Nevada Oct 24, 2008

NevadaOct 24, 2008

Session Overview

Health Information Exchange: Why? What? Who? How?

Challenges Along the Way

Results – Making a Difference

Acronyms to Enjoy

RHIO = Regional Health Information Organization governance model / funding mechanism

HIE = Health Information Exchange clinical / consumer / claims / public health

NHIE = National Health Information Exchange (standardized interface, certified

technologies

NHIN: Nationwide Health Information Network

“network of networks”

EHR + PHR + HIE + PHIN + ???

750,000 patients in multi-state region

2/3 of patients live in Tennessee

1/3 live in Virginia

5% in other states

Hospitals: 18

Physicians: 1200

Public Health: 7 regional, 2 state

Payor: 25% Medicare

20% Medicaid

18% uninsured

2-20% commercial

Small – Med Employers:

Eastman Chemical 7500

ETSU – 6500

Hospitals – 5500, 5400

CareSpark’s Mission

CareSpark’s mission is to improve the health

of people in NE Tennessee and SW Virginia

through the collaborative use

of health information

Regional Population Has High Disparities of:

• Diabetes

• Cardiovascular Disease

• Hypertension

• Lung Disease

• Cancer

• Premature Mortality

CareSpark region has $2,400 higher per capita patient care coststhan other regions of the country

Regional Health Status

Trend are getting worse

Drug Caused Death Rates 2002 - 2003

Quality Measures For VACompared With Best Practices

0

20

40

60

80

100

120

Pe

rce

nt

Go

als

Me

t

VA

Best Other

2002 Data

17 Measures

Source: SBCCDE, CITL, Gordian Project analysis

Redundancy

Treatment

Errors

Diagnostic

Electronic Medical Record

Clinical Data Sharing

Decision Support

Value is Derived from Better Medical Decisions

Patient Data

What Will CareSpark Do?

Outcomes Improvement •Individual health outcomes Population health status

Decision Support(real-time, at point of care, across all systems)

Patient-specific info (Rx, Dx, Hx)

Clinical Best Practices

PHR / EMR / CCR

Cost-Efficient Use of Resources

Reduced duplication, errors, administrative costs

CareSpark’s Strategic Outcomes

Population Health ClinicalPremature Mortality Adult Diabetics, Rx filled, vision / foot, HBA1C<7

New Diabetes CasesLipid Panel LDL < 100Flu Vaccines for 65+ Pneumo Vax for ages 65+, <2ER Visits for Health Attack Stroke TherapyPost- MI followup Cancer Screenings (PAP, Mammogram, colorectal)

Financial Savings -- ROI• Patient• Clinician• Facilities• Purchaser (health plan, employer, taxpayer, individual)

Awareness & Adoption of Best Practices

Public Health

ClinicianPurchaser

(Payors / employers)

Individual

(patient / consumer)

Population Health Informaticist

Community

Community-Wide Collaboration

Active, representative participation, including• Employers: Eastman Chemical Company, CGI, BAE Systems, City of Kingsport,

• Payors: Blue Cross Blue Shield of Tennessee, John Deere Health / United Healthcare, Cariten

PHP, Highlands Wellmont Health Network

• Hospitals: Mountain States Health Alliance, Wellmont Health System, Johnston Memorial

Hospital, Quillen V.A. Medical Center, Laughlin Memorial

• Physician Practices: Holston Medical Group, Highlands Physicians, Health Alliance PHO,

Cardiovascular Associates, ETSU University Physicians, Clinch River Health Services, Frontier Health, Southwest Virginia Community Care Network, Blue Ridge NeuroScience, C-Health

• Health Education: East TN State University School of Medicine / College of Nursing/ College

of Public and Allied Health, University of Appalachia College of Pharmacy, University of Virginia

• Public Health: Sullivan and Northeast Regional Health Departments in TN, Cumberland

Plateau and Lenowisco Health Districts in VA, Tennessee Department of Health, Virginia Department of Health and Human Resources

• Community Non-Profits: Kingsport Tomorrow, United Way of

Kingsport, Rotary Club of Kingsport, Kingsport Chamber of Commerce, Bristol Chamber of Commerce, NETWORKS Sullivan County Partnership

