1. Health Information Exchange: Value, Incentives, and How to get there. David C. Kendrick, MD, MPH Asst. Provost for Strategic Planning, OUHSC Medical Director for Community Medical Informatics OU School of Community Medicine Greater Tulsa Health Access Network

2. Agenda HIE Ongoing benefits: Value aside from ARRA – Financial – Clinical New, one-time opportunities: ARRA Incentives in Oklahoma Terms How do we get there?

3. National perspective At >17% of GDP, healthcare costs have grown out of control The value delivered is limited– US ranks below most other industrialized nations on most quality metrics, despite spending more Healthcare IT has been recognized as a part of the solution– and now is prioritized and funded – American Recovery and Reinvestment Act

4. 2007 COMMONWEALTH FUND Report State Scorecard Summary of Health System Performance

6. 2009 State of the State’s Health Summary

7. Oklahoma is the only state where the death rate has gotten worse….. Some Factors 1.Economic downturn  healthy people and jobs left Oklahoma 2.Poverty remained 3.Heart Disease – (Diabetes) 4.Cancer 5.Access to Care 6.Obesity Age-adjusted Death Rates Past 25 Years

8. Current Situation Payers Demographics Medical claims Pharmacy claims Case mgmt records Payers Demographics Medical claims Pharmacy claims Case mgmt records Doctor offices EHR Claims Rx Case mgmt Community outreach Rx Imaging Hospitals (inpt) ER/UC Public Health Other PCPs Specialists Ancillary care PT/OT/Aud/Diet Ancillary care PT/OT/Aud/Diet Labs Manual connection (mail, fax) Electronic connection Safety Net Clinics and community agencies Patient

9. Where to begin? Cannot quickly “grow” more doctors Cannot make new hospitals appear Cannot force our patients to exercise, stop smoking, and lose weight Must make the best use of limited resources: – Leverage technology to create a lean healthcare system – Must build the business case for funding this effort Focus: – Electronic Medical Records (EMRs) are important, but... – Health Information Exchanges (HIEs) provide immediate benefit and greater cost savings – Community-wide care coordination will provide yet more benefit and cost savings

10. Definitions: EMR vs. HIE vs. HIO vs. CCC HIE

11. Scale State-wide: A Network of Networks Common technology Local governance

13. Anatomy of a HIE Health Information Exchange Electronic Master Patient Index Population Care AnalyticsPatient PortalPhysician Portal Medical Education

14. 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 for coordinating orders of all types, including referrals, consultations, radiology and diagnostic tests, PT/OT, etc. Decision analytics- Tools and algorithms to assist with patient identification and prioritization of patients for interventions, and for each patient, prioritization of appropriate interventions Patient Portal- To give 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

15. What’s the value of HIE? 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

16. Motivation 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?

17. 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 Kepa Zubeldia, MD – President and CEO, Claredi Corporation

18. HIE Value Construct Providers Hospitals Pharmacies Radiology Centers Other Providers Public Health Agencies Payers Clinical Laboratories

19. HIE Value Construct Providers Hospitals Pharmacies Radiology Centers Other Providers Public Health Agencies Payers Clinical Laboratories Avoided redundant tests, Electronic test ordering and results delivery Avoided ADEs, drug utilization savings, automated transaction sets Avoided redundant imaging, Electronic imaging ordering and results delivery Electronic Rx, refills, interaction checking, adherence data Electronic submission of reportable conditions and vital statistics Electronic referrals, consultation letter delivery, chart requests

20. Provider Value by Stakeholder: Tulsa Providers Hospitals Pharmacies Radiology Centers Other Providers Public Health Agencies Payers Clinical Laboratories $24 $28 $4.4 $2.8 $11 $32 $33 $0.39 $33 $38 $ Millions

21. Provider Value by Stakeholder: Tulsa Providers Pharmacies Radiology Centers Other Providers Public Health Agencies Payers Clinical Laboratories $24 $28 $4.4 $2.8 $11 $32 $33 $0.39 $33 $38 $ Millions Adverse Drug Event (ADE) Clinical Results Per Physician Tulsa Preventable ADEs Avoided8.96,300 Preventable life-threatening ADEs Avoided0.59420 Avoided ADE-related visits5.64,000 Avoided ADE-related hospitalizations0.82580

22. Provider Value by Stakeholder: Oklahoma City Providers Hospitals Pharmacies Radiology Centers Other Providers Public Health Agencies Payers Clinical Laboratories $30 $35 $5.4 $3.4 $14 $0.48 $39 $45 $ Millions

