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Creating a Medical Networkin Massachusetts
US-German Summit onPrimary Care
Washington, DCApril 9, 2010
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Thesis Sharing Data Improves Patient Care
Interoperable health IT can improve individual patient care in numerous ways,including:1
Complete, accurate, and searchable health information, available at the point of diagnosisand care, allowing for more informed decision making to enhance the quality and reliabilityof health care delivery.
More efficient and convenient delivery of care, without having to wait for the exchange ofrecords or paperwork and without requiring unnecessary or repetitive tests or procedures.
Earlier diagnosis and characterization of disease, with the potential to thereby improveoutcomes and reduce costs.
Reductions in adverse events through an improved understanding of each patientsparticular medical history, potential for drug-drug interactions, or (eventually) enhancedunderstanding of a patient's metabolism or even genetic profile and likelihood of a positive
or potentially harmful response to a course of treatment. Increased efficiencies related to administrative tasks, allowing for more interaction with
and transfer of information to patients, caregivers, and clinical care coordinators, andmonitoring of patient care.
1http://healthit.hhs.gov/, U.S. Department of Health & Human Services, accessed 1/27/2010
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The Current Problem
Unfortunately, data sharing across organizational boundaries is not widelyavailable today for a number of historic reasons
Absence of incentives and return on investment few or fragmented short-term financialincentives (payer-specific pay-for-performance) and virtually no long-term studies orevidence on the value of sharing data
Misaligned incentives perception that value accrues to organizations other than the onesmaking the investment (providers pay for implementation and purchasers and payersgain, or payers make the investment and the patients next payer reaps the benefit, etc.)
Legal liability access to or availability of data generated elsewhere somehow compelsthe receiver to verify it and act on it
Privacy sharing violates patient confidentiality (real or perceived)
Competitive barriers current practice rewards health care organizations for developinglong term patient relationships; many fear making it easier for patients to exercise choiceby opening up their records
Technical limitations absence of standards in the past and, because of all the otherfactors, market solutions have been specialized, ill-adapted, expensive and not very good
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ARRA / HITECH Sets a New Data Sharing Agenda
The American Recovery and Reinvestment Act of 2009 (ARRA, or the Stimulus)(Pub. L. 111-5) enacted February 17, 2009 includes provisions to promote theadoption and meaningful use of interoperable health information technology
Collectively cited as the Health Information Technology for Economic and Clinical HealthAct (HITECH)
Implementation is directed by the Office of the National Coordinator for Health InformationTechnology (ONC) in the Office of the Secretary of the U.S. Department of Health andHuman Services
ONC has adopted a set of five Health Outcomes Policy Priorities that will guidemeaningful use, interoperability and data sharing for the foreseeable future:
Improve quality, safety, efficiency, and reduce health disparities
Engage patients and families Improve care coordination
Improve population and public health
Ensure adequate privacy and security protections for personal health information
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Implementation Challenges for Health IT and InformationExchange
Hospital workflow is complex and difficult to change without unintendedconsequences some of which can be potentially life-threatening
Many settings need many solutions
Hospital is different from ambulatory
PCP vs, specialist (and changing models for primary care)
Needs are often different across specialties and patient demographic groups
Labs, pharmacies, imaging centers, long-term care . . . the list goes on and on
Where to focus point of care, secondary use or both in parallel?
Different dynamics, with much of the attention so far on the former, and on thepatient/provider relationship
There is much to be learned related to access to large volumes of health care data forresearch, comparative effectiveness, etc.
Questions abound surrounding the payers role as the focus is almost exclusivelyon enabling the provider
What is the role of the patient or family?
What role does consumerism play? What tools are and will be available? Will patientsengage in using data to manage their care?
