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Trends in Health Information Exchange and Implications for Public Health. June 12, 2013. The inverse-square law of health information exchange. HIE is maturing. HIE 1.0. hie 2.0. Focused on “the noun ” Assumed hierarchy of HIEs

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hie is maturing
HIE is maturing

HIE 1.0

hie 2.0

  • Focused on “the noun”
  • Assumed hierarchy of HIEs
    • State- and regional-level HIEs feeding into a National Health Information Network
  • Assumed repository-style architectures with rich applications
  • Focused on “the verb”
  • No organized hierarchy of HIE organizations
    • No “National Network”
    • State-level HIEs highly varied and locally driven
    • Greatest growth in “private HIEs”: vendor- and ACO-driven
  • Wide variety of integration approaches
what is driving this transition
What is driving this transition?
  • Limited successes of the prior model
  • Bottom-up demand -- systems are not interoperable because not enough customers asked for interoperability
    • Meaningful Use incentives
    • Value-based purchasing
    • Market expectations about standards of care
    • Younger provider expectations about use of technology
    • Consumer expectations about use of technology
  • Supply-side
    • EHR certification requirements – common denominator important in a fragmented industry
    • Technology advancements in cloud services, mobile, broadband, storage, patient-matching capability, etc
hie building blocks
HIE Building Blocks

Business models

HIT/HIE Uses

Functional requirements

Enterprise Integration & Management

Business process harmonization

Population, Risk, and Financial Management

Content and vocabulary standards

Documentation standardization

Analytics definition synchronization

Measurement & Reporting

Case management and patient access

Patient-matching

Medical record indexing

Consent management

Data access and use contracts

Clinical portals (patient/provider)

Registries & Repositories

MU capability

Cross-system query

Accountable care capability

Interfaces to connecting systems

Security and transport standards

Physician/facility directory

Message & document delivery

EHR functions

Amount of central orchestration required

data needs vary with business goals
Data Needs Vary With Business Goals

Enterprise Integration & Management

  • Business integration

Population, Risk, and Financial Management

Population, Risk, and Financial Management

  • Business alignment
  • Team-based care
  • Patient engagement

Measurement & Reporting

Case management, and patient access

Case management & patient access

Case management & patient access

Case management & patient access

  • Performance mgmt
  • Population mgmt
  • Utilization mgmt
  • Case facilitation

Registries & Repositories

Registries & Repositories

Registries & Repositories

Cross-system query

Cross-system query

Cross-system query

Message & document delivery

Message & document delivery

Message & document delivery

Message & document delivery

  • Become electronic
  • Fill in gaps in care transitions

EHR functions

EHR functions

EHR functions

EHR functions

Independent actors

IPA/PHO

Accountable care entities

IDN

h ie 2 0 comes in many shapes and sizes
hie 2.0 comes in many shapes and sizes

National level collaborative HIE organizations (e.g., Healtheway)

State-level and regional collaborative HIE organizations

Transaction-specific national level (e.g., Surescripts)

Level of external coordination needed

Level of highest growth

Enterprise-level HIE organizations (e.g., “private HIEs”)

Vendor-specific (e.g., Epic, eClinicalworks)

Point-to-point (e.g., LabCorps, hospital labs)

Point-to-patient

hie 2 0 comes in many shapes and sizes 2
hie 2.0 comes in many shapes and sizes (2)

Visual integration

Data integration

Document integration

  • Ability to export and import structured data
  • Incorporate in EHR and usable for all EHR analytic and decision support functions
  • Ability to export and import clinical documents
  • Attach to patient record and viewable
  • Ability to provide view into another clinical system at point-of-care
  • No exchange of data or documents

Growing rapidly and likely to increase even more with maturation of directed exchange capabilities

Growing increasingly common to solve immediate need without interfacing and application workflow redesign

