1. Southwestern Va Medical Technology Summit Oct. 2, 2009

2. Presentation Overview Background Coordination of Care for Individuals Regional Public Health Status Improvement Current Status Regional Participation and Capabilities State-level initiatives National Future Plans Support participants to achieve “Meaningful Use” Expansion of cooperative efforts Tracking and reporting of outcomes

3. Background: Regional Health Improvement 750,000 citizens (2/3 in Tennessee, 1/3 in Virginia) Disproportionately High Rates for Premature mortality Chronic Diseases Prescription Drug Overdose Uneven Access to Services 18 hospitals 1400 physicians 18% uninsured CareSpark’s Mission: to Improve the Health of People in northeast Tennessee and southwest Virginia through the Collaborative Use of Health Information

4. CareSpark’s Core Strategies Provide patient information and decision support at the point-of-care Align financial incentives for patients, providers, purchasers Empower patients to make informed decisions and healthy choices Compile and analyze aggregate data for population health improvement 1. 2. 3. 4.

5. Community-Wide Collaboration Employers: Eastman Chemical Company, CGI, BAE Systems, City of Kingsport, Food City, ntara, the Creative Trust, Steadman Corporate Design, Payors: Blue Cross Blue Shield of Tennessee, John Deere Health / United Healthcare, Cariten PHP, Highlands Wellmont Health Network, CIGNA Hospitals: Mountain States Health Alliance, Wellmont Health System, Johnston Memorial Hospital, Quillen V.A. Medical Center, Laughlin Memorial Physician Practices: Holston Medical Group, Highlands Physicians, Health Alliance PHO, Cardiovascular Associates, ETSU University Physicians, Clinch River Health Services, Frontier Health, Southwest Virginia Community Health System, Mountain Region Family Medicine, Medical Care PLLC Health Education: East TN State University School of Medicine / College of Nursing/ College of Public and Allied Health, University of Appalachia College of Pharmacy, University of Virginia Public Health: Sullivan and Northeast Regional Health Departments in TN, Cumberland Plateau and Lenowisco Health Districts in VA, Tennessee Department of Health, Virginia Department of Health and Human Resources Community Non-Profits: Kingsport Tomorrow, United Way of Kingsport, Rotary Club of Kingsport, Kingsport Chamber of Commerce, Bristol Chamber of Commerce, NETWORKS Sullivan County Partnership Patient Advocacy Groups: American Cancer Society, Minority Health Coalition, Mountain Empire Older Citizens, Savvy Patient Technology Companies: ActiveHealth, AllScripts, Anakam, BCTI, Cisco, CGI, Deliberare, Healthvision, Holston Technology, Initiate Systems, Intellithought, Intel, LucentGlow, OnePartner, Oracle, Wellogic

6. Key Strategic Decisions 1. Enable voluntary participation by all patients and providers in region 2. Enroll patients through default Passive Enrollment (“opt-out”) with option for Active Enrollment (“opt-in”) 3.Hybrid Model, combining Federated Repositories and Centralized Repository for limited clinical data - Enabling coordination of care decision support, monitoring and aggregate data analysis 4. Data Access and Uses P atient: view content of records, view access log Provider: payment, treatment, operations Public health: required reporting and authorized queries Payers: de-identified aggregate data Research: IRB-approved studies 5.Fee-Based Revenue Model - Contracts with public agencies, insurers and employers - Transaction fees for data providers (labs, hospitals, large practices) - Contributions (cash and inkind) 6. Commitment to standards (ISO, IHE / HITSP / NHIN, other)

7. CareSpark Data-Sharing Options Data Sharing OptionIntended Data UseData Sharing Result Identified DataPatient Care and Treatment All data sent to CareSpark will be identified data in order to match patient records from multiple providers. Identified data will be available to authorized providers for access of additional healthcare information about the patient. De-Identified DataAnonomized – patient data can never be re-identified Approved Population Health Improvement activities Identified data available to CareSpark will be de-identified according to the approved requirements and stored separately. Pseudo-Anonomized – Patient data can be re- identified, if necessary, but only by the party who provided the pseudo- anonoymized data LimitedPublic HealthIdentified data available to CareSpark will be de-identified with the specified additional fields required for a limited dataset according to the approved requirements and stored separately.