Its easy to lose the patient focus when considering all of the effort providers require
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Feb 2009ARRA / HITECH becomes
US law, introducingincentives for meaningful
use of EHRs and healthinformation exchange (HIE)
Medical Network History in Massachusetts
Jun 1996HIPAA becomesUS law, requiring
standardizedelectronic
transactionprocessing forclaims, etc.;
PartnersHealthCare
begins to focuson administrativesimplification asmore feasible
productivity toolthan electronic
exchange of laband pharmacy
orders
Sep 1998Payer / provider
connectivity
solution isincorporated asNew England
Healthcare EDINetwork(NEHEN)
1997 2009 20101998 2007 20081999 2005 20062003 20042001 200220001996
October 2003NEHEN meets federal
HIPAA compliance deadlinefor 23 organizations,representing over 40hospitals and 5,000
physicians
Jan 2003Mass. state govt. begins
restructuring of health andhuman services agencies withcommon IT systems and portal
Feb 1997
Two payers and twoother hospital
organizations joinPartners in developingconnectivity solution,
managed by CSC
Jun 2003MA-SHARE forms asclinical counterpart to
NEHEN, initially focusedon emergency medicine
Oct 2005 Jan 2007
MA-SHARE / CSC leaddevelopment of initial federal
NHIN prototype (linking toIndiana and California)
1999 - 2003NEHEN experiencessteady growth as
HIPAA complianceand productivity
solution
Jan 2005CSC assumes program
management of MA-SHARE andarranges Markle Foundationfunding for development of
Record Locator Service
Dec 2004Massachusetts
eHealth Collaborative
forms to provideEHRs to community-based physicians andcollect measurementdata in Quality Data
Center
Jul 2009
MA-SHARE andNEHEN merge,
retaining NEHENname and CSC asprogram manager
Apr 2009Universal health
insurance becomesMassachusetts law,creating insurance
exchange(Connector)
Feb 2010Health reformbecomes USlaw; HITECH
funding beginsflowing to USstates
2006-2008NEHEN payers funddevelopment of all-payer NEHENNetportal for smaller
providers
Aug 2008EHRs and health
information networkmandated by
Massachusetts law
Dec 2008Payers and providers (as EMHI)fund alignment of NEHEN and
MA-SHARE plans with state and
federal direction
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NEHENs Evolution and Growth
1998 2003 2004 2006 2007 - 2008 2009 2010
Payer / provider
direct connect
Developed payer /
provider HIPAAtransaction sets
BCBSMA and MassHealth join Large group practices join Geographic expansion beyond
metropolitan Boston
MassHealth NewMMIS
requires significantchanges to NEHEN forMedicaid
5010 compliance focus Interest in advanced eligibility
features and other use cases
Hosted portal and
shared
infrastructure
Payers commit to portaldevelopment and initialsupport for small providers
Completed NEHENNetand all-payer portal
NEHEN Hub to lowercost / complexity ofconnectivity
Portal rollout and growth Interest in sharing infrastructure
across clinical andadministrative, small and largeproviders
Clinical HIE MA-SHARE formed as
independent initiative
MedsInfo-ED pilot
Connecting for Health RecordLocator Service grant andprototype
Rx Gateway launched ONC NHIN contract
ONC NHIN prototype
completed Adopted push model
and Push Pilot BIDMC Childrens
Northeast
EMHI sponsors interoperability
planning and endorses NEHEN Meaningful use focus
Clinical summaries Labs and public health Quality reporting E-prescribing
Other
developments
Met October 2003HIPAA compliancedeadline
CSC invited to take over MA-SHARE program management
Significant grant funding(Markle, ONC, CMS/AHRQ)
State passes Chapter305, calling for EHRsand HIE (MeHI and HITCouncil form)
ARRA/HITECH promisesmeaningful use incentive
funding for HIE MA-SHARE and NEHEN merge
Customers 23 35 39 41
Hospitals 46 55 59 61
Users ~1,300 ~1,500 ~1,800 ~2,000+
Classic providers ~12,000 ~16,000 ~18,000 ~20,000
Small providers ~750 ~1,200
Transactions ~24 million / year ~40 million / year ~60 million / year 100 million + / year
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Exchange Partner
Conceptual Architecture and Workflow
Provider
Directory /
Routing
Internet
/ Network
Treatment events (visits,tests, discharges, etc.) trigger
patient data being published orpushed from one or moresource systems for exchange
Published
Patient
Data
Data is translated to CCD standard
Message is addressed using prov ider directory
Message is logged and retained for tracking by sender
Source ProviderSource EMRs
and Clinical
Systems
Secondary
Local
System
Exchange
Infrastructure(can be local
to each partner orcentrally hosted)
Provider
Directory /
Routing
Received
Patient
Data
Message or notification of available data is securely
routed to intended receivers
Message can also be routed as encrypted or securee-mail
Fax
Server
Fax
Message can also be routed as facsimile, directly to faxor through fax server at receiver if logging is required
