or tribes.  At any given time, individuals are members of  several groups in a hierarchy, from the local or  proximal (eg, my street, my neighborhood) to  proximal (eg  my street  my neighborhood) to  larger groups (eg, my region, my country).  The most meaningful group affiliation at any  given time depends on the scale and nature of  external threats or conflicts. 11
  12. 12. The Scale and Nature of External Threats to Health Care *Insert obligatory slides on spending trends, regional variation, per  capita costs relative to other industrialized nations, etc. capita costs relative to other industrialized nations  etc *Insert obligatory slides on McGlynn study, IOM reports, AHRQ  annual quality report, etc. *Mention growing dissatisfaction with health care, for example… Majority of Americans Give Quality of Health Care a C, D or F. US News  & World Report; April 14, 2011.  New Survey: 72 Percent in U.S. Think Health System Needs Major  New Survey: 72 Percent in U S  Think Health System Needs Major  Overhaul. The Commonwealth Fund; April 15, 2011. 12
  13. 13. The Scale and Nature of External Threats to Health Care 13
  14. 14. Agenda g 1. 1 Uniting the Tribes of Health System Improvement 2. HITECH Status Report 3. Uniting the Tribes in 17 US Markets: The Beacon  Communities 4. Health IT as Infrastructure for Accountability 14
  15. 15. The HITECH Framework: Meaningful Use at its Coreit  CRegional Extension Centers ADOPTION Workforce Training Improved Individual & Population Health Outcomes Medicare & Medicaid MEANINGFUL USE IncreasedIncentives and Penalties Transparency & Efficienc Efficiency State HIE Program Improved Ability to Study & y yStandards & CertificationSt d d  & C tifi ti EXCHANGE Improve Care Delivery Privacy & Security Health IT Practice Research 15
  16. 16. Conceptual Approach to Meaningful Use p pp g Improved Outcomes Advanced care processes with decision Capture / p support share data 16
  17. 17. Meaningful Use Survey Findings g y g Percent of Non‐Federal Acute Care  Percent of Office‐Based Physician  Hospitals Planning to apply for CMS’  Practices Planning to apply for CMS’  EHR Incentive Programs  EHR I ti  P   EHR Incentive Programs EHR I ti  P 90 90 81% 80 80 70 70 60 60 50 50 41% 40 40 30 Planning in 30 Planning in Subsequent Subsequent 20 Year Y 20 Year Y Planning in Planning in 10 2011 or 2012 10 2011 or 2012 Application Application 0 0 US H Hospitals it l Physician Practices Ph i i P ti 17Source: American Hospital Association Information Technology Survey, 2010; National Center for Health Statistics, National Ambulatory Medical Center Survey, 2010.  17
  18. 18. ONC Programs g Technical  $693 million Assistance – 62 Regional Extension Centers Workforce  $118 million Training – 84 Community Colleges training new  health IT support personnel State Health  Information  $564 million Exchange – 56 grants to states and territories HITECH laws and policy developmentInteroperability gy Technology standards and certification 18 18
  19. 19. ONC Program Results to Date g Technical  57,716 providers enrolled with the  Assistance Regional Extension Centers Workforce  3,600 graduating this spring Training State Health  Information  46 state plans approved Exchange 449 certified EHR products on the market Interoperability conforming to standards 19
  20. 20. State Health Information Exchange Program g gGoal: Ensure that every provider has at least one option for meeting health information exchange requirements of meaningful useFour year program, 56 states and territories were awarded$548 Million awarded in total funding for HIE planning and implementationStates need an ONC approved State Plan before federal St t   d   ONC  d St t  Pl  b f  f d l funding can be used for implementation –46 have been approvedMultiple approaches are being pursued, many oriented around core services and gap‐filling 20
  21. 21. State Health Information Exchange Challenge Grants g g10 Awards ($16 million) for Breakthroughs in Key Areas – Reducing preventable hospital admissions (NC) p g g , , , – Improving long‐term care transitions (CO, MA, OK, MD) – Consumer‐mediated exchange (IN, GA)  – Meta‐data approaches to granular data sharing (IN) – Di ib d  Distributed query for population health (MA, MT)  f   l i  h l h (MA  MT) 21
  22. 22. Health Information Exchange (The Verb) g 22
  23. 23. Health Information Exchange (The Verb) g Document/Message  Security and Trust  Directories and Certificates Standards relationshipsVocabulary Standards Delivery Protocols 23
  24. 24. Capabilities for Nationwide Health Information Exchange p g– Secure transport p– Content standards– Computable consent– Patient matching  –R Record locator service d l t   i– De‐identification– Distributed query– Meta data 24