  • Essentially not happening, except:
    • Specific transaction streams such as eRX and labs
    • Within EHR network, such as Epic and eCW
    • Sophisticated implementations such as Healtheway
national level hios are most comprehensive hie implementations but still quite thin
National-level HIOs are most comprehensive HIE implementations, but still quite thin
  • Over 20 participants (4 federal) as of September 2011
  • Over 90,000 transactions conducted
  • HIE solution based on NHIN standards enabling send/receive and query/retrieve
  • DURSA covering complete set of exchange patterns
  • Five provider organizations (Geisinger, Kaiser, Mayo, Intermountain, Group Health)
  • Complete solution based on NHIN standards enabling send/receive and query/retrieve
state level collaborative hie activity high in certain areas
State-level collaborative HIE activity high in certain areas

Directed transactions

Query transactions

14 million directed exchanges per month

3.2 million directed exchanges per month

42 remaining HIE activities had fewer than 1,000 monthly transactions

200K+ directed exchanges per month

37 remaining HIE activities had no query-based transactions

Source: ONC HIE Dashboard

ehr vendors with high penetration generating large amount of vendor specific hie traffic
EHR vendors with high penetration generating large amount of vendor-specific HIE traffic
  • Large majority of customers (200+) participating in query-based exchanges
  • Currently CCD/CDA query-based exchange is ~2.2 million records for ~385K unique patients per month
  • Volume doubled over previous year
  • Does not include HL7 directed exchange transactions
  • 16,743 providers using query-based exchange
  • ~2.5 million new CCD records made available on query exchange hubs or sent directly to referral providers per month
  • Processed over 75+ million lab result records in 2012
  • ~1.5 million query-based exchanges per month
  • ~58.5 million directed exchange transactions per month (including HL7 lab result delivery)

Source: Epic, eClinicalWorks, Cerner

lab market is highly fragmented
Lab Market Is Highly Fragmented

116,634 physician office laboratories

  • Fragmentation may be increasing as hospitals increase lab business to offset revenue decreases in other areas
  • Fragmentation makes it difficult to generate collective action for a national lab network like Surescripts
  • Meaningful Use is the only industry-wide force driving standardization of lab results delivery
  • High fragmentation of lab market makes it difficult to measure progress of electronic transactions
  • ONC is now fielding national lab survey

5,604 commercial labs

  • Quest: ~30%
  • LabCorp: ~20%
  • Only Quest and LabCorp cover the entire US
  • Next largest, Spectra, covers 1/3 of US counties and county-equivalents

8,807 hospital labs

% of labs conducted

Source: Quest Diagnostics 2009 Annual Report; CMS CLIA Update July 2012

large fraction of lab results delivery still via fax and paper
Large fraction of lab results delivery still via fax and paper

% lab electronic lab results

  • Progress in electronic results delivery tied to EHR penetration
  • Interface implementation is significant barrier to progress – lack of standardization and competing priorities
  • MU Stage 2 may not be enough of a spur to significantly increase electronic delivery from hospitals – does not require electronic delivery and standardization of electronic delivery is menu set item

Paper/fax delivery

HL7 interfaces

~585 million lab results delivered by Cerner customers per month

Source: Cerner Corporation

large fraction of lab results delivery still via fax and paper1
Large fraction of lab results delivery still via fax and paper

% lab electronic lab results

  • athenahealthhas unique data because they track ALL lab result reports delivered to their customers
  • Small number of labs account for majority of electronic results
  • Effort required for interface deployment is barrier both on the lab side as well as on EHR vendor side
  • athenahealthcompleting about 15 new lab interfaces per month
  • Large practices have higher lab interface rate (68%) than small practices (56%) who get lower priority from labs -- commercial labs do not cover cost of interfaces to small practices
  • Not interfaced with ~6800 labs
  • ~3,400 fax
  • ~3,400 paper, portal, etc

HL7 interfaces with ~600 labs

Analysis of 29 million lab result records received by athenahealth customers

Source: athenahealth

large gap in loinc mapping capabilities
Large gap in LOINC-mapping capabilities

% LOINC-encoded labs

  • Vast majority of labs do not send LOINC-encoded results
  • 1 national lab does, another national lab can but currently does not because has not been asked to
  • Large commercial labs capable of LOINC-encoding, however, vast majority of hospitals are not and will take significant effort to get them there
  • MU Stage 2 may not provide enough of a spur given difficulty of effort, allowed variation in state public health requirements, and competing priorities