Message is logged and retained for tracking by receiver
Message is inspected for handling and routinginstructions
Acknowledgement is returned to sender based onagreed process and business rules
Message is available for printing (e.g., for paper chart)
Message is available for online viewing from exchangeinfrastructure or in portal
CCD data is translated to proprietary format for use inreceiving system(s)
Exchange infrastructure can also be leveraged forinternal / local exchange within the provider
CCD Standard
Messages
Receiver EMRs
and Other
Systems
Portal or
Dedicated
Viewer
Server
Interface Engine,
Portal or
Direct Interface
Interface Engine,
Portal or
Direct InterfacePrinter
Fax
Server
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Hosted Portal / HIE Service
Hosted by service provider (MA-SHARE) Provides document / data storage, HTTP viewing for subscribers, and
common provider index for dissemination to local gateway participants
Peer-to-Peer Participant
Local gateway users control integration, etc. Can leverage infrastructure for internal integration Interfaces can be direct or use interface engine or similar tools
Architecture Overview
Local Provider
Directory
Internet /Network
PublishedPatient Data
EMRs and Other
Enterprise
Systems
Secondary
Local
System
Server
CCD Standard
Messages,
e-mail or fax
encapsulation
Interface
Engine
or Portal
HIE Application
Server / Gateway
Fax
Server
Web
Server
Service Subscriber
No infrastructure support requirement just Internet connection, fax ore-mail
Summary /
Results Viewer
Fax
Summary /
Results
ViewerE-Mail
Server
Web
Server
Printer
E-mail, fax or
HTTP encapsulation
Published Patient Data
Community Provider Directory
Peer-to-Peer Participant
EMRs and Other
Enterprise
Systems
Secondary
Local
System
Server
Interface
Engine
or Portal
Fax
Server
Web
Server
PublishedPatient Data
HIE Application
Server / Gateway
Local Provider
Directory
HIE Application
Server / Gateway
CCD Standard Messages,
HTTP encapsulation
Summary /
Results Viewer
External
Networks
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Patient visits PCP or specialist andestablishes trusted relationship and
consents for release of data
As a result of a referral,admission, or emergency, patient
registers in hospital
Patient is dischargedfrom hospital
Standard formatdischarge summary orER report is transmitted
to HIE network
HIE service checksprovider directory forrouting instructions
HIE service routesdischarge summary to
PCP, specialist or otherinterested and trusted party(e.g., health insurance case
manager)
Consents andprovider routingpreferences are sent to
HIE service
Patient receives care anddetails are noted in hospital
medical record
Sample Use CaseSend / push / route hospital data to interested parties
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Patient visits PCP orspecialist and
establishes trustedrelationship and
consents for release ofdata; consents and
provider routingpreferences are sent to
HIE service
Provider refers patient to aspecialist, hospital or other provider for
consultation or service
Standard formatvisit summary withconsultation notestransmitted to HIE
network
HIE service checks providerdirectory for routing instructionsand sends referral request withpertinent patient information /history, diagnosis and service
requested to consulting
provider; business rules can bestored in HIE service for
elements of real-time decisionsupport
HIE service routes visitsummary to PCP, specialist
or other interested and
trusted party (e.g., healthinsurance case manager)
Patient visits consultingprovider, receives services,
and details are noted in patientchart , electronic medical
record or other result is created(e.g., at lab)
HIE service submitsreferral authorization request
to payer for approval andreferral #
Sample Use CaseSend / push / route data in support of a referral or consultation
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Sample Use CaseSend / push / route visit and other data for standardized quality measurement /reporting and public / population health management
Patient visits PCP,
specialist, hospital orother provider andestablishes trusted
relationship andconsents for release of
data
Consents andprovider routing
preferences are sent toHIE service (as required)
Standard format visitsummary or batch with data
for determining quality
metrics is sent to payer,government agency or other
organization based onbusiness rules in HIE
service
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Sample Use CaseSend / push / route data for personal health records (PHRs)
Patient visits PCP,
specialist, hospital orother provider andestablishes trusted
relationship andconsents for release of
data
Consents andprovider routing
preferences are sent toHIE service
Standard formatvisit summary
is sent to patientproxy for personalhealth record (e.g.,Google, Microsoft
HealthVault, Dossia,etc.)