• Patient Advocacy Groups: American Cancer Society,

Minority Health Coalition, Mountain Empire Older Citizens

• Local Technology Companies: Intellithought, LucentGlow,

Deliberare, Holston Technology, the Creative Trust, ntara

Board of Directors

CareSpark ManagementClinical

Outcomes / Evaluation Population Health workgroup Financial Savings Workgroup

Technical

Finance

CareSpark RHIO Organizational Structure

Communications

Nominating Legal AuditPersonnel

Patient Physician Public Health PurchaserFacilitiesStakeholder Advisory Groups

Project Management Office

Partner Partner Partner Partner

Health Information Control

CareSpark Board of Directors

Board Membership• Selected as individuals, not organizational rep’s• Expectation: put community good ahead of individual or organizational

agenda• Self-perpetuating (nominating process, board members elect successors)• 1-3 year staggered terms, two-term maximum• Balance of leadership experience, necessary skill-sets, network contacts to

achieve strategic goals, representative of stakeholder and regional demographic composition

Current Members include:CIO of large health system, CEO of independent pharmacy, CEO

of behavioral health provider, CEO of hospital-physician network, CFO of large insurer, Health Benefits director for large employer, President of large multi-speciality practice, CEO of community health center, Director of regional public health department, Chief of Staff for local V.A. hospital, Exec Director of regional seniors programs, VP for local university / rural health education

CareSpark’s Core Strategies

Provide patient informationand decision support on

demand at the point-of-care

Provide patient informationand decision support on

demand at the point-of-care

Align financial incentives to assure

fair return on investment

Align financial incentives to assure

fair return on investment

Empower patientsto make healthy

choices & informed decisions

Empower patientsto make healthy

choices & informed decisions

Provide selected aggregate datafor population

health improvement

Provide selected aggregate datafor population

health improvement

1.1. 2.2.

3.3. 4.4.

Coordinating organization facilitates rules of engagement: • Data-sharing Agreement • Legal Framework• Standards• Interoperability• Transparency• Value• Quality/Cost

Framework for Trust and Collaboration

Broadband % of Access, Stakeholders, Automation

EMR / EHR/PHR Implementation

Structured Notes & Paper Records

Administrative Transactions (claims…)

ePrescribing Roll Out

Secure Clinical Messaging (labs, imaging, email…)

H.I.E.

Co

mm

on

Po

rtal

Tennessee State-level leadership

Virginia Health IT Framework

Virginia RHIO initiatives

Key Strategic Decisions

1. Enable participation by all patients and providers in region

2. Enroll patients through default Passive Enrollment (“opt-out”) with option for Active Enrollment (“opt-in”)

- Passive or Active enrollment managed through Master Patient Option Preference (MPOP) and Local Patient Option Preference (LPOP)

3. Hybrid Model, combining Federated Repositories and Centralized Repository for limited clinical data- Enabling decision support, monitoring and aggregate data analysis where regionally approved

4. Data Access and UsesPatient: view content of records, view access logProvider: payment, treatment, operations Public health: required reporting and authorized queriesPayers: de-identified aggregate dataResearch: IRB-approved studies

5. Fee-Based Revenue Model- Contracts with insurers and employers- Transaction fees for data providers (labs, hospitals, large practices)- Contributions (cash and inkind)

6. Commitment to standards (IHE / HITSP, ISO)

Convergence of Data

Administrative

Billing & Claims

Clinical

Personal Health Record

Research

Best Practices

Patient-Centered

Care

From Patient Perspective

Perceived Risks• Privacy

(unauthorized access or release)

• Use of data (denial of care, coverage, or employment)

• Identity theft• Government as “big

brother”• Incorrect matching of

records• Incorrect data entry

Perceived Benefits• Convenience• Access to critical

information (allergies, rare diseases)

• Reduced duplication = reduced cost

• ability for proxy to manage care (adults caring for elderly parents from a distance)

• Advanced directives

The Importance of Standards

Standards for data content (what are the important pieces of information necessary? Is terminology consistent?)

Standards for data transmission (how is data sent?)CDA = (clinical document architecture) exchange of fixed, legally defensible document upon requestCCR = (continuity of care record) assembly “on the fly” from discrete data elements in multiple systemsCCD = (continuity of care document) standard document that includes common discrete data elements

Standards for security (access, authorization, audit)use existing international standards from other industries

Standard policies (who decides what to share, with whom and for what use?consumer-directed permissions for access to / useaddress issues of liability and enforcement

Funding / sustainability (who benefits, so who pays?)savings accrue mostly to purchasers (insurers, employers, taxpayers, self-pay consumers)“transparency” for capital and operating costs, ROI, quality outcomes

