1. How to Develop a Sustainable Community Health Information Infrastructure William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors Founder and President, Health Record Banking Alliance Health Information Technology Workshop Institute for Family Health July 10, 2009 © 2009 NH I I ADVISORS

2. 2 2 © 2009 NH I I ADVISORS “ The development of an information technology infrastructure has enormous potential to improve the safety, quality, and efficiency of health care in the United States ” - Institute of Medicine, Crossing the Quality Chasm, 2001 “ The development of an information technology infrastructure has enormous potential to improve the safety, quality, and efficiency of health care in the United States ” - Institute of Medicine, Crossing the Quality Chasm, 2001

3. 3 3 © 2009 NH I I ADVISORS Sustainable Community HII I. Defining the Goal II. A Framework for Understanding the Challenges III. Solution: Health Record Bank  Functions & Operation  Rationale  Business Model IV. Next Steps

4. 4 4 © 2009 NH I I ADVISORS Health Information Today n Scattered Records l Each person's records are scattered at whatever locations care has been given l Mostly paper n Information sharing not effective l Cumbersome, expensive, time-consuming, and fallible l No mechanism to collect patient information from disparate sources n No responsible institution l Each patient's complete records (from all sources) are not available for care l Need to create these institutions

5. 5 5 © 2009 NH I I ADVISORS Health Information Today (cont.) n Consequences of health information deficit l Medical errors common – 44,000-98,000 preventable deaths/year (just in hospitals) l Quality poor – only 55% of adults receive recommended care (RAND study) l Costs out of control – rising >10% annually – consuming an increasing proportion of GDP – now $2+ trillion/year and growing

6. 6 6 © 2009 NH I I ADVISORS Goal: Comprehensive Patient Information at Any Point of Care n All medical records must be electronic n Combine multiple scattered records into complete “master” record n Enable rapid review l Graphs l Charts l Enhancement of relevant information n Automated reminders to improve quality and reduce errors

7. 7 7 © 2009 NH I I ADVISORS II. A Framework for Understanding the Challenges n P - Privacy n I - Information n U - Usage n S - Sustainability

8. 8 8 © 2009 NH I I ADVISORS Privacy & Patient Control n Surveys of “information hiding” l 2006: 13% of consumers l 2007: 17% of consumers n Consumers already control information in their records n Without control, too many will opt out OR politically force system shut down n Choices are today’s system or consumer control -- complete information without consent is not (and should not be) a viable option n Patient control essential

9. 9 9 © 2009 NH I I ADVISORS Privacy Requirements n Patient Control l Essential for trust l Forces stakeholder cooperation n Trusted Institution l Local governance (now) l Government regulation (later) n Trusted Architecture l Secure repository l Operate like classified military system

10. 10 © 2009 NH I I ADVISORS Information n Electronic l Need financial incentives for physician electronic health record (EHR systems) n Interpretable l Standards very desirable n Transmitted (at no charge) l Patient requests for records must be honored under HIPAA n Stored l Central repository (in a community)

11. 11 © 2009 NH I I ADVISORS Usage n Ensure use in care l ? Financial incentives n Avoid process disruption in physician offices l Need very high market penetration l --> Community implementation

12. 12 © 2009 NH I I ADVISORS Sustainability n Subscription fees / sponsorship n Advertising n Query fees (with patient permission) n Alerts & reminders

13. 13 © 2009 NH I I ADVISORS III. Solution: Health Record Bank (HRB) n Secure community-based repository of complete health records n Access to records completely controlled by patients (or designee) n “Electronic safe deposit boxes” n Information about care deposited once when created l Required by HIPAA n Allows EHR incentives to physicians to make outpatient records electronic n Operation simple and inexpensive

14. 14 © 2009 NH I I ADVISORS Clinical Encounter Health Record Bank Clinician EHR System Encounter Data Entered in EHR Encounter Data sent to Health Record Bank Patient Permission? NO DATA NOT SENT Clinician Inquiry Patient data delivered to Clinician YES optional payment Clinician’s Bank Secure patient health data files Health Record Bank Operation

15. 15 © 2009 NH I I ADVISORS HRB Rationale n Operationally simple l Records immediately available l Deposit new records when created l Enables value-added services l Enables research queries n Patient control --> l Trust & privacy l Stakeholder cooperation (HIPAA) n Low cost facilitates business model n Allows EHR incentive options l Pay for deposits from existing EHRs l Provide Internet-accessible EHRs

16. 16 © 2009 NH I I ADVISORS HRB Business Model n Costs (with 1,000,000 subscribers) l Operations: $6/person/year l EHR incentives: $10/person/year n Revenue l Advertising: $6/person/year l Queries: ? l Reminders & Alerts: >= $12/person/year – “Peace of mind” alerts – Preventive care reminders – Medication reminders n No need to assume/capture any health care savings (!!)

17. 17 © 2009 NH I I ADVISORS IV. Next Steps n For-profit HRB startups n For-profit HRB establishes community non-profit for governance l Consumers l Physicians n For-profit operates HRB under contract from community non-profit l Pays fee to non-profit for governance l Provides EHRs or EHR incentives to physicians

18. 18 © 2009 NH I I ADVISORS Health Record Bank Organization Customer Support Marketing Operations HRB Operator Board of Directors Management Health Record Bank Operator (for-profit) regulate via contract % of revenue RESPONSIBLE FOR: Policy Governance Oversight RESPONSIBLE FOR: Obtaining Capital Operating HRB Executive Director Other Staff(Optional) Community Non-profits Community Board of Directors Many communities use single HRB

19. 19 © 2009 NH I I ADVISORS Summary: Sustainable Community HII I. Goal: Comprehensive Electronic Records II. Challenges  Privacy (patient control)  Information (EHR incentives)  Usage (integrate with existing workflow)  Sustainability (feasible business model) III. Solution: Health Record Bank IV. Next Steps  Community Health Record Bank providers fund non-profits for governance

20. 20 © 2009 NH I I ADVISORS Questions? William A. Yasnoff, MD, PhD, FACMI william.yasnoff@nhiiadvisors.com 703/527-5678 For more information: www.ehealthtrust.com www.healthbanking.org www.yasnoff.com