8. CareSpark’s infrastructure We’ve Built a standards-compliant Clinical Document Exchange Network Exchanges clinical documents between providers Accepts patient demographic information from Providers Controls clinical data in accordance with patient consent preferences Supports direct integration and access through provider EMRs (standard and non-standard) Allows access for providers without EMR High levels of security

9. Technical Architecture

10. CareSpark Oracle Health Information Exchange Infrastructure XDS Patient Identity Source (MPI) XDS Patient Identity Source (MPI) Cloverleaf CT Time Client ATNA Audit Repository XDS Document Repository XDS Document Repository XDS Key Store XDS Key Store Initiate EMPI PostGreSql ATNA WinSysLog Service Providers DB Server Consent Repository MPOP Consent Patient Identity Feed Patient Queries Send Clinical Documents Query For Clinical Documents Retrieve Clinical Documents Subscriber Identity Feed Clinical Documents CareSpark Providers EMR Patient Management System ActiveHealth Subscriber Management System CareEngine XDS PIX Service XDS PDQ Service XDS Reg Service XDS Rep Service Two-Factor Authentication Two-Factor Authentication Clinician Portal Clinician Portal XDS Document Registry XDS Document Registry XDS Registry NIST XDS Registry NIST ADT Service Wellogic Healthvision CGI OnePartner/ BCTI Anakam CareSpark XDS Data Store - For Patient Care

11. Jan 06 CareSpark RHIO Timeline Jun 08Jan 10Jan 07Jan 11Jan 09 Jan 05 Tn non-profit org chartered document registry and repository Build clinical data repository Physician Portal, authenticatio n Decision Support delivered electronically Data- sharing agreements Claims-based decision support Clinical document Exchange MPI build begins Strategic Planning Revenue- generating services (med hx, results delivery) Immunization registry

12. Funding Sources – Planning Phase BlueCross BlueShield of Tennessee$162,125 Foundation for eHealth Initiatives $100,000 (Office for Advancement of Telehealth, HRSA, DHHS) AllScripts HealthCare Solutions$ 25,000 John Deere Health$ 41,500 Eastman Chemical Company$ 50,000 Mountain States Health Alliance$ 50,000 Wellmont Health System$ 50,000 Novartis Pharmaceuticals Corporation$ 15,000 Frontier Health$ 10,000 Health Alliance PHO$ 10,000 Highlands Physicians Inc.$ 10,000 Holston Medical Group$ 10,000 United Way of Greater Kingsport $ 10,000 Rotary Club of Kingsport $ 10,000 East TN State University / Medical Education Assistance Corp.$ 5,000 Laughlin Memorial Hospital$ 2,500 Johnston Memorial Hospital $ 2,500 Kingsport Tomorrow$ 1,500 Cardiovascular Associates$ 250 Total funds contributed:$562,875

13. Revenue Sources July 2005 – July 2009 Local Support $4,185,120 Employer contributions: $ 678,000 State grants / contracts $1,600,000 Technology Partners $2,250,000 CareEngine enrollment fees $1,257,120 State contracts $1,669,600 Tennessee $1,369,600 Virginia $ 250,000 Federal contracts $4,917,098 NHIN Prototype $ 308,000 NHIN Trial Implementation $3,609,125 NHIN Option year 1 $ 999,973 Total Funding: $10,771, 818

14. Participation and Capabilities July 2009July 2010July 2011 Patients 175,0002,500,0005,000,000 Data Sources 525100 Clinician users 755003000 Record types Labs Meds Allergies Radiology reports Diagnosis Immunizations Claims Discharge summaries Authorizations e-Prescriptions Secure messaging Real-time decision support Patient access Biosurveillance

15. CareSpark’s Strategic Objectives Population HealthClinical Premature Mortality Adult Diabetics, Rx filled, vision / foot, HBA1C<7 New Diabetes Cases Lipid PanelLDL < 100 Flu Vaccines for 65+Pneumo Vax for ages 65+, <2 ER Visits for Health AttackStroke Therapy Post- MI followupCancer Screenings (PAP, Mammogram, colorectal) Deaths from Rx OverdosePain Medication Financial Savings -- ROI Patient Clinician Facilities Purchaser (health plan, employer, taxpayer, individual)

16. Convergence of Interests Administrative Billing & Claims Clinical Consumer / Personal Health Record Research Best Practices Patient- Centered Care Technical Infrastructure Financial Incentives Privacy & Confidentiality Governance and Policy Patient- Centered Care