CareSpark RHIO Consortium Partners

National / International: Local / Regional:ActiveHealth the Creative

Trust AllScripts DeliberareAnakam Holston

TechnologyCisco IntellithoughtCGI LucentGlowDell OnePartnerGE HealthcareHealthvision / Quovadx State:Initiate Systems TennesseeIntel Virginia MisysOracle Federal:Siemens DHHS / ONCWellogic

Market / thought leaders committed to interoperability, collaboration and results

CareSpark IHE Architecture

Data P

articipan

ts

CareSpark Data StoreCareSpark Data Store

XDSDocumentRegistry

XDSDocumentRegistry

XDS PatientIdentitySource(MPI)

XDS PatientIdentitySource(MPI)

PortalPortal

Hospital 1 Phys PortalHospital 1 Phys Portal

IHE DocConsumer

IHE DocConsumer

Hospital 1Hospital 1

IHE DocSource/ DocConsumer

IHE DocSource/ DocConsumer

Physician Practice 1Physician Practice 1

IHE DocSource/ DocConsumer

IHE DocSource/ DocConsumer

Document RepositoryDocument Repository

Document RepositoryDocument Repository

FILTERFILTER

Clinical DataRepository

Clinical DataRepository

Public HealthData Mart

Public HealthData Mart

De-IdentifiedData Mart

De-IdentifiedData Mart

Car

eSp

ark

XD

S D

ata

Sto

re

-

F

or P

atie

nt C

are

Cli

nic

al D

ata

R

epo

sito

ry

-

F

or

Pub

lic H

ealth

Im

prov

emen

t

XDS PIXServiceXDS PIXService

CT TimeServiceCT TimeService

XDS PDQService

XDS PDQService

ATNA AuditRepositoryATNA AuditRepository

XDSDocumentRepository

XDSDocumentRepository

XDSKey Store

XDSKey Store

Public Health Department 1Public Health Department 1

Additional Providers and other data participantsAdditional Providers and other data participants

IHE DocSource/ DocConsumer

IHE DocSource/ DocConsumer

IHE DocSource/ DocConsumer

IHE DocSource/ DocConsumer

Document RepositoryDocument Repository

Data

Transformation

Data

Transformation

Technical Architecture

Internet

Provider 1

Active Health

Data BaseServer

ApplicationServer

`

MPI ClientFilters and Encryptions

Application Server

Data BaseServer

CareSpark Secure & Redundant

Network A

CareSpark Secure & Redundant

Network B

Note 1: Patient access will be via the internet thorough Https Protocol (SSL)

LoadBalancer

AppFirewall

Note 2: Although not pictured, the Internet connectivity, the Application Firewall and the Load Balancer will all be redundant, to avoid a single point of failure.

See Note 2.

See Note 3

NHIN

Patient`

See Note 1.

Note 3: All non-patient connections to the Internet are secured connections, via SSL.

EMPIFilters and Encriptions

EMPIFilters and Encriptions

Data BaseServer

Data BaseServer

Router

Provider 2`

MPI ClientFilters and Encryptions

` Small Doctors Office

`Provider using

ASP

Application Server

Provider

MPI ClientFilters and Encryption

Nationwide Health Information Network: “network of networks”

NHIN Prototype Demonstration 2006-07

design for exchange between

CareSpark, West Virginia, Kentucky providers,

federal agencies

NHIN Trial Implementation 2008

* Core Services:

Consumer permissions

Security exchange

Standardized interfaces

Summary medical record

* Medication Management

eRx, med history, decision

support

* Consumer Empowerment

personal health record, registration

and medication history

CareSpark NHIN Architecture

CareSpark(Hosted at CGI)CareSpark(Hosted at CGI)

OracleOracle

XDS PatientIdentitySource(MPI)

XDS PatientIdentitySource(MPI)

