Nevada Oct 24, 2008

Session Overview Health Information Exchange: Why? What? Who? How? Challenges Along the Way Results – Making a Difference

Acronyms to Enjoy RHIO = Regional Health Information Organization governance model / funding mechanism HIE = Health Information Exchange clinical / consumer / claims / public health NHIE = National Health Information Exchange (standardized interface, certified technologies NHIN: Nationwide Health Information Network “network of networks” EHR + PHR + HIE + PHIN + ???

750,000 patients in multi-state region 2/3 of patients live in Tennessee 1/3 live in Virginia 5% in other states Hospitals: 18 Physicians: 1200 Public Health: 7 regional, 2 state Payor: 25% Medicare 20% Medicaid 18% uninsured 2-20% commercial Small – Med Employers: Eastman Chemical 7500 ETSU – 6500 Hospitals – 5500, 5400

CareSpark’s Mission CareSpark’s mission is to improve the health of people in NE Tennessee and SW Virginia through the collaborative use of health information Regional Population Has High Disparities of: Diabetes Cardiovascular Disease Hypertension Lung Disease Cancer Premature Mortality CareSpark region has $2,400 higher per capita patient care costs than other regions of the country

Regional Health Status

Trend are getting worse

Drug Caused Death Rates

Quality Measures For VA Compared With Best Practices 2002 Data 17 Measures

Source: SBCCDE, CITL, Gordian Project analysis Redundancy Treatment Errors Diagnostic Electronic Medical Record Clinical Data Sharing Decision Support Value is Derived from Better Medical Decisions Patient Data

What Will CareSpark Do? Outcomes Improvement Individual health outcomes Population health status Decision Support (real-time, at point of care, across all systems) Patient-specific info (Rx, Dx, Hx) Clinical Best Practices PHR / EMR / CCR Cost-Efficient Use of Resources Reduced duplication, errors, administrative costs

CareSpark’s Strategic Outcomes 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) Financial Savings -- ROI Patient Clinician Facilities Purchaser (health plan, employer, taxpayer, individual)

Awareness & Adoption of Best Practices Public Health Clinician Purchaser (Payors / employers) Individual (patient / consumer) Population Health Informaticist Community

Community-Wide Collaboration Active, representative participation, including Employers: Eastman Chemical Company, CGI, BAE Systems, City of Kingsport, Payors: Blue Cross Blue Shield of Tennessee, John Deere Health / United Healthcare, Cariten PHP, Highlands Wellmont Health Network 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 Care Network, Blue Ridge NeuroScience, C-Health 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 Local Technology Companies: Intellithought, LucentGlow, Deliberare, Holston Technology, the Creative Trust, ntara

Board of Directors CareSpark Management Clinical Outcomes / Evaluation Population Health workgroup Financial Savings Workgroup Technical Finance CareSpark RHIO Organizational Structure Communications NominatingLegalAuditPersonnel PatientPhysicianPublic HealthPurchaserFacilities Stakeholder Advisory GroupsProject Management Office Partner Health Information Control

CareSpark Board of Directors Board Membership Selected as individuals, not organizational rep’s Expectation: put community good ahead of individual or organizational agenda Self-perpetuating (nominating process, board members elect successors) 1-3 year staggered terms, two-term maximum Balance of leadership experience, necessary skill-sets, network contacts to achieve strategic goals, representative of stakeholder and regional demographic composition Current Members include: CIO of large health system, CEO of independent pharmacy, CEO of behavioral health provider, CEO of hospital-physician network, CFO of large insurer, Health Benefits director for large employer, President of large multi-speciality practice, CEO of community health center, Director of regional public health department, Chief of Staff for local V.A. hospital, Exec Director of regional seniors programs, VP for local university / rural health education

CareSpark’s Core Strategies Provide patient information and decision support on demand at the point-of-care Align financial incentives to assure fair return on investment Empower patients to make healthy choices & informed decisions Provide selected aggregate data for population health improvement

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…) ePrescribing Roll Out Secure Clinical Messaging (labs, imaging, …) H.I.E. Common Portal Tennessee State-level leadership

Virginia Health IT Framework

Virginia RHIO initiatives

Key Strategic Decisions 1.Enable participation by all patients and providers in region 2. Enroll patients through default Passive Enrollment (“opt-out”) with option for Active Enrollment (“opt-in”) - Passive or Active enrollment managed through Master Patient Option Preference (MPOP) and Local Patient Option Preference (LPOP) 3.Hybrid Model, combining Federated Repositories and Centralized Repository for limited clinical data - Enabling decision support, monitoring and aggregate data analysis where regionally approved 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 insurers and employers - Transaction fees for data providers (labs, hospitals, large practices) - Contributions (cash and inkind) 6. Commitment to standards (IHE / HITSP, ISO)

Convergence of Data Administrative Billing & Claims Clinical Personal Health Record Research Best Practices Patient- Centered Care

From Patient Perspective Perceived Risks Privacy (unauthorized access or release) Use of data (denial of care, coverage, or employment) Identity theft Government as “big brother” Incorrect matching of records Incorrect data entry Perceived Benefits Convenience Access to critical information (allergies, rare diseases) Reduced duplication = reduced cost ability for proxy to manage care (adults caring for elderly parents from a distance) Advanced directives

