Harris Capabilities Briefing
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Florida Health Information Exchange Status
FHA – AHCA – Harris Meeting
August 23, 2012
Harris Capabilities Briefing
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Agenda
Florida HIE Overview
Technical Implementation
Security Implementation
HIE Policy
Adoption
Sustainability
Harris Capabilities Briefing
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Florida HIE Overview
Janet Hofmeister
Harris Capabilities Briefing
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• Florida wins Florida Health Information Network Grant
•Health Information Exchange Coordinating Committee convened 2004
• Florida applies for ONC State Health Information Exchange Grant
•Concept of governance by Not-for-Profit
•No organizations identified 2009
•AHCA awarded HIE Cooperative Agreement Program Award in March
• Legislature directs issuance of Invitation to Negotiate (ITN) by July
•Harris awarded four-year, $19 million contract in November 2010
•Contract signed in February
•Direct Secure Messaging Deployed in July
•Patient Lookup Group 1 testing completed in December 2011
• Strategic Health Intelligence goes live!
• PLU Groups 2 & 3 selected; Group 4 applications received (Aug)
• Outreach Contracts selected 2012
History of the Florida HIE
Harris Capabilities Briefing
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Contractual Requirements and Status
Major Contractual
Requirements Status
Develop Direct Secure
Messaging
Complete – last enhancements to be deployed in
September
Develop Patient Lookup
Services
Complete – final gateway of gateways upgrade ready in
September
Create and implement DSM
adoption program
Complete – Plan in place and adoption efforts ongoing,
including DoH, Lab, Pharmacies, Payer & EHR vendor
outreach
Deploy up to 20 PLU nodes Ongoing – 12 adopters selected; 1 site is live and other
11 are working towards complete deployment;
Group 4 applications received; Group 5 deadline is 12/1
Connect to NwHIN In progress – Evaluating partners
Create Sustainment Plan Complete – Plan developed
Distribute Outreach Funding In progress – Awardees selected and contracts being
executed
Harris Capabilities Briefing
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Exchanging health information from the Florida Panhandle to the Keys
• Connects provider networks including:
• Physicians
• Hospitals
• Regional Health Information Organizations
• State Government Agencies
• Others as Healthcare evolves (i.e., ACOs., etc)
• Provides timely, secure, authorized exchange of
patient health information for treatment
• A network of networks:
• Open-source, standards-based
• Leverages existing local HIE networks to connect Florida’s
healthcare providers
• Consists of two major services:
• Direct Secure Messaging (DSM)
• Patient Lookup (PLU)
Florida HIE Overview
Harris Capabilities Briefing
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• Patients, Caregivers, Consumers
• Providers - Doctors, Nurses, Physician Assistants,
Nurse Practitioners and others
• Regional Extension Centers (RECs)
• Hospitals, Clinics, Physicians’ Groups
(Public and Private)
• Regional Health Information Organizations (RHIOs)
• Health Information Exchanges (HIEs)
• Integrated Delivery Networks (IDNs)
• Independent Practice Associations (IPAs)
• Long-Term Care and Mental Health Facilities
• Department of Health & County Health Departments
• State Immunization Records (Florida SHOTS)
• Federally Qualified Health Centers (FQHCs)
• National, independent, state labs
• E-Prescription Networks
Florida Stakeholders
Harris Capabilities Briefing
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Florida HIE Technical
Implementation
Chris Phillips
Harris Capabilities Briefing
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Direct Secure Messaging (DSM) is a secure e-mail system that allows participants to push encrypted health information to other participants and to respond to requests for information • Conforms to DIRECT Standards
• For Treatment, Payment and Healthcare Operations
• Content agnostic
Patient Look-Up (PLU) allows clinicians to query for and pull patient records from other participating nodes on the statewide network • Conforms to CONNECT Standards
• For TREATMENT purposes only
• Patient authorization is required
• Exchange is via the CCD
Florida HIE Services
Harris Capabilities Briefing