  25. 25. Emerging Direct Ecosystem» 50+ vendors have committed to roll‐out Direct‐enabled functionality,  and ~20 states include Direct in their approved State HIE plans* EHRs HIEs & HIOs States4Medica Med3000 AAFP MedAllies Alabama Aprima MEDgle Ability MedCommons CaliforniaAllscripts NextGen Akira Technologies MEDfx FloridaCare360 OpenEMR ApeniMed Medicity IllinoisCerner Polaris Atlas Development MedPlus IowaeClinicalWorks RelayHealth Axolotl Mirth Kentuckye‐MDs Sage Healthcare CareEvolution MobileMD MinnesotaEpic Siemens Covisint National Health Svcs MissouriGE Healthcare Sunquest Garden State Health  NetDirector MontanaGreenway WorldVistA Systems Inc. Orion Health New Hampshire GSI Health ProviderDirect New Jersey Harris RedwoodMedNet North Carolina HINSTx HINST Secure Exchange  S  E h   Ohio Ohi PHRs Ingenix Solutions Oregon Inpriva Surescripts Rhode Island Dossia IVANS Techsant Technologies South Carolina Microsoft HealthVault Kryptiq Corporation yp q p Thomson Reuters Texas Lifepoint Informatics Verizon Vermont RelayHealth Wellogic West Virginia Wisconsin* Source: (as of April 2, 2011) 25
  26. 26. Security & Interoperability Framework y p yPromote a sustainable ecosystem that drives increasing interoperability and standards adoptionCreate a collaborative, coordinated, incremental standards process that is led by the industry in solving real world problemsLeverage “government as a platform” – provide tools, coordination, and harmonization that will support interested parties as they develop solutions to interoperability and standards adoption.  26
  27. 27. S&I Framework’s Transitions of Care InitiativeChallenge:  Meaningful Use Stage 1 and foreseen Stage 2 requires information to be exchanged in Transition of Care. requires information to be exchanged in Transition of Care  Implementers confused on how to use the specifications to exchange required data req ired data Exchange of clinical summaries hampered by ambiguous common definitions of what data elements must be exchanged, how they must be encoded, and how those common semantic elements map to MU specified formats. (C32/CCD and CCR) Lack of a robust toolset to aid in development and validation of conformant  templated clinical documents is a major impediment to the widespread adoption of standards. 27
  28. 28. Security & Interoperability Framework Stakeholders y p yCall for Participation: The overall success of the S&I Framework is dependent upon volunteer experts from the healthcare industry and we welcome any interested party to get involved in S&I Framework Initiatives, participate in discussions and provide comments and feedback by joining the Wiki.For more information on how to get started as a volunteer please visit: siframework org/wiki/display/SIF/Getting+Started+as+a+Volunteer 28
  29. 29. Agenda g 1. 1 Uniting the Tribes of Health System Improvement 2. HITECH Status Report 3. Uniting the Tribes in 17 US Markets: The Beacon  Communities 4. Health IT as Infrastructure for Accountability 29
  30. 30. Beacon CommunitiesONC allocated $265 million over 3 years to 17 communities, including $15M for technical assistance and evaluation, to including $15M for technical assistance and evaluation  to demonstrate the feasibility and the health care delivery benefits of widespread HIT adoption and exchange of health information.Core aims: Build and strengthen health IT infrastructure as a foundation to  improve quality of care, health outcomes, and cost efficiencies; i   li   f   h l h    d    ffi i i Demonstrate that health IT‐enabled interventions and  that health IT enabled interventions and  community collaborations achieve concrete cost/quality  performance improvements; Test new innovations to improve health and health care 30
  31. 31. Beacon Community Programs 31 31
  32. 32. Beacon Communities •Governance •Subsequent •IT & •First wave of measurement interventions 2012 & waves of2010 infrastructure i f t t 2011 •Innovation interventions •Interventions networks 2013 •Dissemination of lessons learned logic models In 2011, Beacon interventions will “engage” ~5,000 providers and “touch”  approximately 600K individuals around specific health improvement  aims: • 9 Beacon Communities’ work includes improving care transitions (e.g.,  k l d process improvements and information flow at hospital discharge). • 10 Beacon Communities’ work focuses on the use of IT tools and process  improvements (e.g., CDS) to improve performance of physician practices. improvements (e g  CDS) to improve performance of physician practices All Beacons submit cost/quality/health data on their performance quarterly. Starting in May 2011, CMS will supply provider‐level reports from Medicare. 32