PortalWellogic

PortalWellogic

CloverleafCloverleaf

XDS PIXServiceXDS PIXService

CT TimeClient

CT TimeClient

ATNA AuditRepositoryATNA AuditRepository

XDSDocumentRepository

XDSDocumentRepository

XDSKey Store

XDSKey Store

XDS PDQService

XDS PDQService

XDS RegService

XDS RegService

XDS RepService

XDS RepService

Two FactorAnakam

Two FactorAnakam

EMPIInitiate

EMPIInitiate

PostGreSqlPostGreSql

XDSDocumentRegistry

XDSDocumentRegistry

XDSRegistry

NIST

XDSRegistry

NIST

ATNAWinSysLog

ATNAWinSysLog

ADTService

ADTService

Web Server

DB Server

VersionControl

Subversion

VersionControl

Subversion

MPOPMPOP

MPOPConsentMPOP

ConsentCustom

InterfacesCustom

Interfaces

Anakam

ESBESB

NHIN request/response

Providers

Any other inbound/outbound end point

Socket TCP

SOAP/HTTP

Flat File

Data

Transformation

Data

Transformation

Protocol

Transformation

Protocol

Transformation

Message

Enhancement

Message

Enhancement

Security

Validation

Security

Validation

RoutingRouting

OrchestrationOrchestration

Anakam

Two FactorAnakam

Two FactorAnakam

Web Server

PHRActiveHealth

PHRActiveHealth

Web Server

e-PrescriptionAllScripts

e-PrescriptionAllScripts

Jun 07

Technical/Financial Timeline

Jun 08 Jun 09Jan 08 Dec 09Jan 09Jan 07

Enrollment of 25,000members

MPI build

document registry andRepository

Build clinical data repository

Physician Portal,

authentication

Real-time Decision support integrated

with HIE

Data-sharing

agreements

Enrollment 250,000 patients

Claims-based Decision support

implemented

Enrollment 35,000

members

Clinical documentExchange

NHIN Trial Implementatio

n

Operating Operating SupportSupport

April 2008 – June 2009April 2008 – June 2009

Operating Operating SupportSupport

April 2008 – June 2009April 2008 – June 2009

Infrastructure Infrastructure DevelopmentDevelopment

July 2005 – March 2008July 2005 – March 2008

Infrastructure Infrastructure DevelopmentDevelopment

July 2005 – March 2008July 2005 – March 2008

Strategic Business Strategic Business PlanningPlanning

July 2004 – June 2005July 2004 – June 2005

Strategic Business Strategic Business PlanningPlanning

July 2004 – June 2005July 2004 – June 2005

Grassroots Sustainability

$100,000 grant from eHealth Initiative

$462,000 match from local partners

$250,000 Commonwealth of Virginia

$308,000 Accenture NHIN Prototype

$1,450,000 Consortium Partners (cash/inkind)

$1,000,000 State of Tennessee

$750,000 contributions and donations

$3,688, 622 NHIN Trial Implementation

$150,000 transactional fees for services

$450,000 contributions and donations

$1,055,225 enrollment of members

Revenue Sources July 2005 – Dec 2008

Employers:Eastman Chemical Company $ 600,000King Pharmaceuticals $ 60,000Cariten PHP $ 8,000Johnston Memorial Hospital $ 10,000

Contracts:State of TN $1,016,900Accenture (NHIN prototype) $ 308,000Commonwealth of Virginia $ 250,000NHIN Trial Implementation $3,988,622

Consortium Partners $1,250,000

cash and inkind

Enrollment Fees (CareEngine Services) $ 431,640

Transaction Fees $ 0

Total $7,923,162

CareSpark Data-Sharing Options

Data Sharing Option Intended Data Use Data Sharing Result

Identified Data Patient Care and Treatment

All data sent to CareSpark will be identified data in order to match patient records from multiple providers. Identified data will be available to authorized providers for access of additional healthcare information about the patient.

De-Identified Data Anonomized – patient data can never be re-identified

Approved Population Health Improvement activities

Identified data available to CareSpark will be de-identified according to the approved requirements and stored separately.Pseudo-Anonomized –

Patient data can be re-identified, if necessary, but only by the party who provided the pseudo-anonoymized data

Limited Public Health Identified data available to CareSpark will be de-identified with the specified additional fields required for a limited dataset according to the approved requirements and stored separately.

Future Initiatives

• National – connect with V.A., CDC and personal health records

• Tennessee – connect with state agencies (public health immunization registry, Tn eHealth Council efforts)

• Virginia – connect with immunization registry, prescription management program

• Local / Regional – support aggregation and analysis of data to address public health issues for region (chronic disease, prescription drug overdose)

Lessons Learned – Regional HIE

• Health care market does not conform to political boundaries

• Evolving standards will assure interoperability across jurisdictions and between systems (clinical, payer, public health, personally-controlled, research-oriented)

• Leverage existing resources and investment through incremental transition

• Build for maximum flexibility to accommodate change (technical, policy, funding, users, evidence-base on outcomes)

Better Health for Central Appalachia

www.carespark.com

Liesa Jenkins, Executive Director423-963-4970

[email protected]