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Florida HIE Federated Data Services
Patient Look-Up (Query/Pull) • Completely federated
• No central Clinical Data Repository (CDR) exists at the Florida HIE Level • All data resides locally
• The Florida HIE is a conduit to share information between end-points who retain control of the data
Direct Secure Messaging (Push) • Has centralized exchange server
• Supports HISP to HISP connectivity
Harris Capabilities Briefing
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Patient Look-Up Use Cases
Providers can perform targeted queries and retrieve a patient’s health records in CCD/C32 format
• Enables reduction of duplicative tests and adverse drug interactions
• Improves the timeliness and quality of care
In Emergency Room – make a broadcast query to access an unresponsive patient’s health records in seconds
• Providers can make more informed and timely decisions about patient care and treatment – which is imperative during an emergency
Back at the PCP, patient records from the ER visit can be retrieved
• Primary care physician can provide better follow-up care after the emergency is over potentially reducing unnecessary ER visits
Harris Capabilities Briefing
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Patient Look-up Functional Architecture
Hospital HIE
Health Choice
Networks
INFRASTRUCTURE
Nationwide Health Information Network (NwHIN)
INTERNET
Others
FQHC Local Lab
FQHC
Community HIE
DSM
FQHC
Hospital HIE
Free Standing Hospital
Harris Capabilities Briefing
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HIE
Patient Look-up Technical Architecture
EXPRESS EXPRESS LITE
INFRASTRUCTURE
Service
Registry Certificates
Terminology
Translation
P2PDirect Provider
Directory
Integration
Engine
DOCUMENT
GENERATION
Integration Engine
DOCUMENT GENERATION
Registry &
Terminology Registry &
Terminology MPI/RLS
EHR
CONNECT
Gateway CONNECT
Gateway
Published Messaging and
Authorization Specification
PATIENT LOOKUP
DOC SUBMISSION
LARGE FILE TRANSFER
NwHIN
Connection Privacy
Reports
Audit Log
PACS EHR
Clinical Data
Repository
MPI/RLS Clinical
Data Repository
Harris Capabilities Briefing
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Use Cases for DSM
Primary care provider refers patient to specialist including summary care record
Primary care provider refers patient to hospital including summary care record
Specialist sends summary care information back to referring provider
Hospital sends discharge information to referring provider
Laboratory sends lab results to ordering provider
Transaction sender receives delivery receipt
Harris Capabilities Briefing
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DSM Functional Architecture
DSM Web Based
(HISP)
INDEPENDENT
PHYSICIANS
Secure Internet Web-Client Access
PHYSICIANS
GROUP HOSPITALS
Quest Diagnostics
HISP
Alabama HISP
IOS HISP
Secure Internet (SMTP w/SMIME)
Lab, HIE or EHR System
Harris Capabilities Briefing
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DSM Technical Architecture
LDAP
Exchange Server (Apache James)
E-mail Web Client (Squirrel Mail)
Provider Directory
DOH Provider License Status
File
Florida HIE Web Page
(Account Mgmt System)
CMS NPPES Licensed Providers Direct
Address Book
Mail • Open source
• Security Certificate
• Thorough vetting uses multiple data
sources
Harris Capabilities Briefing
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Integration between Systems and DSM
Automatic interfaces to healthcare systems, EHRs (Inbox or clinical content)
Reliable delivery notifications
Interface & specifications available October 2012
Using SMTP/POP3 or XD*
Systems or EHRs must develop their own interface to meet specifications
Harris Capabilities Briefing
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Florida HIE Security
Implementation
Andre Hebert
Harris Capabilities Briefing
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Florida HIE Security and Privacy Principles
Secure, encrypted transmission, centralized audit reports, alerts, and HIPAA compliance
Protect patient privacy and consent through Subscription Agreement policies
Support various policy frameworks that might be implemented within the Edge Systems
PLU participant organizations are vetted based on the thoroughness of their privacy and security policies (among other criteria)
DSM registrants undergo one of the most comprehensive identity validation process currently in production, compared to similar systems nationwide