  33. 33. Examples from Beacon Communities pCentral Indiana spreading admin/clinical measurement and P4P model from 9 to 42 countiesGrand Junction Colorado redesiging primary care with strong HIE and measurementTulsa spreading Doc‐t0‐Doc electronic specialty referral system and deploying Archimedes provider and region‐level CDS/predictive modelingg 33
  34. 34. Examples from Beacon Communities pNorth Carolina deploying Asthmapolis to support pediatric asthma improvementSan Diego deploying mHealth linked to immunization registry to alert parents of young children about immunizationsBangor, Maine using remote monitoring to help manage frail elderlyGeisinger, Intermountain & Mayo spreading tools and technologies beyond IDS to broader community  34
  35. 35. Beacon Community 90‐Day Launch Plan Program GoalsCommunity  Core cost, quality, and population health Objectives Obj ti   CO CO improvement aimsMeasured  MO MO MO MOOutcomes Well‐defined measurable improvement goals Defining risks and barriers and establishing plans to prevent or mitigate themOutputs O O O O O O Operational & process results of core activitiesActivities A A A A A A Tasks/interventions leading to outputsResources R R R R R R R R R R R R Resources needed to support activities and meet   stated outcome goals Sustainability plan outlining provider reimbursement, program  revenue, and other strategies 35
  36. 36. Geisinger (“Keystone Beacon Program”) Summary of 1 out of 10 Beacon/Geisinger Community  Program Goals Objectives (Logic Models)Community  Improve quality and efficiency among targeted patients with Chronic Objectives  j CO Obstructive Pulmonary Disease (COPD) and Heart Failure (HF)  Reductions in hospital admissions, avoidable 30‐day hospital readmissions, Measured  MO MO and ED visits among target patients; increased access to/utilization of Outcomes p primary care services among same patients y g p Specific plans to prevent or mitigate implementation risks and barriersOutputs O O O O Medication reconciliation outputs, hospital discharge counseling,  targeted case management contact, web‐based portals, others  Comprehensive HIT‐enabled care model includes care process redesign and Activities A A A A teaming; integration across all systems of care, care protocols; performance  feedback to patients and clinicians, and reminder systems  Specific funding allotments to core activities phased in over new areas and Resources R R R R R R R R over time; dedicated administrative, IT, and clinical teams Sustainability plan: integration of accountable care payment model aligned  S t i bilit   l  i t ti   f  t bl     t  d l  li d  with health IT‐enabled performance improvement goals 36
  37. 37. Keystone Beacon CommunityLead Geisinger ClinicService Area Central PennsylvaniaPopulation Total patient population in catchment area: 256,203 Total # of target providers: 16 practices, 3 hospitals Total target patient population: 51,000Select •Improve the management and outcomes for patients with COPD and CHFPerformanceP f •Ex: 90% of t E f target patients on ACEi or ARB, 100% with follow up <7 days post discharge t ti t ARB ith f ll 7d t di hImprovement •Increased patient engagementGoals •Improve medication reconciliation •Reduce all cause hospitalizations, 30-day readmissions, and preventable ED visits for patients with CHF, COPD, and within 30 days of surgery •Improve influenza vaccination rates to 100% for patients with CHF and COPDSelect Hospital-Based Care ManagersInterventions •Identify high-risk patients with CHF, COPD, and other chronic disease to facilitate smooth transfers to either home or a long-term care facility using the Provenhealth Navigator System (4 CM to start) Care Managers in Ambulatory Physician Practices •Facilitate medication management and action plans for patients with COPD and CHF (3 CM to start) •Teach self-management action plans including nutrition and daily weights; •EHR-enabled exacerbation protocols for CHF and COPD management Remote Care Managers •Centralized call center for 3 CM who will provide telephonic management for 4 weeks post discharge. Patient Portals, PHRs, and Patient Engagement at e t o ta s, s, a d at e t gage e t •Patient portals, secure messaging, and self management tools interoperable with the EHRs facilitate patient engagement and patient-provider communication Computerized Clinical Decisions Support Tools •Alerts identify candidates for influenza vaccine, trigger guideline based care, and notify providers via HIE connection of patient hospitalizations/ED visitsOther Notable The Beacon Community considers patient engagement, satisfaction, and perceived quality of life as importantCharacteristics measures. The Beacon Community has active engagement of long-term care facilities.