Patient andauthorized parties
can access personalhealth record
through PHR proxyservice provider
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Physician / clinicianuses software of his orher choice to create anelectronic prescription
E-Prescribing
System
Electronic prescription is transported toHIE service for submission and tracking (viaput / push or get / pull, based on business
rules)
HIE service submits eligibility verif ication topayer for pharmacy benefit eligibility and any
other available data
Payer
Pharmacy Intermediary
(SureScripts-RxHub) /
Pharmacy Benefit
Manager
HIE service submitselectronic prescription / claim
to pharmacy processingaggregator / intermediary ordirectly to pharmacy benefit
manager (PBM) for formularycompliance, etc.
Mail Order /
Retail
Pharmacy
Pharmacy processingaggregator / intermediary
sends electronic prescriptionfill order to mail order or
retail pharmacy
Pharmacy processingaggregator / intermediary
sends acknowledgement toHIE service
HIE service sendsacknowledgement and otherprescription data back to E-
Prescribing System ordirectly to prescribing
physician / clinician (via e-
mail, fax or standard formatmessage)
Sample Use CaseRoute electronic prescriptions
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Patient uses medicationsdispensed at retail or mail order
pharmacy, or purchased over thecounter (OTC)
As a result of a referral,admission, or emergency,patient registers in hospital
Medication history requestis sent to HIE; HIE retrievesretail and mail order history
from national network and anyother available history fromother participating sources
(payers, PBMs, otherhospitals, etc.)
Medication list isvalidated with patient,
incorporating OTC, herbalsupplements, etc.
Inpatient prescriptionorders are created based
on treatment plan andhome listIf patient is discharged, new
discharge prescriptions are writtenand submitted to HIE service forrouting to external pharmacy for
fulfillment
If patient is transferred,reconciled medication list isrouted to next provider of
care via HIE service HIE service routes reconciledmedication list to interested and
trusted party (e.g., PCP)
Sample Use CaseRetrieve and reconcile medication history
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Sample Use CaseAdjudicate and manage claims and/or patient responsibility in near real time
Patient visit orencounter resultsin medical claim
being created inprovider billing
system
Claim is transported to HIE service forsubmission and tracking (via put / push or get /
pull, based on business rules)
HIE service submits eligibilityverification to primary and secondary
payers identified in claim
HIE service transports claim to responsible partyidentified via clearinghouse or other intermediary asspecified in business rules / payer address table;
secondary claim created as necessary
HIE service submits claim statusinquiry based on business rules
HIE service matches solicited and unsolicited inquiryresponses (including payer scrubber reports) to claim,
identifying those requiring further editing
HIE service collects electronic remittances and matches toclaims, on a solicited and automatic basis
Claim detail and statusavailable for viewing in HIE
service; business users view andedit claims as necessary tocorrect insurance and other
information, with original andcorrected images of claim stored
and clearly identified, allowingedited claims to be and sorted
and grouped according tobusiness rules
HIE service triggers workflow related to denial management and secondary claimsubmission, based on business rules and claim conditions
Business users able to use HIE service to perform drill-down analysis and report on claims,claim status and claims management metrics and performance
BillingSystem
Payer /Fiduciary /
Clearinghouse
Payer /Fiduciary /
Clearinghouse
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Smaller Providers /Other Portal or EMR
Lite Subscribers View data for patient
care, etc., onhosted portal
PHR and OtherVendors
Collecting data
for patientsand families
Pharmacies / PBMs Processing
prescriptions andproviding
medication data
to other parties
Payers Collecting quality
and other data
Target HIE CapabilitiesConceptual view and data flow
Hospital / Health
System / Labs /
Large Provider Providing / consuming
clinical summariesand other data forpatient care
Data Routers /
Aggregators
Collecting andprocessing
data for otherparties
CMS / OtherFederal Agencies
Collecting qualityand other data