Harris Capabilities Briefing
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Security Controls:
Florida HIE Data Center Overview
Layered Security Architecture
DSM
CONNECT Gateway
Harris Capabilities Briefing
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DSM
CONNECT Gateway
Security Controls:
Data Center Physical Security Layer
• Warning signs
• Security guards
• Locked gates and doors
• Locked cabinets and racks
• Electronic badges
• Closed circuit television
cameras
• Alarm systems
• Raised flooring (water
damage protection)
Harris Capabilities Briefing
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DSM
CONNECT Gateway
Security Controls:
Network/Infrastructure Security Layer
• TLS – Data Encryption
(RSA- 2048-bit)
• Firewalls - DMZ
• IDS/IPS
• HTTPS Reverse Proxy
• Anti Virus Protection
• Access Control Procedures
• System Monitoring
• Limited Remote Access
• Data Backups
Harris Capabilities Briefing
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DSM
CONNECT Gateway
Security Controls:
Application Security Layer
• Account Registration
• User Authentication
• Role Based Access Control
• Data Segregation
• Data Encryption (at rest)
• Vulnerability Mgmt
• Audit Logging
• Account Locking
• Inactivity Timeouts
Harris Capabilities Briefing
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Security Controls:
Supporting Network Security Processes
Security across entire system development lifecycle • Design • Development • Test
• Staging • Deployment
Change control and configuration management • Configuration Control Board (CCB)
• Comprehensive CM approach with integrated Microsoft TFS IDE
Security and program risk management • Security risk plan and assessment
• HIPAA Compliant
Personnel training • Operational system and architecture
• HIPAA/HITECH and legal
Operational procedures • Account management • Remote access process • System maintenance
• Disaster recovery • Security incident process • Help Desk processes
Harris Capabilities Briefing
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Vetting for DSM Participation
On-line self registration: • Only certain types of organizations allowed to register
• Based on taxonomy code listed in NPPES database
• Registrant is authenticated to validate that they are who they say they are • Access to FAX machine listed in NPPES database
• Valid and active Florida license verified for individuals and organizations • License number listed in NPPES database
• Validated against the Florida Department of Health (DOH) database (on-line) and AHCA facility license database (off-line)
• Individuals are authenticated by the organization they are affiliated with • Organization Point of Contact (POC) must approve individual accounts
Group registration: • Manual vetting of organization and organization POC by AHCA
• AHCA or Florida DOH licensed facility – clear and active
• Provider, State Agency, Plans/Payers POCs are validated via personal inspection of credentials and third party database
• Plans/Payers are also validated that they are licensed in Florida or participating in Florida Medicaid
• Organization POC responsible for vetting individuals within their organization per NIST Level 3 guidelines
Harris Capabilities Briefing
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Florida HIE Policy
Carolyn Turner
Harris Capabilities Briefing
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Consent Models
DSM is Delegated Model
• Responsibility of Exchanging Parties
• DSM Content Anonymous to System
• Use Determined by Exchanging Parties
• Limited Authorization Form may be used
PLU is Consent to Access Model
• Patient Authorization Required • Must use Florida Form or legal equivalent
• Provider retains document
• Authorization is universal for named provider
• Break the Glass Permitted
• PLU Organizations Must Audit Patient Authorization
• PLU Organizations Must Share Audit Plans
• Patients May Restrict Access per HIPAA (not available for PLU)
• Re-Disclosure Notice (42 CFR Part 2) Required at each Access of PLU
Harris Capabilities Briefing
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Permitted Uses of Service
Patient Look-Up
• Treatment
• Health Care Operations as Authorized by Patient
• Public Health
• Disability Determinations
Direct Secure Messaging
• Treatment
• Payment
• Health Care Operations
• Public Health
• Meaningful Use Reporting
• HIPAA Authorization Required Purposes - Research