  38. 38. Five Domains of the Beacon “Learning System" g y Domain Focus Area1 Establishing Beacon strategic direction; aligning Beacon  Leadership & Stewardship Community performance improvement goals with policy at the  local and national level. Communications and outreach.2 Achieving meaningful use goals; collaborating on the testing and  HIT & Meaningful Use documentation of new technologies (e.g., clinical data repositories,  master patient indices, EHR interfaces to HIEs)3 Learning from best practice care delivery innovations (e.g., care  g g Clinical Transformation transitions programs, medication therapy management programs,  medical homes, remote monitoring)4 Data & Performance  Developing robust performance measurement and feedback  Measurement capabilities; testing new measures and measurement approaches  (e.g., patient‐reported outcomes measures)5 Strategic planning and implementation activities focused on  Sustainability and  payment reforms to sustain performance improvements and    f     i   f  i   d  Payment Reform support infrastructure developed under the Beacon Program 38
  39. 39. Greater Cincinnati Beacon CommunityLead HealthBridgeService Area Greater Cincinnati RegionPopulation Total target pediatric population: 18,000 Total adult patient population in catchment: 1,530,337 Total target pediatric population in year 1: 4600 Total target adult population: 159,000 Total target providers in year 1: 123 Total target providers: 50Select •Improve management for adult diabetes p gPerformance •Ex: LDL < 100, BP < 130/80, A1C < 7, and aspirin useImprovement •Reduce ED visits and 30-day readmissions for diabetes by at least 15%Goals •Improve outcomes for pediatric asthma •80% of population achieves symptom control, 60% for Medicaid •Reduce pediatric asthma ED visits, school days missed, and hospitalizations by 60% •Improve flu vaccination rates f hi h risk asthmatic patients t 80% I fl i ti t for high i k th ti ti t to •Improve smoking cessation among diabetic patients by at least 5% from baseline, goal 10% by 2013Select Patient Centered Medical HomeInterventions •Model to be deployed in 20 practices, facilitate judicious and coordinated care, payment reform Physician Data Reporting and Performance Feedback •Diabetes Quality Institute to monitor data and enact rapid cycle change for diabetes management Care Coordinators in Ambulatory Physician Practices •Support asthma and diabetes management plans •MDI coaching for asthma •Self management coaching Computerized Clinical Decision Support Tools •Facilitate appropriate use of spirometry •Alerts for ED admissions and hospitalizations for asthma exacerbation •Screen for symptom control in asthma •CDS in schools for referral to PCP based on symptoms •Identify candidates for influenza vaccination (asthma, long-term care facilities) Identify long term Medication Therapy Management •Medications in hand at time of hospital or ED dischargeOther Notable GE has committed to providing $1 million of in-kind resources, including equipment, software and funding toCharacteristics assist with performance measurement, public reporting and payment reform.
