Electronic Health Information Exchange in Massachusetts xxxxxxxxxxxx

and Beyond

HealthAlliance Hospital Grand Rounds January 4th, 2011 Larry Garber, M.D. Fallon Clinic Medical Director of Informatics SAFE Health Principal Investigator

Agenda
Health Information Exchanges Review of SAFE Health project Review of NEHEN The Massachusetts State HIE

Health Information Exchanges

Local Health Information Exchanges (HIEs) Regional Health Information Organizations (RHIOs) National Health Information Network (NHIN)

Lab Rx Imaging

Hospital

Payers

MD

HIE

Rehab

Other MDs

LTC & SNF

Patients VNA

DPH

Health Information Exchange (HIE)

Lab Rx Each organization has 1 interface Hospital Only patient demographic MD data stored centrally Other Central hub exists MDs only to help with routing of clinical Patients data Imaging

Payers

HIE

Rehab

LTC & SNF DPH VNA

Legislation for HIEs - State

MA Health Care Reform Act of 2008
$15M for community-based HIEs and EHRs All hospitals and community health centers must implement interoperable electronic health records systems by 2015

Legislation for HIEs - Federal

American Recovery and Reinvestment Act of 2009

$1B in up-front grants for EHR and HIE implementation Up to $64K for MDs and $11M for hospitals if:
using EHR in a meaningful manner performs clinical quality measures

EHR is connected to other organizations and the DPH (typically through a Health Information Exchange)

Secure Architecture For Exchanging Health Information A Public Utility for Electronically Exchanging Clinical Information in Central Massachusetts

Objective of SAFE Health

Build and operate a regional health information exchange infrastructure to enable secure, real time transfer of patients health information between multiple different organizations with patient consent in order to improve patient safety, quality of care, and efficiency of healthcare delivery.

Objective of SAFE Health

Build and operate a regional health information exchange infrastructure to enable secure, real time transfer of patients health information between multiple different organizations with patient consent in order to improve patient safety, quality of care, and efficiency of healthcare delivery.

High Level Design Goals

 Integrate seamlessly into physician & staff workflows  Clinical data flows from EHR to EHR, and is viewed by clinicians directly in their EHRs  User authentication and role-based access is performed by each connected entity through EHR  Patients Opt-In once at the connected entity level for all data content/types for TPO uses only  All authorized entities can access entire patient record  One central demographic repository (EMPI)  No central clinical data repository  Leverage existing systems at each organization with minimal modification

SAFEHealth Setup
EMPI pre-populated Edge servers pre-populated

Other Mass Providers

HealthAlliance ER

Payers

Fallon Clinic

New Patient Registers in ER

ADT to SAFEHealth SAFEHealth assesses consent status

Other Mass Providers

HealthAlliance ER

Payers

ADT Fallon Clinic

No Consent on File
Consent prints next to registrar Patient added to portal work queue HealthAlliance ER

Other Mass Providers

Payers

Fallon Clinic

Patient Signs Consent

Registrar enters into Consent Portal

Other Mass Providers

HealthAlliance ER

Payers

Fallon Clinic

Patient Signs Consent

Registrar enters into Consent Portal Consent status synchronized Authorized clinical data synchronization HealthAlliance ER

Other Mass Providers

Payers

Fallon Clinic

ER MD Sees Patient
Reviews SAFEHealth data in ERs EHR ER Discharge Note sent to authorized entities HealthAlliance ER

Other Mass Providers

Payers

Fallon Clinic

Care Continues
Authorized clinical data synchronization for up to 1 year from last visit or until consent revoked HealthAlliance ER

Other Mass Providers

Payers

Fallon Clinic

Timeline
2004 Awarded $1.5 Million AHRQ HIE Grant $4 Million donated by:
Fallon Clinic Fallon Community Health Plan HealthAlliance Hospital UMass Memorial Medical Center

6/2009 SAFEHealth go-live

Current Status of SAFEHealth

 Local Servers were installed and connected at Fallon Clinic and Health Alliance Hospital Leominster Campus  Core Server is hosted by Fallon Clinic  1 Million patients were pre-loaded into EMPI  2 years of clinical data pre-loaded into CDR  HealthAlliance is currently providing ER notes

Current Status (Continued)

Fallon Clinic is currently providing notes with:
Medication List Allergies Problem List Immunization History Code Status Advance Directive Status PCP and phone number Vital Signs Recent Lab/Radiology Results

