Interoperability: A Non-Technical Perspective Challenges in Healthcare and American Idol Today

1. Interoperability: A Non-Technical PerspectiveChallenges in Healthcare and American Idol Today Mark Refowitz 8th Annual CA Information Mgt. Conference April 10,2008

2. What do Interoperability and American Idol have in Common? • Cool sounding terminology: HL7, XML, DICOM, ASC-X12, ICD-9 v. “You are the bomb”, “Dawg:That was hot!” • Need for standards at their core • Need for agreement on standards • Voting to reach consensus • Technical and Subject Matter Experts

3. Interoperability • Definition: In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged. (National Alliance for Healthcare Information Technology)

4. Idol Interoperability • Working together to foster a hit TV Show

5. Interoperability - Levels • Non-Electronic: Paper, Mail, Phone Call • Machine Transportable: Fax, E-Mail • Machine Interpretable: Structured Messages and Standardized Content

6. American Ideal Levels • Auditions • Make it to Hollywood • Top 24 • Top 10-American Idol Tour • 10, 9, 8, 7 ……… • Finalists (last two standing) • American Idol

7. Interoperability-Can Be Achieved • Worldwide Network of International Banking • ATM Networks • Debit Cards • Credit Cards • Portability of credit and finance in all areas of commerce

8. Contrast Internet Banking and…

9. Universal ATM Access, With…

10. This:

11. “Paper Kills” (and wastes) • Inevitable human errors are not prevented; people die. • 20% of labs and tests ordered b/c previous results can’t be found. • Filing, retrieving, faxing, moving paper costs billions. • Difficult to get data for research and reporting.

12. Challenges in Healthcare • No definitive agreement on standards • Realities of the “marketplace” • Medical Care delivered by multiple providers • No single format for medical records • Multitude of software applications used to assist in the delivery of care • Consumers are mobile • Security and Privacy Concerns • Government Regulations

13. Challengers in AI-7

14. The current state-of-the-art? “It was just common sense. A local Blue Plan sent brown paper bags to its members. The idea was for them to put all their prescription drugs, over-the-counter medications and herbal supplements in it. People then took the bags to their doctors….” -- Ad in New York Times, 1/12/05

15. To move beyond the paper bag • Get IT into physicians and consumers hands • Create the networks to allow information sharing • Achieve ironclad security and privacy • Ensure that new capabilities are used to improve quality, safety, and efficiency

16. Interoperability Goals in Healthcare • Longitudinal electronic medical record with full information about each patient • Access to information by consumers that would allow them to better understand and improve their health status • EMR will make it easier for consumers to move between and among providers • Improve care by reducing errors and duplication through HIE

17. Murphy-Kennedy 21st Century Health Information Act • Bring stakeholders together for collaborative solutions • Establish ground rules for interoperability • Spur regional solutions from the ground-up • Change systemic dynamics Goal: Sustainable, secure, interoperable health information networks with broad provider participation and the capacity to transform the practice of medicine

18. We need consumers and providers involved

19. How do we link all of these different systems? How do we secure transmissions among over the internet? How do we identify the different 200 Mary Chavezes living in the state of California? How do we eliminate duplicates? How do we combine clinical data from two patients that appear distinct but are the same? How do we handle 5,000-100,000 inquiries a day? How do we view the data? What clinical data do we want to display? How do we normalize laboratory data from different labs? How do we combine problem lists from various institutions? How do we develop a system robust enough to display large MRI records? How do we assure that allergies are correct? How do we know if the list of medications is current or old or whether the patients actually took them or not? How do we capture immunizations from various providers? How do we organize documentation? How do we filter documentation by specialty? How do we obtain nonstandard clinical studies? How do we lock confidential-sensitive data such as HIV status, psychiatric history, sexually transmitted diseases, pregnancies, and abortions? What standards do we employ? How do we authenticate bona fide users? Just a Few Questions

20. How do we let patients view their own data? How do we prevent intrusion by hackers and viruses? What do we do about HIPAA? What type of business agreements are needed? How should the governance be structured? Who gets a seat at the Board of Directors table? How do we deal with government regulation? Who should be included as partners? Do we include health plans, and if so, which ones? What clinical practices do we include? What do we do with clinical practices that do use an electronic medical record? Where do we draw the line on interfacing to one-of-a-kind, small practice EMRs? How do we capture lab tests done in physicians’ offices? How do we pay to establish the system? How do we pay for sustaining the system? How do we do clinical research and obtain patient consent? Do we need a data repository for research? How do we apply decision support without having a data repository? Just a Few More Questions

21. Architecture Master Patient Index Master Interface Engine Institutional Interface Engines Web Results Viewer Scalable Applications Data Elements Demographics, Problem List, Diagnoses, Lab, Radiology, Medications, Allergies, Immunizations, Documentation, Admission, Discharge, Outpatient, ED Other Clinical Studies: EKG/Echo, PFTs Insurance How to block confidential/ sensitive data: HIV, Psych, STDs Decision Support Standards: HL-7, XML, SNOMED, LOINC Security Secure data transmission User authentication: passwords, biometrics Patient authentication Hackers/Virus Legal and Regulatory Business Agreements, HIPAA Governance Government Entity, University, 501c3 Board of Directors – who gets a seat? Partners Health Plans, Labs, Insurers/Payers Patients Hospitals For Profit, Non-Profit Providers, Clinical Practices Small, Medium, Large Funding Initial – proof of concept vs. sustainability Research Health Services, Public Policy Connecting Clinical DataIssues that need to be addressed

22. Payers Hospital Health Information Exchange Labs Data repository Network applications Outpatient RX Physician office Ambulatory centers Public health “Wiring” Healthcare Current system fragments patient information and creates redundant, inefficient efforts Future system will consolidate information and provide a foundation for unifying efforts Hospitals Public health Primary care physician Laboratory Pharmacy Specialty physician Payors Ambulatory center (e.g. imaging centers)

24. Data management Data access and use • Results delivery • Secure document transfer • Shared EMR • Credentialing • Eligibility checking Payers Hospitals Hospital • Results delivery • Secure document transfer • Shared EMR • CPOE • Credentialing • Eligibility checking Health Information Exchange Physicians Labs • Results delivery Labs Data repository Network applications Outpatient RX • Surveillance • Reportable conditions • Results delivery Public health Payer • Secure document transfer Payer Physician office Ambulatory centers Public health • De-identified, longitudinal clinical data Researchers Data Reuse

25. IT has the power to transform health care • Enables comprehensive patient information at the point of care. • Enables clinical decision-support to improve care. • Enables efficiencies in administration. • Enables empowerment of patients. • Enables tremendous new research capabilities. • Enables robust public health surveillance. • Enables robust and streamlined quality reporting.