  40. 40. What are we learning? gIt’s early but…Clearly defined populationsStrong leadership & governanceSpecific health care objectivesPerformance measures and feedback systemsEvidence‐based interventionsStrategies to learn from interventions 40
  41. 41. Agenda g 1. 1 Uniting the Tribes of Health System Improvement 2. HITECH Status Report 3. Uniting the Tribes in 17 US Markets: The Beacon  Communities 4. Health IT as Infrastructure for Accountability 41
  42. 42. The “Era of Accountability” is about lowering the cost of improvement.improvement 42
  43. 43. Past and Emerging Models of Accountability in Provider PaymentsPerformance‐based payments - “Peanuts for process” Peanuts for processBundled payments - Prospective payment system (PPS) (1980s) - Participating Heart Bypass Center Demonstration (“CABG”) - Bundled or “episode” payments in new health lawShared savings - Physician Group Practice Demonstration (“PGP” Demo) - Healthcare Quality Demonstration (“646” Demo) Healthcare Quality Demonstration ( 646  Demo) - Accountable Care Organizations in new health law 43
  44. 44. ACA Provisions Catalyzing a Shift from Fragmented Care to Coordinated Care SUMMARY IMPLICATIONS Patient-Centered Medical Homes (Section 3502)Community-based, interdisciplinary inter-professional teams that Will drive improved organization of outpatient caresupport primary care practicesGovernment to provide grants or enter into contracts with eligible Will fund care coordination and a team-based approachentities Accountable Care O A t bl C Organizations (S ti i ti (Section 3022)Shared-savings program that encompasses primary care, Requires vertical coordinationspecialist practice, and hospitalsCare processes to be redesigned for the efficient delivery of Most of the savings are likely to come from hospitalshigh qualityhigh-quality services Bundled Payments (Section 3025)Pilot program Will provide incentives for care-delivery systems to reduce costs in order to increase marginsApplicable to eight conditions selected by the Secretary of healthand human servicesAn ‘episode’ of care defined as the period from 3 days beforeadmission through 30 days after discharge Readmissions Reduction Program (Section 3025) g ( )Reduces payment for readmissions Will motivate hospitals to engage with care coordinators and organize delivery systems betterApplicable to three conditions selected by the Secretary of HHS;to be expanded in 2014Secretary to determine definition of ‘readmissions’ Hospital-Acquired Conditions (Section 3008)Payments for care for hospital-acquired conditions to be Will provide hospitals an incentive to standardize protocols andreduced starting in 2015 procedures to reduce hospital acquired conditions
  45. 45. Synergies with Proposed ACO Rule y g pMeaningful use as core expectation  Fifty percent of the ACO PCPs need to be meaningful users by the second year  g of the contract Information must follow the patient  ACOs creating data  lock‐in  by limiting or blocking information flow risk  ACOs creating data “lock in” by limiting or blocking information flow risk  having their agreements terminatedQuality measure alignment Large overlap between the clinical quality measures in the EHR Incentive  Program and in the proposed ACO ruleFocus on care coordination and seamless transitions Builds on HIE and Beacon workPatients as full partners Access to both medical records and evidence‐based data  A    b h  di l  d   d  id b d d   45
  46. 46. Key Roles for HIT in the Era of Accountability y yPutting accountability in accountable care organizationsPutting coordination into medical homesDivvying up bundled payments among providers y g p p y gpTracking health care acquired infections in real timeFacilitating enrollment in health information exchangesFacilitating enrollment in health information e changesCreating the efficiencies that will make expanded access affordableAccelerating data collection and reporting for population healthFacilitating secure access to consumer health information 46
  47. 47. Key Roles for HIT in the Era of Accountability y yEHR: HIE:  CDS:Electronically  Exchanging  Improved care capturing and  p g health  decisions processing  informationinformation about patients and populations l ti 47
  48. 48. Key Roles for HIT in the Era of Accountability y yIn addition to EHR, HIE and CDS deployment…Data Aggregation CDWs, Linking payer and clinical data, Distributed data models, etcAnalytics  Predictive modeling, performance measurement, assessing cost across  episodes of care, etc p , 48
  49. 49. Going Forward g Better Better Transform  a so Technology Information Health Care Goal V: Achieve Rapid Learning and Technological Federal Health IT Strategic  Advancement Ad tPlan 2011‐2015 Goal IV: Empower Individuals with Health IT to  Improve their Health and the Health Care System Goal III: Inspire Confidence and Trust in Health IT Goal II: Improve Care, Improve Population Health,  and Reduce Health Care Costs through the Use of  Health IT Goal I: Achieve Adoption and Information Exchange  through Meaningful Use of Health IT 49 49