1. NewYork-Presbyterian System SelectHealth – an HIV Special Needs Plan (SNP) The Challenge.... 1400 people living with HIV and receiving care from a multitude of different providers, institutions, and agencies unstable housing, complex co-morbidities (mental health, chemical dependency, HCV) result in care and services routinely being provided in a critical ‘information vacuum’ HUGE opportunity to do better, to reduce errors, to effect improved care coordination! The Solution (?)…. “My Health Profile” Adopt an evolving standard for Health Information Exchange, the Continuity of Care Record (CCR), for all individuals Provide easy access for patients, their designees, and their providers Utilize Health Information Exchange network(s) as the ‘backbone’ of the overall program

2. NewYork-Presbyterian System SelectHealth Core Elements of CCD CCD Identifying Information Patient’s Health Status Diagnoses Medications Laboratory results Procedures/Imaging Allergies/adverse reactions Social history/Family history Advanced Directives/Life Documents Care Documentation Practitioners PI - Peter G. Gordon, MD & Co-PI - Eli Camhi, MSSW Ron Hesse, Project Coordinator Suzanne Bakken, RN, DNSc, Evaluator *Offers patients and providers access to key elements of their clinical, psychosocial, and administrative record over a secure, web-based portal. For more information email pgg2@columbia.edu or call 212-305-3272 HRSA Special Projects of National Significance Information Technology Networks of Care Initiative (2007-2011) My Health Profile: a Member Continuity of Care Document (CCD)*

4. My Health Profile project Success Stories #1. Patient Empowerment! Over 120 patient users have logged in >500 times Each has received an Internet 101, My Health Profile training session, unique passwords, and emergency access cards Adoption of service (technology) has been rapid Structured feedback has been overwhelmingly positive Security and privacy concerns have been addressed

5. Community Based Case Management Laboratories Pharmacies Primary Care Site Hospitals Social Service Agency Patient ‘Centered’ Care My Health Profile project Success Stories #2. Improved Coordination of Care

6. The SHIN-NY Physicians Offices and Clinics Hospitals, Nursing Homes, IDNs, etc Pharmacies and PBMs Diagnostic Centers Patients’ Personal Health Records Managed Care NYS DOH UPHN SHIN-NY** Multiple RHIOs* SHIN-NY** Medicaid Public Health CDC *RHIOs = Policy **SHIN-NY = Technology Home Health Care and Telemedicine Biosurveillance Immunization and Child Health Other NYS DOH Databases Local Health Depts. NYC Health Dept.