Agenda

1. Technology Models for Building Health Information Infrastructure IJohn LightfootVP TechnologyHealthvision, Inc.jlightfoot@healthvision.com

2. Agenda • Value of Health Information Interoperability • How does a community get there? • Real-life RHIO example • Technology Models • Standards • Challenges for a National Model

3. Value of Healthcare Information Exchange and Interoperability (HIEI): CITL Key Findings • Standardized, encoded, electronic healthcare information exchange would: • Save the US healthcare system $337B over a 10-year implementation period • Save $78B in each year thereafter • Total provider net benefit from all connections is $34B • Net benefits to other stakeholders: - Payers $22B - Pharmacies $1B - Laboratories $13B - Public Health $0.1B - Radiology centers $8B • Dramatically reduce the administrative burden associated with manual data exchange • Decrease unnecessary utilization of duplicative laboratory and radiology tests

4. CITL HIEI Taxonomy

5. Annual Net Return after Implementation Net Return over 10-year Implementation Level 2 $22B $141B Level 3 $24B -$34B Level 4 $78B $337B Value of HIE standards is the difference between Level 3 & 4 HIEI National Net Cost-Benefit

6. $400 $300 Level 1 Level 2 Level 3 $200 $100 $- 0 1 2 3 4 5 6 7 8 9 10 $(100) $(200) Years 10-Year Cumulative Net Return by HIEI Level in billions Level 4

7. Patient-centric design Disparate IT systems are unified through a shared information architecture Collaborative Care Model All providers have access to complete, up-to-date patient information Patient Centric Database Technology Infrastructure The Connected Healthcare Community Diagnostic Labs Pharmacies Hospitals Patients Managed Care Physicians & Staff

8. How does a community get there? Four Step Process

9. Strategic Planning • Governance • Funding Models • Information Systems Strategy • Information • Systems Strategy • e-health Interoperability Platform • Implementation / Integration Services • Application / ASP / Service Delivery • Implementation / Integration Services • Application / ASP / Service Delivery • Connecting Hospitals, Labs, Pharmacies • Connecting Physicians • Connecting Patients • Ongoing Training & Support • Office Workflow Optimization • Benefits Analysis • Trading Partner Management Phases

10. Imagine . . . . • Connecting 8 competing hospitals, 2 competing reference labs, and thousands of physicians and pharmacies to build an entire community’s shared patient record • Providing an entire care team (primary care physicians, specialists, nursing staff and hospital staff) access to an integrated patient record view • Viewing historical and codified lab data from multiple labs (reference, in-patient and ambulatory) • Delivering comprehensive current problem lists and allergies to the point of care • Having access to a patient’s medication history and knowledge tools that check allergy and drug to drug to reactions • Driving formulary compliance on prescriptions and lower cost substitutions for high prescribing physicians that save the community as much as $15,000 per physician per year • Providing a community infrastructure that supports EMR interoperability so that physicians with different IT systems can share relevant patient information among them • Implementing all of this within a 3–6 month timeframe

11. Reality • Taconic IPA (Mid-Hudson Valley, NY) has established an operating RHIO • 1000+ current users (400 physicians) using a shared data exchange • 4 Hospitals, 2 Reference Labs (LabCorp and Quest) connected • EMPI established to handle person identity resolution • System live and users trained within 90 days of project kickoff • Data Exchange (Connectivity) • CDR – Shared Patient Record • Community Portal (Physician View) • EMPI – Person Resolution • eResults Software Applications • 18 Hospital and Lab interfaces • 3 EMR vendors (Allscripts, NextGen, GE) agree to interoperability w/ CCR and HL7 Data Exchange • Contract Signed on October 1, 2004 – system live and users trained December 31, 2004.

12. “Stunning” Interoperability

13. Technology • Delivered via an ASP model • IBM servers on Intel architecture • Portal built on a Microsoft platform • Windows Server 2000/2003 • Internet Information Server • SQL Server 2000 • Data exchange and routing via Cloverleaf interface engine • EMPI services provided by Eclipsys • Clinical vocabularies and libraries from IMO, Multum, Healthwise and others

14. Healthvision - Scale • 1000+ hospitals utilize servers daily • Manage a Microsoft environment of approx 250 servers • Platform database grows 12-15% per month and currently is approx 2 TB in size • Over 8 million unique patients in database • Interface Engine processes approximately 310,000 clinical transactions per day • Support 2.0 Million+ unique users/month • Over 11.7 TB per year in network traffic

15. Technology Model • Regional Clinical Data Repository • Longitudinal patient record across all systems • Reference pointers back to images and documents • Single sign-on to third party systems • CCOW support • Intelligent routing of HL7 and CCR data to EMRs • Record Locator Service to find national records • National exchange of clinical data among RHIOs

16. Clinical Advantages of a Regional CDR • Effective re-use of clinical data • Codified data for reporting, graphing, and clinical decision support • Ongoing surveillance • Hazardous conditions • Missed disease management opportunities • Potential errors • Adverse effects • Automatic alerts to providers • Data from multiple sources combined • Clinical alerting rules run across combined data

17. Clinical Advantages of a Regional CDR • Longitudinal, patient-centric view • Multiple providers in multiple locations easily share data from multiple systems • Proven physician and staff acceptance

18. Technical Advantages of a Regional CDR • Centralized security access model for easier management of access to protected health information • Time to market • Common data framework • Common configuration tools • Common implementation process • Reusable interface libraries • System performance and reliability • End user not waiting while multiple systems are queried • Easily scalable with increased number of source systems and users

19. Technical Advantages of a Regional CDR • Easy to integrate new modules • Applications leverage a common set of clinical data and system services • Not dependent on source system availability • Easy to provide redundancy and eliminate single points of failure • Person resolution complexity • Fully decentralized system requires matching patients across multiple systems in real time • Allows timely human resolution of ambiguous matches

20. Technical Advantages of a Regional CDR • Standard legacy system interfaces • HL7 and now CCR • Takes advantage of built-in interface capabilities already built in to most clinical information systems • Centralized security model • No need to provision multiple individual systems

21. Standards • In order to deliver interoperability, adherence to standards is key • HL7 for registration and results exchange • CCR for visit snapshot • ICD9 for problems • CPT for procedures • NCPDP for pharmacy • X.12 for eligibility and billing • Problem with standards is definition • HL7 too loose • CCR doesn’t define vocabularies

22. Healthvision Interoperability platform

23. Challenges to a national model • Scalability • Can systems scale from a few million patients to a few hundred million? • Identity resolution • How do you quickly resolve patient identity across systems nationally? • Privacy concerns over a national patient identifier • Security model • How do you know who should get access to what data on a national level?

24. Questions or CommentsJohn LightfootHealthvision, Inc.jlightfoot@healthvision.com(972) 819-4353 Thank You!