1. The Health Information Technology Summit West March 8th, 2005
Results from an Ambulatory Clinical Decision Support System: Indications of the Potential Clinical and Financial Impact of RHIOS
The Health Information Technology Summit West March 8th, 2005

2. Can RHIOs promise be realized?
I’m going to show evidence that RHIOs can work
Based on “quasi RHIO”
Health plan centered model
Initial pieces of the puzzle
Fully-loaded RHIO can have tremendous impact
Needs robust clinical decision support

3. Introduction The Current Focus of Efforts to Transform Healthcare
Meeting challenges of IOM “Chasm”
Necessity for Health Information Technology / RHIOs
Crucial Link
Access to aggregated electronic health data
Using the data to provide clinical decision support
Potential Impact of RHIOS
Results from a large existing, ambulatory clinical decision support program
NOT an EMR or EHR – rather using health plan data to create a patient-centric electronic record

4. The challenge has been set
Healthcare Costs Continue to Soar
Employer & Health plan perspective:“Employer-sponsored health insurance premiums rose 11.2 percent this year, registering the fourth consecutive double-digit annual increase.” The Washington Post, September 10, 2004
Consumer perspective: 31% of all the incremental per capita income we'll earn between 1999 and 2010 will go to healthcare” Chernew, et al, Health Affairs July/August 2003
Large Gaps in Quality of Care
Institute of Medicine’s “Quality Chasm”
“Our results indicate that, on average, Americans receive about half of recommended care processes.” McGlynn, et al, The Quality of Heatlhcare delivered to Adults in the United States, New England Journal of Medicine, June 26th, 2003

5. Focus of the HIT dialog
Currently has been inpatient and administrative issues
CPOE
Workflow improvement tools
Critical Paths
Sharing data through EHR
Transactional and redundancy cost savings
“Fully standardized HIEI could yield a net value of $77.8 billion per year…” Walker, et al; The Value of HealthCare Information Exchange and Interoperability, Health Affairs, 19 January 2005

6. Has to be more than digitizing paper

7. Opportunity
The RAND study quantifies a large gap in care in Outpatient Settings
Consequence is avoidable hospitalizations
Addressing ambulatory care is feasible and will produce impact on inpatient costs
Need to push EHR and interoperable systems
Also need focus on clinical decision support
“…less-aggressive assumptions could lead to more realistic expectations..” ; “The best argument for working toward better HIEI would combine the potential for savings with the potential for improved patient care” Baker; Benefits of Interoperability: A Closer Look at the Estimates, Health Affairs, 19 January 2005

8. Evidence of the opportunity
There is an impact on clinical quality
And…
Improving clinical quality reduces costs
I’m going to show evidence of the impact of focusing on both
Healthcare information exchange
Clinical decision support to drive improvements in quality of care

9. Definition of a RHIO

10. RHIO Components Multi-stakeholder effort
Exchange of health data through interoperable systems
Community support – common geography or common interests
Enables improvements in quality of care

11. One representation of a RHIO
Hospitals
Primary care physician
Specialty physician
Ambulatory center (e.g. imaging centers)
Payors
Pharmacy
Laboratory
Public health
Current system fragments patient information and creates redundant, inefficient efforts
Pharmacy
Laboratory
Hospitals
Primary care physician
Specialty physician
Ambulatory center (e.g. imaging centers)
Payors
Public health
Health
Information
Exchange
Future system will consolidate information and provide a foundation for unifying efforts
“Wiring” Healthcare – Indiana Health Information Exchange, NYS eHealth Initiative
J. Marc Overage, MD, PhD

12. A demonstration of the potential of RHIOs
“quasi-RHIO” – a first layer of the components
Multi-stakeholders – employers, health plan, PBM, clinical laboratories, physicians, patients
Exchange data – drug data (NDC), medical data from claims (ICD9,CPT), Lab results (LOINC), messaging to physicians, Messaging to patients, new information from physicians, patients
Regional or National Community - accessing health plan network, employers and plan members
Crucial Link - Focused on Clinical Decision Support
Combine access to data, exchange of data and clinical decision support
More than enabling improvement in quality of care, we need to explicitly drive those improvements

