1. A Paradigm Shift for Sharing Health Information: the Health and Prevention Promotion Initiative (HAPPI) William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors Adjunct Professor, Division of Health Sciences Informatics Johns Hopkins University IOM Committee on Recommended Social and Behavioral Domains and Measures for Electronic Health Records April 8, 2014 © 2014 NH I I ADVISORS

2. 2 2 © 2014 NH I I ADVISORS Paradigm Shift Fetch & Show Based on manual “fetch & fax” Inefficient & expensive Prone to error (record sources unavailable) Impractical to search data Hard to protect patient privacy No sustainable business model Repository Based on “deposit to account” Efficient & inexpensive Reliable & secure Searchable for public health & research Privacy assured via patient control Compelling business model for all stakeholders Health Record Bank

3. 3 3 © 2014 NH I I ADVISORS Prevention & Population Health n Challenges l New activity – Providers do not do this now – Must hire new staff & establish procedures l Inefficient for each provider – More costly per capita to focus on limited “populations” l Benefit externalities – Member “churn” limits ROI for prevention – No incentive for long-term prevention investments

4. 4 4 © 2014 NH I I ADVISORS Prevention & Population Health n Potential Solution: Collaborative Community Prevention Organization l All providers pool resources l Community organization does prevention & population health for all n Issues l Ongoing funding l Continuous provider cooperation – Initial capitalization – Annual operational funding l Incentives good but not compelling l Need comprehensive patient info

5. 5 5 © 2014 NH I I ADVISORS n Distributed Architecture is Wrong Path l Trying to replicate manual process of contacting other providers directly for records HIE Efforts are Failing HIE Index Other EHRs Other EHRs Assembly Clinician EHR Patient Encounter 5 4 3 2 1

6. 6 6 © 2014 NH I I ADVISORS HIT Architecture Choices n Distributed architecture – does not work l Leave information in place; retrieve in real time when needed l Problems – Inefficient – Error prone – Does not scale – Hard to protect privacy – Impractical to search data n Centralized architecture (health record banks [consumer-mediated exchange])

7. 7 7 © 2014 NH I I ADVISORS Effective HIE Approach: 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

8. 8 8 © 2014 NH I I ADVISORS http://www.healthbanking.org/video1.html What is a Health Record Bank?

9. 9 9 © 2014 NH I I ADVISORS HRB Architecture Patient Records Clinician EHR Patient Encounter HRB 1 3 2

10. 10 © 2014 NH I I ADVISORS How HRBs Create Value Health Record Bank including free/subsidized EHRs for physicians More complete electronic health record information Patients choose optional services with compelling value Patients sign up for HRB (recommended by physicians) Free benefits to physicians and patients $

11. 11 © 2014 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: ~$3/person/year (option to opt out for small fee) l Reminders & Alerts: >= $18/person/year – “Peace of mind” alerts – Preventive care reminders – Medication reminders l Queries: >$3/person/year n No need to assume/capture any health care cost savings (!!)

12. 12 © 2014 NH I I ADVISORS Pro Forma Example (Houston) Month Initial Capital: $4.4 MM Breakeven: 16 months EBITDA Year 4: $41 MM+

13. 13 © 2014 NH I I ADVISORS Health and Prevention Promotion Initiative (HAPPI) n Combine Community Prevention Organization with Health Record Bank n Health Record Bank l Provides needed information l Ensures all-electronic records l Generates revenue (apps, ads, data) l Provides funds for itself and more n Excess Funds from HRB Pay for Prevention and Population Health n Supports Learning Health System

14. 14 © 2014 NH I I ADVISORS The Pursuit of HAPPI-ness PATIENT CONTROL CENTRAL REPOSITORY Stakeholder Cooperation ensures Electronic Patient Data provides Benefits 1. Clinical:  Quality,  Costs 2. Reminders/Alerts 3. Research 4. Learning Health System Benefits 1. Clinical:  Quality,  Costs 2. Reminders/Alerts 3. Research 4. Learning Health System produces pay for enables Prevention (stakeholder need) empowers Privacy protects reinforce Financial Incentives Financial Incentives ensure Key Design Decisions Initial Steps: 1. Free/subsidized EHRs for physicians 2. Physicians recruit patients for free HRB accounts

15. 15 © 2014 NH I I ADVISORS All Stakeholders Benefit

16. 16 © 2014 NH I I ADVISORS Paradigm Shift Fetch & Show Based on manual “fetch & fax” Inefficient & expensive Prone to error (record sources unavailable) Impractical to search data Hard to protect patient privacy No sustainable business model Repository Based on “deposit to account” Efficient & inexpensive Reliable & secure Searchable for public health & research Privacy assured via patient control Compelling business model for all stakeholders HAPPI

17. 17 © 2014 NH I I ADVISORS Questions? William A. Yasnoff, MD, PhD, FACMI william.yasnoff@nhiiadvisors.com 703/527-5678