Statistics after first year:

2,000 patients have signed consents 10 people revoked their consents 50% have consented for all of Massachusetts 75% agreed to receiving payer data 22,000 documents have been securely exchanged

Lessons Learned: Where to file data

1. In a separate portal, is not as good as 2. In EHR in a separate area, which is not as good as... 3. In EHR integrated with similar types of data

SAFEHealth uses #2 and #3

Value of SAFEHealth
(Based on surveys)

Higher quality, faster, safer care Fewer tests/admissions Consent process didnt interfere with registration process Access to clinical data fits into the workflow of clinicians

Sustainability of SAFEHealth
Focus has been on reducing operating expenses
Internally-developed software Hosting core server in Fallon Clinics data center No formal third-party organization/RHIO

Just need a Data Use and Reciprocal Support Agreement (DURSA) in order to establish trust and baseline requirements for HIPAA and state regulations (e.g. minimal requirements for authenticating users)

Sustainability of SAFEHealth
Each organization is responsible for their own server maintenance/license/replacement and data mapping costs...

Currently ~$2,000/year/organization!
So the actual cost savings becomes almost irrelevant

New England Healthcare Exchange Network

The Evolution of NEHEN

NEHEN established for Administrative Transactions NEHEN adds members, transactions and portal. MA-SHARE clinicals: MedsInfo-ED, RLS, NHIN, Rx Gateway NEHEN/MA-SHARE merge. CDX Gateway (XDR): Clinical Summary Push, MAeHC Quality Data Center integration

1996
HIPAA

2003
Standard Admin Txn & Trust

2008/2009
MA Chapter 305 ARRA/HITECH

2011
Meaningful Use & Standard Clinical Txn

NEHENs Growth: Payers Practices/Facilities EDI Physicians Portal Physicians Transactions

4 65 ~12,000 ~24M/yr

8 81 ~18,000 ~750 ~60M

16 88 ~20,000 ~1,200 ~100M

Flexible Implementation Options

NEHEN Express

Integrated
(Meditech, IDX, Epic, etc.)

Intranet and Hosted Portal versions NEHEN Express

Use when integrated EDI is unavailable in core system Supports ad hoc business processes like collections Provides means of acquiring early experience with process change (in parallel with core system integration) Extends functionality to outlying practices and business processing areas

Integrated version IDX, Meditech, Eclipsys, Epic & others

Preferred method for workflow improvement in core business processes Avoids double-keying / re-keying Eases distribution and reduces training requirements for registration clerks, billing clerks, etc.

Hybrid
(NEHEN Express & integrated.)

Hybrid Integration version - use a combination of NEHEN-Batch and core system features
Cost effective and quicker integration method for Eligibility Verification
An extract file is built of all scheduled patients from core system and sent to NEHENBatch NEHEN-Batch, builds the inquiry transactions and sends it to the payer When Eligibility Responses are returned, they are written back into the patients file (in a comment field) within the core system and Responses are made available within NEHENLite for online viewing or reporting

Architecture Overview
Peer-to-Peer Participant
EMRs and Other Enterprise Systems Interface Engine or Portal Published Patient Data Local Provider Directory HIE Application Server / Gateway

Peer-to-Peer Participant
Published Patient Data Local Provider Directory HIE Application Server / Gateway CCD Standard Messages, e-mail or fax encapsulation Interface Engine or Portal EMRs and Other Enterprise Systems

Secondary Local System

E-Mail Server

Web Server

Fax Server

Fax Server

Web Server

E-Mail Server

Secondary Local System

Summar / Local gateway users control integration, etc. ult Vi r Can leverage infrastructure for internal integration Interfaces can be direct or use interface engine or similar tools

E-mail, fax or HTTP encapsulation

Service Subscriber
Summar / ult Vi r

Web Server

Fax

E-Mail Server

Printer No infrastructure support requirement just Internet connection, fax or e-mail

Internet / Network

Summary / Results Viewer

CCD Standard Messages, HTTP encapsulation

Hosted Portal / HIE Service

Published Patient Data

External etwor s

Community Provider Directory HIE Application Server / Gateway Hosted by service provider (NEHEN) Provides document / data storage, HTTP viewing for subscribers, and common provider index for dissemination to local gateway participants

Architecture & Workflow

Source Provider
Source EMRs and Clinical Systems Interface Engine, Portal or Direct Interface Published Patient Data