17. Nationwide Health Information Network: “network of networks” NHIN Prototype Demonstration 2006-07 design for exchange between CareSpark, West Virginia, Kentucky providers NHIN Trial Implementation 2008 * Core Services: Consumer permissions Security exchange Standardized interfaces Summary medical record * Medication Management eRx, med history, decision support * Consumer Empowerment personal health record, registration and medication history

18. Health Information Exchange in Tennessee

19. Tennessee Roadmap for Health IT Tennessee eHealth Council: seed funds for RHIO’s, grants for eRx, broadband Coordinating organization facilitates rules of engagement: Data-sharing Agreement Legal Framework Standards Interoperability Transparency Value Quality/Cost Framework for trust and collaboration Broadband % of Access, Stakeholders, Automation EMR / EHR/PHR implementation Structured notes & paper records Administrative transactions (claims…) E-prescribing roll out Secure clinical messaging (labs, imaging, email….) H.I.E. Common Portal

20. Virginia RHIO initiatives

21. Virginia Health IT Council

22. Health Information Exchange Stages of Evolution Pre-operational 1: Recognize need 2. Organizing and planning 3. Securing resources 4. Developing and implementing Operational 5. Transmitting data 6. Sustainable business model 7. Expanding participation In August 2008, 57 report being operational, 88 pre-operational

23. HIT-Enabled Health Reform Achieving Meaningful Use 2009201120132015 HIT-Enabled Health Reform Meaningful Use Criteria HITECH Policies Protect privacy and security, 2011 Meaningful Use Criteria (Capture/share data electronically) 2013 Meaningful Use Criteria (Advanced care processes with decision support, patient access) 2015 Meaningful Use Criteria (Improved Outcomes) 23

24. 24 Overview of Federal HIT Programs

25. Federal Stimulus Funds HITECH legislation in February 2009 Increased privacy and security requirements Funding for health information exchange (State HIE Cooperatives) Funding for National Research Center (“comparative effectiveness”) and Regional Health IT Extension Centers Funding for Healthcare Workforce Development Incentives for adoption and “meaningful use” of health information technology +++ EMR eRx HIE Quality Reporting Patient Access = $$$$$$$$ 2011-2015

26. State HIE Cooperatives Health Improvement Partnership of Tennessee (HIP-TN) not-for-profit entity formed to facilitate and oversee application and distribution of ARRA funds workgroups: Technical, Privacy & Security, Clinical, Governance / Policy, Financial Sustainability Board members from this region: Doug Varney, David Sensibaugh Virginia Health IT Interoperability Commission established under Virginia Department of Health by executive order priorities to be addressed: childhood immunizations, infant mortality Local appointee: Liesa Jenkins

27. Regional Health IT Extension Centers Virginia: statewide collaboration with regional variation, led by Va Health Quality Center Tennessee: statewide proposal submitted by QSource, contracting with regional partners for delivery of services Letters of intent submitted Sept. 8 Full proposals due Oct. 16, if requested

28. Future Plans for CareSpark Local Increased participation: Enhanced capabilities Sustainability Providers Secure messaging for users Fees for services Patients Clinical data repository Regional Extension Centers Knoxville / Danville Population Health Improvement Virginia Public healthOther Immunization telemedicine Rx MonitoringHIT Commission VHEN Tennessee Public healthOther Immunization HIP-TN Rx Monitoring National NHIN GatewayOther Federal agencies (VA, SSA)Benchmarking Other HIE’s (NC, KY, WV)Sharing best practices

29. Next Steps for YOU 1.Begin planning for EMR  Assess your organization’s business requirements, including functionality, cost, privacy and security protection  Evaluate, select certified, standards-based solution, contract, train users and implement (assistance from Regional Health IT Extension Center or other)  Consider modularity for future needs: eRx, decision support, analytics and reporting, patient access 2.Participate in Health Information Exchange  Enter into Data-sharing agreements  Access broadband services and network(s)  Train users  Inform patients  Shared costs for infrastructure and services 3.Monitor your results  Measure your own results (efficiency, cost, patient outcomes)  Report outcomes to access incentives payments  Benchmark with peers, share best practices  Participate in research to improve effectiveness 4.Take pride in your success!

30. Better Health for Central Appalachia www.carespark.com Liesa Jenkins, Executive Director 423-963-4970 ljenkins@carespark.com