13. Clinical Decision Support
“quasi-RHIO” Communication and Data Exchange
Laboratories
Medical Data (Claims)
Hospital
LOINC
Clinical Decision Support
CareEngine System
LabCorp
LOINC
Quest
LOINC
Health
Plan
Medco
Caremark
Express Scripts
Physicians
Prescription Data
System with batch processing of data

14. Current Customers: Health Plans
(AmeriChoice)
Different order for commercial vs. Medicare vs. Medicaid

15. Current Customers: Employers (among many others)
Use different order when presenting as part of different health plans (e.g., Anthem)?

16. Health plan-based and other PBMs
Through health plan relationships
Different order for commercial vs. Medicare vs. Medicaid

17. Clinical Laboratories
                              
Clinical Laboratories
Regional and Hospital Labs
Through health plan relationships
Use different order when presenting as part of different health plans (e.g., Anthem)?

18. Data exchange without a fully loaded RHIO
Medical Claims Source 3: Region 1, Region 2, Region 3
Different Sources
Different People
Different Frequencies
Different Formats
Different Member IDs
LabCorp:, Region 1, Region2
Region 3
Quest Lab: Region 1, Region 2
Region 3
Medical Claims Source 3: Region 1, Region 2, Region 3, Region 4
Medical Claims Source 2: Region 1, Region 2
CareEngine
Pharmacy Claims: Source 1
Region 1,
Pharmacy Claims: Source 3
Region 1, Region 2, Region 3, Region 4
Pharmacy Claims: Source 2
Region 1, Region 2, Region 3

19. Clinical Decision Support
CareEngine® System
Incorporates widely accepted evidence-based standards of care
Creates a “virtual EMR” from health plan data, PBM data, lab data

20. CareEngine® System & Clinical Decision Support

21. Patient Data

26. Health Management Tool (HMT)

27. Medical Knowledge

28. January, 2000 article showing that the prescription medication Ramipril significantly reduces strokes, myocardial infarctions and death in a broad range of high-risk patients

29. Decision Support

31. Exchange of Information

37. Provider Feedback
Thank you for your June 30, 2004 letter informing me about your impression that Mr. John --- needs to be on statin therapy. I am writing to commend you on this service because of the recognition that a tremendous number of people in this country are going to benefit by the use of statins but who are not taking them at this time.

39. Types of information exchanged

40. Results

41. QualChoice Case Study

42. QualChoice Case Study

43. QualChoice Case Study

44. Results – Clinical Decision Support Trial
Reduced Hospitalizations – 19% for those with identified issues or 8.4% lower per year spread over the entire population
Reduced Medical Costs - $817/year lower paid claims for those with identified issues or $96/year spread across the entire population

45. Using the results to push forward on RHIOs
A Health Plan Model…
Financial impact
$96 per person per year or 5% of a plan’s premium revenue
Incentive is the impact on a plan’s profitability
Clinical Impact
Significant improvement in clinical results
Impact on need to demonstrate improvement in quality of care

46. What’s Missing - Fully-loaded RHIO
First layer of the components in our current system
Multi-stakeholders
Exchange data – drug, claims, lab test, messaging
Accessing health Plan network and membership
Focused on clinical decision support
Needs fulfilled by a ‘fully-loaded’ RHIO
More interoperability to provide access to more data
Hospital data
Physician electronic records
Access to system to deliver messaging – from clinical decision support - to doctors
Access to more data collected from patients – likely through support of health plans

47. Our Desire is…… Leverage existing relationships
Employers
Health plans
Credibility of existing clinical decision support with doctors
Form a fully-loaded RHIO
Health plan centered model
More complete, faster access to data
Better exchange of information
Targeted communications – more than solely a view of data
Powered by Clinical Decision Support
Communication to physician office systems