23. Provider Value to Oklahoma Providers Hospitals Pharmacies Radiology Centers Other Providers Public Health Agencies Payers Clinical Laboratories $99 $116 $16 $10 $39 $127 $136 $1.5 $123 $141 $ Millions

24. Provider Value by Stakeholder: Oklahoma Providers Hospitals Pharmacies Radiology Centers Other Providers Public Health Agencies Payers Clinical Laboratories $99 $116 $16 $10 $39 $127 $136 $1.5 $123 $141 $ Millions Adverse Drug Event (ADE) Clinical Results Per Physician Oklahoma Preventable ADEs Avoided8.925,000 Preventable life-threatening ADEs Avoided0.591,700 Avoided ADE-related visits5.616,000 Avoided ADE-related hospitalizations0.822,300

25. Net value of HIE Implementation Years 1-10 Annual, Steady-State Starting Year 11 Benefit$ 1.6 Billion$ 250 Million Cost$ 0.7 Billion*$ 42 Million* Net Value$ 0.9 Billion$ 210 Million *Software as a service, Cloud computing, and Interoperability standards have lowered the cost of implementation and maintenance by an order of magnitude Implementation Years 1-10 Annual, Steady-State Starting Year 11 Benefit$ 6.4 Billion$ 990 Million Cost$ 2.7 Billion*$ 160 Million* Net Value$ 3.7 Billion$ 830 Million Implementation Years 1-10 Annual, Steady-State Starting Year 11 Benefit$ 2.0 Billion$ 310 Million Cost$ 1.1 Billion*$ 71 Million* Net Value$ 0.9 Billion$ 240 Million Tulsa: Oklahoma City: Oklahoma:

26. But wait, there’s more... CMS and Medicaid Incentive payments for “Meaningful use of an EHR”: – $44,000 to Medicare providers, $63,000 to Medicaid – Formula-driven bonus to hospitals: $2-11M per hospital What does this mean to OK? – Assume 9,000 MD’s, DO’s, PA’s, NP’s are eligible – Assume the following hospital bed distribution: FacilityAdmissionsBeds Less Than 50 =8051,0602,074 From 50-199 =51146,8854,595 From 200-399 =9223,1542,555 400 or more =6157,0883,250 146STATE TOTALS578,18712,474

27. CMS wants EMR and HIE adoption... *Assume N=9,000 MDs, DOs, PAs, and NPs focused 30% of the time on Medicare patients, and 12,474 hospital beds

28. 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

29. 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

30. Beyond incentives Federal Agencies offering – $20B for healthcare IT – $17B for Medicare and Medicaid incentives – $3B short term and $300M immediately 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 state plan of action – We must build that plan of action now

31. HIE Progress to date Early summer: Small working group met and produced a document: – Outlined 14 “Items for consideration” July 30 th : Major stakeholder’s meeting. ~35 people – Reduced “Items for consideration” from 14 to only 3: Meet requirements established by Federal legislation for funding Establish planning process, including HIT Policy Committee Identify the State Designated Entity – Agreed that OHCA could be the temporary custodial State Designated Entity until the planning process is complete or October 16, whichever comes first. August 14: OKHITECH Summit held, wide invitation list, comments and feedback sought August 14-21: Online comment period August 20: State HIE Cooperative Agreement Program (SHIECAP) Released

32. State HIE Cooperative Agreement Program (SHIECAP) Governor must identify State Designated Entity Each applicant must have a State Coordinator for Healthcare IT Focus: State Strategic Plan and Operational Plan States without plans can spend as much as 6 months on a planning process Applicants who fail to submit acceptable plans will be subsumed into other nearby states

33. State HIE Cooperative Agreement Program (SHIECAP) Approval: Merit-driven Funding: (mostly) Formula-driven – $4M base for 50 successful applicants – Additional funding up to $36M per applicant apportioned thusly: applicant region‘s population (5%), number of PCPs (40%), Acute Care Hospitals (30%), and Medically Underserved and Rural Providers (25%). A final 10% of the total funds will be apportioned based on an assessment of the relative HIT need of the region, as determined by evaluation of the Letter of Intent. – Oklahoma’s likely take: $6-8M

34. Deadlines and current status September 11: Letter of Intent Due – State Designated Entity- Done, at least temporarily – Review of existing capabilities statewide – Report of total expenditures to date in 5 key areas October 16: Final application due – Details of planning process – Key individuals identified to execute the process December 15: Award announcements January 15: Work begins

35. Thanks! David-Kendrick@ouhsc.edu

36. Potential Model 1: Government Lead HIE

37. Potential Model 2: Public utility with State oversight

38. Potential Model 2: Common technology Local governance