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Health Information Exchange 101 Problem, Definitions, Value, Policy. David C. Kendrick, MD, MPH Asst. Provost for Strategic Planning OUHSC. National perspective. At >17% of GDP, healthcare costs - out of control

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health information exchange 101 problem definitions value policy

Health Information Exchange 101Problem, Definitions, Value, Policy

David C. Kendrick, MD, MPH

Asst. Provost for Strategic Planning


national perspective
National perspective
  • At >17% of GDP, healthcare costs - out of control
  • Value delivered is limited– US ranks below most industrialized nations on quality metrics, despite spending more
  • Healthcare IT - part of the solution – prioritized and funded
    • American Recovery and Reinvestment Act
  • Patient Centered Medical Home gaining as the delivery model of choice
healthcare reform likely possible
Healthcare Reform likely possible
  • Details change daily, but will probably might include
    • Coverage expansion for the uninsured, perhaps through a public plan or premium assistance programs
    • Emphasis on preventive care
    • More prominent role of the Patient Centered Medical Home
    • Emphasis on Healthcare IT
oklahoma is the only state where the death rate has gotten worse
Some Factors

Economic downturn healthy people and jobs left Oklahoma

Poverty remained

Heart Disease – (Diabetes)


Access to Care

Oklahoma is the only state where the death rate has gotten worse…..


Death Rates

Past 25 Years

what we can t do
What WE CAN’T Do
  • “Grow” more doctors quickly
  • Create new hospitals overnight
  • Force patients to:
        • Exercise
        • Stop smoking
        • Lose weight
what we can do
What We Can Do

Leverage Technology

  • Complex populations
  • Limited Resources:
    • Create a lean healthcare system
    • Improve Care Coordination
    • Business case for:
      • Funding
      • Efficiency
where to focus
Where to Focus?
  • Electronic Medical Records (EMRs) important, but . . .
  • Health Information Exchanges (HIEs)
    • immediate benefit and greater cost savings
  • Community-wide care coordination (CCC)
    • more benefit and cost savings
Physician Organization in Relation to Quality and Efficiency of CareThe Commonwealth Fund, April 2008

Evidence Increasingly shows that improved “systemness” drives quality and efficiency


a group of independent but interrelated elements

Designed to work as a coherent entity

where will there be savings
Where Will there beSavings?


From the Exchange of Clinical Information among care providers

Reduction in duplicate Dx procedures

Prevention of Medical Error


Center for Information Technology Leadership 2005

current situation
Current Situation

Hospitals (inpt)




Medical claims

Pharmacy claims

Case mgmt records


Doctor offices



Safety Net Clinics and community agencies




Case mgmt

Community outreach

Other PCPs


Manual connection (mail, fax)

Electronic connection


Ancillary care


Public Health

health information useful
Health Information - Useful

Available at the POS

Logically presented


Medicare patient - 5.6 providers/yr

(7.7 providers/yr including 2 PCPs)

Community Care Coordination

health information organization
Health Information Organization


Greatest Value Your Data is Local (CCC)

Business Model - Self Supporting


Quality, Safety & Efficient Delivery

Govern, Sets Rules

Statewide Network of Networks

Disaster Bioterrorism Public Health

National (NHIN)

scale state wide a network of networks
Scale State-wide: A Network of Networks
  • Local governance
  • Common technology
anatomy of a hie
Anatomy of a HIE

Patient Portal

Physician Portal

Population Care Analytics

Health Information Exchange

Medical Education

Electronic Master Patient Index

anatomy detailed version
Anatomy: Detailed Version
  • HIE - Central Data Repository for a core set of clinical variables
  • eMPI - Master Patient Index tracks unique patients and ensures data integrity
  • Community Order Entry/Physician Portal- Centralized system coordinating orders, referrals, consultations, radiology and diagnostic tests, PT/OT, etc.
  • Decision analytics - Tools and algorithms for patient identification, prioritizing patients for interventions, prioritizing appropriate interventions each patient
  • Patient Portal - gives patients access to their own community health records, ability to communicate with their providers:
    • eVisits, Schedule requests, Refill requests, Patient educational materials, Self-care logs (BP, BS, asthma, etc.), Health Risk Assessments (Depression screen, Cardiac risk), Review records shared across the community
  • Comprehensive clinical education support
    • Trainee portfolios, Evaluations, Delivery of relevant didactic educational materials
organizing the concepts
Organizing the Concepts
  • What is the relationship between Health Information Exchanges and the Patient Centered Medical Home?