State Public Health Collecting vital statistics,syndromicsurveillance andimmunizationdata
Medicaid / Other
State Agencies Providing / collecting
quality andother data
Municipal Health
Departments Collecting disparity
and syndromicsurveillance
data
HIE Hosting infrastructure,
community servicesand portal /viewer(s)
Supported message / data types CCD-based
Clinical summaries at visit,discharge, transfer Procedure, problems, meds,
allergies, test results
Quality data Filtered or based on above
Immunization reporting Biosurveillance / reportable
diseases Filtered or based on above
Lab results Embedded in clinical summary
NCPDP-based Prescription fills / refills Meds. history / formulary (limited)
ANSI X12-based
All existing administrative txns.= Developed / supported in MA
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Privacy and Security
CoreHIE
Services
Core Technical and Operational HIE Services
Insurance Eligibilityand Claims
EHR Lite
ePrescribingLab Orders and
Results
Quality ReportingPublic Health
ReportingMedication History
Visit Summary Coordination of Care
Payors LabsPBMs PharmaciesPublic Health CMS (QualityReporting)
Hospitals with EHRProviders
Meaningful
UseTrading
Partners
HIE Edge Service
Practices with EHR Physician without EHR
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Optional Services Based on Todays Requirements andCapabilities
OptionalHIE
Services
Claim Status,
Remittance
Consent
Management Clinical Messaging
Secure MessageRouting
ProviderAuthentication
Participant Directory
Master Patient Index /
Patient Matching
Hospitals with EHR Practices with EHRProviders
Physician without EHR
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Other US and International Approaches
U.S. states of interest
California Failed efforts Santa Barbara Care DataExchange ($20M+) and CalRHIO
Florida
Fragmented market solutions with separatepayer and state overlays
Indiana
Sophisticated and custom-built; unique basedon 35+ years of foundation and grant funding(Regenstrief Institute)
New York
Widespread, implemented at local level,seeking a balance of public/privatecollaboration
Ohio
Sophisticated market-based solutions inCleveland and Cincinnati, not coordinated
Utah and Delaware
Effective state-mandated networks, butconcentrated and unique demographics
International experience
Denmark 5M pop., socialized Common purpose-built system deployed atthe county level
Hospital-centric, with extensive sharing withina local region
Netherlands 16M pop., public/private
Landelijik SchakelPunt (National Switch
Point) focus on data sharing and RecordLocator Service (RLS)
Smart card for physician / user authentication
Public initiative not integrated with private
United Kingdom 60M pop., nationalized
20 billion National Health Service project
National Spine: Messaging, Authentication,Demographics, Summary Care RecordSecondary Uses Service
EHRs implemented locally
Integrated Care Records Service (Primary,Community, Mental Health, Acute)
Picture Archive and Communications Service
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Conclusions
As 2010 begins, health care leaders in the U.S. in particular need to recognize
that the data sharing landscape is emerging but unsettled and pay attention to: New regulations and standards
Vendor strategies and plans core EHR, systems integration and specialized
State and local health information initiatives (public / private)
IT incentive programs from Medicare, state Medicaid and private payers (P4P)
Choose a strategy for data sharing matched to business plans
Aggressive maximizing benefits based on external incentives, efficiencies, revenuegains and patient goals; choose commercial solutions carefully
Steady progress stay abreast of others, look to act collaboratively and avoid penalties
Conservative at minimum, avoid penalties, which could be stiff or hospitals in particular
Consider two forms of risk
Inaction may lead to foregone incentives and inability to access implementation resources Precipitous action may result in choosing solutions that arent ready for prime time
Places to start
Cost avoidance areas where current costs can be lowered with IT solutions
Most leaders will need to make sure their organizations can walk before they run, but theyneed to get started now!
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Contact Info
Greg DeBorClient Partner, Health ServicesComputer Sciences Corporation266 Second AvenueWaltham, MA 02451
781-290-1308
www.csc.com/health_serviceswww.csc.com/de
www.nehen.orgwww.nehennet.org