Harris Capabilities Briefing
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Who Can Join Each Service
Patient Look-Up: Providers
• Hospitals and Hospital Systems
• Regional Health Information Organizations
• Health Information Exchanges
• Health Care Clinic Systems
Direct Secure Messaging: Providers, Payers and State Agencies
• Providers include hospitals, physicians, ambulatory facilities, pharmacies, home
health agencies, community mental health, nursing homes, hospices, clinical labs
• Payers include commercial insurers, Medicaid health plans, Medicare Advantage,
Healthy Kids, third-party administrators
• State Agencies include AHCA, DCF, DOEA, APD, and DOH and others authorizing
employees who exchange Protected Health Information (PHI) with health care
providers and health plans
Harris Capabilities Briefing
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Florida HIE Adoption
Evan Carter
Harris Capabilities Briefing
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PLU Adoption/Current Participants
Current PLU nodes
Organization Members Region
Atlantic Coast HIE Memorial Healthcare System Miami-Dade/Broward
Big Bend RHIO TMH, CRMC Leon & surrounding counties
Community Health Centers Alliance FQHCs Statewide
Florida Department of Health County Health Departments Statewide
Florida Hospital - Adventist Florida Hospital Facilities Central Florida
Health Management Associates HMA Facilities Statewide
IOS Health Systems Ambulatory EHR providers Statewide/South Florida
Kindred Healthcare Long-term care facilities Statewide
Orlando Health Orlando Health Facilities Central Florida
UF&Shands Shands Gainesville & Jacksonville North Florida
South Florida HIE FQHCs Statewide/South Florida
Strategic Health Intelligence Baptist, Sacred Heart Hospitals Escambia & surrounding counties
Harris Capabilities Briefing
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PLU Adoption/Current Participants
Harris Capabilities Briefing
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PLU Application/Onboarding Process
PLU Readiness Questionnaire and/or Self-Onboarder Checklist
available online or from Florida HIE adoption staff
Questionnaires can be submitted at any time
Onboarders are selected quarterly from available applicant pool
• Selections based on quantitative scoring for organization’s technical readiness,
size, privacy & security policies, and location
12 current onboarders have been selected in 3 different groups
Group 4 selection process underway
• 5 new applications received
Group 5 selection process will occur in December, 2012
• 3 to 4 applicants to be selected
• Group 5 will likely be the last group of onboarders selected that will receive free
technical assistance from Harris Corp.
Harris Capabilities Briefing
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PLU Application Types
Technical Assistance
Facilitated Registration (3 to 4 spots left)
Self-Onboarder (unlimited)
Software Package
Full Express Organization requires: • New MPI & RLS • Harris technical assistance for onboarding
Organization requires: • New MPI & RLS Organization will receive software package from Harris Corp. and follow instructional documentation to complete onboarding
Express Lite Organization requires: • Harris technical assistance for onboarding
Organization already has an internal MPI & RLS to be integrated with the Florida HIE
Organization already has an internal MPI & RLS to be integrated with the Florida HIE Organization will receive software package from Harris Corp. and follow instructional documentation to complete onboarding
Harris Capabilities Briefing
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DSM Registration Process
Harris Capabilities Briefing
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DSM Current Statistics
• All statistics through July, 2012
• Goal for end of 2012 is 1,000 registered accounts
Harris Capabilities Briefing
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Outreach Sub-Contracts
Total funding: $1.9M
Awarded to participating entities to develop the software interfaces or
other software necessary to develop downstream connections to
underserved entities and expand health care provider access to the state-
level HIE network for Patient Look-Up (PLU); and/or to assist participating
entities in deploying HIE, including Direct Secure Messaging (DSM)
services to underserved entities through outreach, technical assistance,
and provider training.