~599 labs send results with proprietary codes

Only 1 lab sends LOINC-encoded results

Analysis of 29 million lab result records received by athenahealth customers

Source: athenahealth

hie activity mushrooming across the region
HIE Activity Mushrooming Across the Region

VITL

NH-HIO

North Adams

Newburyport

NYeC

Winchester

Beverly

Emerson

Holyoke

Berkshire

Health

NEHEN

Baystate

SafeHealth

South Shore

Sturdy

RIQI

Cape Cod Health

slide17

MassHealth

DPH

Current state of the market favors a network of networks connected via a single statewide open HISP supported by centralized project managementIllustrative example

BIDMC

Partners

NwHIN

Berkshire Health System

EOHHS

NEHEN

Direct gateway services

PKI/certificate mgmt

Web

portal

Provider/entity

directory

Audit

log

Atrius

SafeHealth

MD

MD

MD

MD

MD

MD

MD

Fallon Clinic

UMass Memorial

MD

MD

MD

data aggregation process steps
Data Aggregation Process Steps

Data requirements

Clinical sources

Transport

Management and analysis

Reporting and data access

H

RX

Labs

Vitals

Problems

Patient

Provider

Payer

etc

H

H

H

MDs

MDs

MDs

MDs

Remediation and Improvement

  • Key questions:
  • How well-defined are reporting/analysis needs, and corresponding data requirements? Will source-level remediation be required?
  • How many clinical sources will be included? What is integration strategy and timeline for disparate EHR systems?
  • Which transport option? What are pros/cons of each?
  • Are there unique data management and analysis requirements?
  • Who will be accessing reports and data? Are there unique reporting and/or data access requirements?
  • How will reporting/analysis integrate with business and care processes?
bidco qdc
BIDCO QDC

Cumulative records 2013 YTD (828,339)

  • Electronic reporting
  • MU, PQRS, AQC, etc

576,765

  • Data management
  • Report viewing
  • Case tracking

BIDCO

QDC

  • Data extraction
  • Queries
  • Pre-defined data marts

231,218

  • Current status:
  • 5,611,698 care event C32 records
  • Covers 614,829 unique patients
  • Covers 2,506 unique providers
  • Management Info System
  • User information
  • Utilization analysis
  • Other

20,356

Documentation & Extraction

Transport

Validation & Analysis

User Access

ahi qdc

Cumulative records 2013 YTD (278,587)

AHI QDC

31,504

84,507

  • Data management
  • Report viewing
  • Case tracking

Pod 1

50,416

87,934

AHI

QDC

  • Data management
  • Report viewing
  • Case tracking

Pod 2

13,061

  • Current status:
  • 760,923 care event C32 records
  • Covers 155,740 unique patients
  • Covers 300+ unique providers

Pod 3

11,165

  • Data management
  • Report viewing
  • Case tracking

Documentation & Extraction

Transport

Validation & Analysis

User Access

implications for public health
Implications for Public Health
  • Heterogeneity will be the hallmark of HIE activity in the coming years
  • Multi-layered HIE modes seem to be developing as business practices mature
    • “B2B”-style patterns to move documents around with little to no centralized coordination – Direct and Directed Query
    • “Supply-chain” style patterns with deep integration among very closely aligned entities seeking centralized orchestration for rich applications to support complex uses
  • Aggregation at the edge
    • HIE as conduit for aggregation rather than as repositories themselves
  • Alignment with Meaningful Use
    • MU Stage 2 includes higher standards for clinical content
    • Aligning with and/or “piggy-backing” on MU and ACO capabilities is most likely path to scaleable model for rich, longitudinal data to meet variety of public and population health purposes
www maehc org micky tripathi phd mpp president ceo mtripathi@maehc org 781 434 7906
www.maehc.orgMicky Tripathi, PhD MPPPresident & CEOmtripathi@maehc.org781-434-7906