Internet / Network

Exchange Partner
Received Patient Data Provider Directory / Routing Portal or Dedicated Viewer Receiver EMRs and Other Systems

CCD Standard Messages

Provider Directory / Routing

Exchange Infrastructure (can be local to each partner or centrally hosted)

Treatment events (visits, tests, discharges, etc.) trigger patient data being published or pushed from one or more source systems for exchange Data is translated to CCD standard

HIE Boundary
Secondary Local System Fax Server

Fax Server

Mail Server Fax

Interface Engine, Portal or Direct Interface

Printer

Message is logged and retained for tracking by receiver Message is inspected for handling and routing instructions Acknowledgement is returned to sender based on agreed process and business rules Message is available for printing (e.g., for paper chart) Message is available for online viewing from exchange infrastructure or in portal CCD data is translated to proprietary format for use in receiving system(s)

Message is addressed using provider directory Message is logged and retained for tracking by sender Message or notification of available data is securely routed to intended receivers Message can also be routed as encrypted or secure e-mail Message can also be routed as facsimile, directly to fax or through fax server at receiver if logging is required Exchange infrastructure can also be leveraged for internal / local exchange within the provider organization

NEHEN Benefits
 Reduction in claim denials
Correcting insufficient or inaccurate eligibility or referral information Correcting invalid PCP, DOB

Reduction in write-offs due to eligibility or exceeding the filing limit  Improved collection of Copays  Labor savings
Reduction in ambulatory care staff needed to manage medications Reduction in time spent on manual transactions: eligibility, claim status inquiry Focusing on the exception processing

 Reduction in Days in A/R & claims rework

Focus on front-end weighted, clinically driven revenue cycle operations

Reduction in bad-debt

NEHEN Benefits (Continued)

 Enhanced communication among providers  Reduction in ambulatory medication errors  Improvement in the Patient Experience  Satisfy Meaningful Use requirements for:
 Clinical Summary Exchange  Medication Reconciliation during transitions of care  Quality Reporting (in conjunction with MAeHCs Quality Data Center)  Public Health Reporting

NEHEN Cost Savings

Brigham & Women's and Mass General Hospital reduced their Total Denial Write Off Rates as a Percent of Net Revenue from 3.78% to 0.88% and from 4.17% to 1.28% respectively Brigham & Women's and Mass General Hospital reduced their A/R Days from 81 days to 55.6 days and from 99 days to 54 days respectively Baystate Health System saved over $1.5 Million in two years by avoiding per-transaction fees

Lessons Learned: Consent

 5% of patients get their peace of mind knowing that they have absolute control over every piece of their clinical data  95% of patients get their peace of mind knowing that their clinical data is always where they need it to be without hassles  Need different mechanisms to accommodate each

Lessons Learned: Consent

 5% who want absolute control:
NEHEN-style push of specific data with patient consent on a one-time basis

 95% who want it where they need it to be:

SAFEHealth-style consent and data flow

Statewide HIE for Massachusetts

Governance Structure and Elements of Public/Private Collaboration

Massachusetts Statewide HIE Concepts

To meet federal and state requirements (including Chapter 305) AND support health care reform initiatives, the HIE technical architecture must support:
Privacy and Security Bi-directional Data Exchange Exchange of standardized Clinical Summaries Public Health Reporting

Patient control of information on the HIE must be consistent with state and federal policy Allow HIE participants (including patients) to contribute data, enabling others to appropriately retrieve data from the HIE Adopt the standards needed to exchange summary data, including the CCD, among various clinical settings Integrate with a reportable data detection and messaging solution to drive improved completeness and accuracy for public health reporting Facilitate data routing to reporting tools and support the possible linkage to registries in the future Provide value to participants, such that they are willing to pay for the services provided

Reporting for Quality and other initiatives Financial Sustainability

40

Network of Networks

Summary
NEHEN has a long history of success focusing on pushing data analogous to the Fax machine SAFEHealths success focuses on patient consent management, automatically moving data, and low operating expenses Massachusetts statewide HIE will leverage existing work and networks through the state

Questions? www.SAFEHealth.org
Lab Rx Imaging

Hospital

Payers

MD
Other MDs Patients

HIE

Rehab

LTC & SNF DPH VNA

Larry Garber, MD

LGarber@MassMed.org

Bibliography
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