Patient Centered Medical Home

Patient Centered Medical Home

Patient Centered Medical Home

Patient Centered Medical Home

Patient Centered Medical Home

Patient Centered Medical Home

Reimbursement Model

Health Information Exchange

Health Information Exchange

medical home hie
Medical Home & HIE

Fragmented Care

More patients

Complex populations

1in 4 - Behavioral Health Diagnosis

(Duals Drive cost )

Medicaid 46% Medicare 24%

Investing in the Aftermath vs Ahead of the curve

Resource Drain from Missed Early Opportunities

medical home goals
Medical HomeGoals

Integrated Systems

More Efficient Use of Resources

Identify & Prioritize patients for Intervention

(ahead of the curve)

Link Providers - Coordinate Care

Raise Quality - Evidence Based Guidelines

Identify Quality issues & Make Rapid Changes

have we given this any thought
Have we given this any thought?
  • 2004: Harvard Center for IT Leadership published a report on the value of health information exchange
    • $77B in annual savings through Health IT
    • Prompted, in part, the creation of the Office of the National Coordinator for Healthcare IT (ONCHIT), the Health IT “Czar”
  • 2006: GKFF commissioned an OK-specific evaluation of the value of HIE
  • Clinicians have incomplete knowledge of their patients
    • Relevant patient data not available in 81% of ambulatory visits Tang 1994
    • 18% of medical errors that lead to ADEs due to missing patient information. Leape JAMA 1995
  • Medicare patients see an average of 5.6 different providers each year= 5.6 silos of data
  • What is the value of HIE for Oklahoma and specifically for the Tulsa region?
hie expert panelists
HIE Expert Panelists
  • David Brailer, MD, PhD
    • Santa Barbara County Care Data Exchange, Health Technology Center
  • William Braithwaite, MD, PhD
    • Independent consultant, “Dr HIPAA”
  • Paul Carpenter, MD
    • Associate Professor of Medicine, Endocrinology-Metabolism and Health Informatics Research, Mayo Clinic
  • Daniel Friedman, PhD
    • Independent public health consultant
  • Robert Miller, PhD
    • Associate Professor of Health Economics, UCSF
  • Arnold Milstein, MD, MPH
    • Pacific Business Group on Health, Mercer Consulting, Leapfrog Group
  • J Marc Overhage, MD, PhD
    • Regenstrief Institute, Associate Professor of Medicine, Indiana University
  • Scott Young, MD
    • Senior Clinical Advisor, Office of Clinical Standards and Quality, CMS
  • KepaZubeldia, MD
    • President and CEO, Claredi Corporation
hie value construct
HIE Value Construct

Public Health Agencies



Providers Hospitals

Clinical Laboratories

Radiology Centers

Other Providers

hie value construct1
HIE Value Construct

Electronic submission of reportable conditions and vital statistics

Avoided ADEs, drug utilization savings, automated transaction sets

Public Health Agencies



Providers Hospitals

Avoided redundant tests, Electronic test ordering and results delivery

Electronic Rx, refills, interaction checking, adherence data

Clinical Laboratories

Radiology Centers

Electronic referrals, consultation letter delivery, chart requests

Avoided redundant imaging, Electronic imaging ordering and results delivery

Other Providers

what about funding
What about funding?
  • One time:
    • ARRA stimulus dollars
    • Other grants
  • Ongoing:
    • Business model must be developed
    • ROI by stakeholder will drive the business model
arra stimulus dollars
ARRA Stimulus Dollars

Washington, D.C.


Federal Agency Grants

State distributions


Heath Dept




opportunity stimulus package
Opportunity: Stimulus Package
  • Federal Agencies offering
    • $20B for healthcare IT, $3B short term and $300M immediately
    • $1B for comparative effectiveness research
    • $1.5B for community health centers
  • Much will be distributed through grant process
      • Will be highly competitive
      • Many other communities have been in this game for years
  • Our communities must
    • Be unified behind a well-developed plan of action
    • We must build the coalition now

Greater Tulsa Health Access Network

from the final arra in order to be eligible for stimulus grants
From the final ARRA:In order to be eligible for Stimulus Grants
  • Must be a qualified State-designated entity
    • Designated by State as eligible to receive awards
    • Non-profit entity
    • Clear objectives to use Healthcare information technology to improve care quality and efficiency through secure data exchange
    • Adopt non-discrimination and conflict of interest policies
    • Broad stakeholder representation on governing board
cms really wants emr and hie adoption
CMS really wants EMR and HIE adoption . . .

*Assume N=1,500 MDs, DOs, PAs, and NPs and 7 hospitals see Medicare patients

†Penalties for non-adoption not yet elaborated, but assume mirror bonuses

from the final arra regional organization must include
From the final ARRA:Regional organization must include
  • Providers, including those focused on low-income and underserved
  • Health plans
  • Patient and consumer organizations
  • HIT vendors
  • Healthcare purchasers and employers
  • Public health agencies
  • Universities
  • Clinical researchers
  • Other staff who use HIT
national meaningful use guidance
National: Meaningful Use guidance
  • In order to qualify for bonus payments (and avoid penalties)
    • By 2011, the following must be exchanged:
      • Doctors: Problem lists, medication lists, allergies, test results
      • Hospitals: Discharge summaries, procedures, problem lists, medication lists, allergies, and test results
    • By 2013, the following must be exchanged:
      • Doctors: Share all care transition data across the community electronically
      • Hospitals: Share all care transition data electronically