• Strategic Health Intelligence (SHI): $900,000
• Community Health Centers Alliance (CHCA): $500,000
• Health Management Association (HMA): $250,000
• South Florida Regional Extension Center (SFREC): $250,000
Harris Capabilities Briefing
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Florida HIE Sustainability
Janet Hofmeister
Harris Capabilities Briefing
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Value Proposition and ROI Tools
• Paper developed jointly by AHCA and Harris, also incorporating research done by the Center for
Information Technology Leadership (CITL) and tools first developed by the Iowa Office of Health
Information Technology (eHealth)
• Covers topics of:
• Services of the FL HIE
• Flexibility offered by the two services
• Methods of connection
• Retention of control of data by the providers
• Proposed costs for both PLU and DSM
• Methods employed to mitigate risk
• Strategy for outreach and adoption
• CITL basis for determining network value
• Return on Investment (ROI) model published by Iowa eHealth
• ROI Worksheets
• The following slides show the ROI calculation worksheets and put the value of the HIE into practical
terms
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Calculation of Return on Investment
• Included in the paper is a set of calculations around different costs that are
incurred by facilities from a sole practice to a large hospital system
• While it is easy to view ROI in terms of dollars and cents, we must always
remember that the true return is in improved care to the patient. Some of
these may include:
• Avoidance of drug interactions or allergies
• Convenience for the patient to have their records available when
needed
• Ease to an ill person of not having to do duplicative tests
• More timely care, less delay in diagnosis and onset of treatment
• Possible life saving treatment for an unresponsive patient
• We encourage both current and potential DSM and PLU to use these charts
to determine the costs to their organizations and what could be saved
should the FL HIE be implemented
Harris Capabilities Briefing
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EHR Interface Savings Calculator
• We provide an HIE for connecting
disparate systems
• By establishing one connection to
the FL HIE, providers can be
connected to many of their
partners at once
• This would eliminate the fee ($5K -
$40K) that is generally charged by the
EHR vendors to establish an interface
with each data trading partner
• PLU can connect to treating
partners such as hospitals,
physicians, & county health depts.
• DSM offers a means to obtain
structured data from labs and
others
Number of hospitals communicate
with:
Number of physician offices or
clinics communicate with: +
Number of laboratories
communicate with: +
Number of pharmacies
communicate with: +
Number of home health agencies
communicate with: +
Number of long-term care settings
communicate with: +
Total number of connections:
Average annual interface cost from
EHR vendor: X $
Cost without HIE: $
Annual cost of HIE: - $
Cost saving: $
Harris Capabilities Briefing
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Savings from Reduced Use of Paper Records
• Reduced expenditures required to
support a paper-based system,
including:
• paper supplies
• filing systems
• dedicated office space required to
store paper charts or reports
• HealthBridge, based in Cincinnati,
estimated a savings of $0.41 per
report with the elimination of
paper delivery of reports
• HealthBridge,
http://www.healthbridge.org
Square footage for record storage:
Rent per square foot: X $
Annual rent for record storage: $
Percent reduction in volume of paper
records after implementation: X
Annual storage cost savings: $
Number of reports per year:
Savings per report (costs of postage,
paper, printers and personnel, based
on detailed time and material
studies):
X $0.41
Annual delivery cost savings: $
Harris Capabilities Briefing
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Savings from using Electronic Patient Charts
Number of chart pulls each day:
Minutes spent per chart: X
Minutes spent pulling charts
each day:
Number of work days per year
(e.g. 250): X
Minutes pulling charts each
year:
Reduction in chart pulls or based
on post implementation study of
practice/facility:
X 35%
Time savings due to HIE
implementation (minutes):
Divide by 60 to determine time
savings in hours: ÷ 60
Time savings due to HIE
(hours):
Average hourly administrative rate: X $
Annual cost saving potential: $
• An alternative way to request and view
patient charts
• For example, providers can query the HIE to
view a patient’s Continuity of Care Document
(CCD) or send the CCD using DSM rather
than having to make a phone call to another
provider and request the patient chart be
pulled and sent via fax
• Journal of Healthcare Information Technology
estimates a 35% reduction in chart pulls in the
first year after EHR implementation (2006
article)
• George Washington University Medical
Faculty Associates estimated a first year
savings of $81,551 after factoring in staff time
for each chart pull
• Reference: Stephen Badger, Journal of
Healthcare Information Technology, Vol
19, No 2, 2006
Harris Capabilities Briefing
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Savings from using HIE instead of FAX
• Enables an alternative form of secure
communication between providers
using DSM or PLU
• Early results of University of Iowa
– Broadlawns Hospital HIE pilot
show the potential for a 40%
reduction in the amount of time
needed to process faxed health
information (e.g., average
handling time was reduced from
10 minutes to 6 minutes).