The Importance of Standards Standards for data content (what are the important pieces of information necessary? Is terminology consistent?) Standards for data transmission (how is data sent?) CDA = (clinical document architecture) exchange of fixed, legally defensible document upon request CCR = (continuity of care record) assembly “on the fly” from discrete data elements in multiple systems CCD = (continuity of care document) standard document that includes common discrete data elements Standards for security (access, authorization, audit) use existing international standards from other industries Standard policies (who decides what to share, with whom and for what use? consumer-directed permissions for access to / use address issues of liability and enforcement Funding / sustainability (who benefits, so who pays?) savings accrue mostly to purchasers (insurers, employers, taxpayers, self- pay consumers) “transparency” for capital and operating costs, ROI, quality outcomes

CareSpark RHIO Consortium Partners National / International: Local / Regional: ActiveHealththe Creative Trust AllScriptsDeliberare AnakamHolston Technology CiscoIntellithought CGILucentGlow DellOnePartner GE Healthcare Healthvision / QuovadxState: Initiate SystemsTennessee IntelVirginia Misys OracleFederal: SiemensDHHS / ONC Wellogic Market / thought leaders committed to interoperability, collaboration and results

CareSpark IHE Architecture Data Participants CareSpark Data Store XDS Document Registry XDS Document Registry XDS Patient Identity Source (MPI) XDS Patient Identity Source (MPI) Portal Hospital 1 Phys Portal IHE DocConsumer Hospital 1 IHE DocSource/ DocConsumer Physician Practice 1 IHE DocSource/ DocConsumer Document Repository FILTER Clinical Data Repository Public Health Data Mart De-Identified Data Mart CareSpark XDS Data Store - For Patient Care Clinical Data Repository - For Public Health Improvement XDS PIX Service CT Time Service XDS PDQ Service ATNA Audit Repository ATNA Audit Repository XDS Document Repository XDS Document Repository XDS Key Store XDS Key Store Public Health Department 1 Additional Providers and other data participants IHE DocSource/ DocConsumer Document Repository Data Transformation Data Transformation

Technical Architecture

Nationwide Health Information Network: “network of networks” NHIN Prototype Demonstration design for exchange between CareSpark, West Virginia, Kentucky providers, federal agencies 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

CareSpark NHIN Architecture CareSpark (Hosted at CGI) CareSpark (Hosted at CGI) Oracle XDS Patient Identity Source (MPI) XDS Patient Identity Source (MPI) Portal Wellogic Cloverleaf XDS PIX Service CT Time Client ATNA Audit Repository XDS Document Repository XDS Document Repository XDS Key Store XDS Key Store XDS PDQ Service XDS Reg Service XDS Rep Service Two Factor Anakam EMPI Initiate PostGreSql XDS Document Registry XDS Document Registry XDS Registry NIST ATNA WinSysLog ADT Service Web Server DB Server Version Control Subversion MPOP MPOP Consent Custom Interfaces Anakam ESB NHIN request/response Providers Any other inbound/out bound end point Socket TCP SOAP/HTTP Flat File Data Transformation Data Transformation Protocol Transformation Protocol Transformation Message Enhancement Message Enhancement Security Validation Security Validation Routing Orchestration Anakam Two Factor Anakam Web Server PHR ActiveHealth Web Server e-Prescription AllScripts

Jun 07 Technical/Financial Timeline Jun 08Jun 09Jan 08Dec 09Jan 09 Jan 07 Enrollment of 25,000 members MPI build document registry and Repository Build clinical data repository Physician Portal, authenticatio n Real-time Decision support integrated with HIE Data- sharing agreement s Enrollment 250,000 patients Claims-based Decision support implemented Enrollment 35,000 members Clinical document Exchange NHIN Trial Implementatio n

Operating Support April 2008 – June 2009 Operating Support April 2008 – June 2009 Infrastructure Development July 2005 – March 2008 Infrastructure Development July 2005 – March 2008 Strategic Business Planning July 2004 – June 2005 Strategic Business Planning July 2004 – June 2005 Grassroots Sustainability $100,000 grant from eHealth Initiative $462,000 match from local partners $250,000 Commonwealth of Virginia $308,000 Accenture NHIN Prototype $1,450,000 Consortium Partners (cash/inkind) $1,000,000 State of Tennessee $750,000 contributions and donations $3,688, 622 NHIN Trial Implementation $150,000 transactional fees for services $450,000 contributions and donations $1,055,225 enrollment of members

Revenue Sources July 2005 – Dec 2008 Employers: Eastman Chemical Company$ 600,000 King Pharmaceuticals$ 60,000 Cariten PHP$ 8,000 Johnston Memorial Hospital$ 10,000 Contracts: State of TN$1,016,900 Accenture (NHIN prototype)$ 308,000 Commonwealth of Virginia$ 250,000 NHIN Trial Implementation$3,988,622 Consortium Partners $1,250,000 cash and inkind Enrollment Fees (CareEngine Services) $ 431,640 Transaction Fees $ 0 Total $7,923,162

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.

Future Initiatives National – connect with V.A., CDC and personal health records Tennessee – connect with state agencies (public health immunization registry, Tn eHealth Council efforts) Virginia – connect with immunization registry, prescription management program Local / Regional – support aggregation and analysis of data to address public health issues for region (chronic disease, prescription drug overdose)

Lessons Learned – Regional HIE Health care market does not conform to political boundaries Evolving standards will assure interoperability across jurisdictions and between systems (clinical, payer, public health, personally- controlled, research-oriented) Leverage existing resources and investment through incremental transition Build for maximum flexibility to accommodate change (technical, policy, funding, users, evidence-base on outcomes)

Better Health for Central Appalachia Liesa Jenkins, Executive Director