• Reference: University of Iowa
Hospitals and Clinics, email message
to Iowa e-Health, March 3, 2011
Items faxed per day, pre-
implementation:
Work days per year (e.g. 250): X
Items faxed annually:
Time to process each fax (in
minutes): X
Divide by 60 to determine time
spent processing faxes in hours: ÷ 60
Hours spent processing faxes
each year:
Reduction in time spent processing
faxes or based on post-
implementation study at facility,
health plan or practice:
X 40%
Hours saved from DSM and/or
PLU:
Average hourly administrative rate: X $
Annual cost saving: $
Harris Capabilities Briefing
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Savings from Reduced Readmissions
• We provide access to continuity of
care documents (CCD) and
hospital discharge summaries to
primary care providers through
PLU or DSM
• Recent study in Connecticut
estimates a 25% reduction in
potentially preventable
readmissions due to the
availability and use of an HIE
Number of admissions annually:
Percent of admissions that are
Potentially Preventable Readmissions
(PPRs):
X
Number of annual PPRs:
Percent reduction of PPRs due to HIE:
*Adjust for local DSM/PLU uptake:
Low, use 0-10%
Medium, use 10-20%
High, use 20-25%
X 25%*
Cost of an admission: X $
Cost savings potential $
Percent uncompensated care: X
Uncompensated cost saving: $
Harris Capabilities Briefing
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Savings from Reduced Emergency Room
Visits
• Access to continuity of care documents (CCD)
through use of PLU or DSM for referrals to
medical homes
• Boston Consulting Group estimated that
13% of repeat ED visits were potentially
avoidable
• The Wisconsin-Institutes for Discovery
reported a benefit to providers as well as
payers due to reduced expenditures on
Medicare and Medicaid patients that are
not fully compensated
• References:
• Boston Consulting Group, Rhode Island
Quality Institute: Business case for Health
Information Exchange, 2008.
• Srikrishna Sridhar, et. al., Optimizing
financial effects of HIE: a multi-party linear
programming approach, American Medical
Informatics Association, 2012.
Number of ED visits annually:
Percent of ED visits that are repeated: X
Number of repeat ED visits:
Percent reduction of repeat ED visits due to HIE: *Adjust for local DSM/PLU uptake:
Low, use 0-5% Medium, use 5-10% High, use 10-13%
X 13%*
Cost of an ED visit X $
Cost saving potential: $
Percent uncompensated care: X
Uncompensated cost saving: $
Harris Capabilities Briefing
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Expected Sustainment Costs
Total Estimated Sustainment Costs: $2,321,660
• Personnel - Technical (Tier 2 & 3), Management, Administration, Legal, Website
support, documentation updates
• Overhead - Office space, utilities, etc.
• Hardware - Computing, networks, security
• Software - License, maintenance, and certificate fees
• Training/Helpdesk - Tier 1 support, document and knowledge base updates
• Accreditation/Certification - Personnel HIPAA certifications
• Outreach and Technical Development - New capability implementation;
business outreach
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How much will it cost and who will pay
Harris Capabilities Briefing
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Allocation of the costs