Regional Health Information Exchange .. Laying the Foundation for a New Revolution in Patient Care

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Regional Health Information Exchange .. Laying
the Foundation for a New Revolution in Patient
Care

• Mark D. McCourt
• Global Solution Sales Leader
• Interoperability and Clinical Decision
  Intelligence

2
In a 1932 visit to London, a reporter asked
Mohandas Gandhi what He thought of Western
Civilization, he replied
I think it would be a good idea.
When asked the same question of the US Healthcare
System, Hank McKinnell, CEO of Pfizer, comes to
the same conclusion
I think it would be a good idea.
A Call To Action, Hank McKinnell, CEO Pfizer
3
Several major trends will have a have profound
effect on the delivery and financing of
healthcare in 2010

• Value Based Purchasing and Reimbursement
• Consumers and payors (employers, health plans,
  and governments) will increasingly direct their
  health care purchasing or reimbursement dollar
  based on value
• Information Liquidity
• Advancements in pervasive technologies,
  interoperability and genomics will increase the
  availability of meaningful health information.
  Such information and new decision support
  approaches will enhance the healthcare
  ecosystems ability to manage and improve the
  health of populations and individuals across
  geographies and the continuum of care
• The Informed Consumer
• The increasing thirst for healthier lives and
  preserving youth, increased out-of-pocket costs
  and the proliferation of the health information
  will transform many patients into active health
  care purchasers

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Change is scary to many people, even the positive
outcomes
My goal is to die before there's a technology
breakthrough that forces me to live to a hundred
and thirty.
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Global Healthcare Challenge Deliver high
quality, service, and access, with a sustainable
cost structure

• Current pressures on the healthcare industry
  raise the urgency to act
• Costs
• Cost of care delivery continues to rise linked
  to demand, inefficiency, and errors
• Government and private industry demanding reform
  in Healthcare to slow inflation
• Resources
• Limited capital for investment
• Limited pool of resources to meet anticipated
  demand for service
• Demographics and Capacity
• Aging population projections will strain the
  current infrastructure
• Public health deficiencies being thrust to the
  forefront of healthcare agenda
• Technology
• The maturation of collaborative technologies and
  analytical tools
• Public agencies focus on informatics as tool for
  governmental reform
• Investment in Information Technology for improved
  collaboration has proven to drive cost down in
  other industries

Prologue Interoperability breaks the barrier to
achieving greater productivity
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Healthcare All Signs Point to a need to Increase
Quality of Care while Reducing the Cost of
Delivery

• Medical errors, many of which can be prevented,
  are too common - the Institute of Medicine
  estimates that 44,000 to 98,000 people die each
  year from medical errors in the hospital1
• Medication errors are found in 1 of every 5 doses
  given in the typical hospital and skilled nursing
  facility, and 7 of those are potentially harmful
  (more than 40 per day in a typical 300-patient
  facility)2
• Health insurance costs have risen over 10 in
  each of the past three years.3 Better
  information systems are essential to reducing
  health care costs
• One study concludes that 14 of hospital
  admissions occur because physicians do not have
  access to complete patient information
• 17 to 49 of diagnostic laboratory tests are
  performed needlessly, because medical history and
  the results of earlier studies are not available
  when the new tests are ordered.4,5
• We have no nationwide monitoring system to
  identify bio-terrorism in a timely manner, to
  identify potential epidemics at an early stage,
  to identify patterns of adverse drug reactions,
  or to integrate a geographically disperse Pt
  record
• 1 To Err Is Human Building a Safer Health
  System (2000). Institute of Medicine (IOM)
  http//www.nap.edu/openbook/0309068371/html/
• 2 Barker KN, Flynn EA, Pepper GA, et al.
  Medication errors observed in 36 healthcare
  facilities. Arch Int Med. 20021621897-1903.
• 3 The 2003 Kaiser Family Foundation and the
  Health Research and Educational Trust Employer
  Health Benefits 2003 Annual Survey found that
  increases in health insurance premiums were
  10.9, 12.9, and 13.9 for 2001, 2002, and 2003
  respectively. See http//www.kff.org/insurance/e
  hbs2003-1-set.cfm for details.
• 4 Tierney WM, McDonald CJ, Martin DK, Hui SL,
  Rogers MP. Computerized display of past test
  results. effect on outpatient testing. Ann
  Intern Med. 198710756974.
• 5 HIMSS. EHR and the Return on Investment.
  2003. http//www.himss.org/content/files/EHR-ROI.
  pdf

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Key forces impacting the current healthcare
ecosystem
Mitigators
Contributors
Core Issues
Pay for Performance
Practitioners and providers are responding positively to structured incentives Payers are using new incentives to assess providers and promote cost efficiency and high performance
Regulatory Compliance
Regulatory oversight is impacting healthcare at the federal, state, and local level HIPAA standards are requiring careful handling, use, and monitoring of patient information FDA is increasing in regulatory stringency for standards in Biotechs and Pharmas MMA provides for a wide variety of payment options for providers
Healthcare System Inefficiency
Inefficiencies are pervasive driven largely by paper-based processes and poor communications across ecosystem players, resulting in redundancy and labor-intensive administrative processes Information technology is widely recognized as offering potential solutions to inefficiency, however barriers exist including availability of capital and the need for associated process culture change
Pay for Performance
Regulatory Compliance
Delivery Model Mismatch With Business Model
Pervasive Medicine
Pervasive devices and technologies are demonstrating significant impacts throughout the value chain, allowing for real-time EHR updates and promoting efficient collaboration Healthcare providers are expanding their reach beyond hospitals walls with the use of handheld devices wireless infrastructures
Suboptimal Quality of Care
Poor healthcare quality is at epidemic levels in the US, resulting in as many as 3M injuries each year more than 300,000 deaths Patients often fail to receive recommended treatments for common conditions CMS have begun linking quality of services to payment incentives based on MMA metrics
Suboptimal Quality of Care Difficult to Measure
Pervasive Medicine
Consumerism
Individuals are increasingly responsible for the cost of their own care, requiring new value propositions markets New incentives are created for customer service, information mgmt, efficiency Increased demand for new drugs technology units of service are fueled by the aging and expanding population and informed consumers
Consumerism
Increasing Healthcare Cost
Healthcare costs are rising annually at 2-4 times the rate of inflation In 2004, employer health insurance premiums increased by 11.2 percent The US spends more than 15 of GDP on healthcare, at least 50 more other developed nations, and rank lower on outcomes such as life expectancy Chronic Disease represents 80 of cost for 20 population
Geometrically Increasing Healthcare Cost
Increasing Complexity of Medicine
Clinical instruments and treatments, many of which cannot be implemented without computerization, are growing increasingly complex Practitioners are employing predictive modeling and analytics to improve diagnoses and effective treatments
Increasing Complexity of Medicine
Sources Forester Trends 2005 Health Plans,,
Gartner PreA dictions for Healthcare Market
Internal HCLS Level 0 and Level 1 Strategy Docs
Enabling Technology Adding both Value and
Complexity
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The traditional institutional approach to systems
and data management make it extremely challenging
to deliver and interpret information
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Moving Toward Improving Quality of Care
Quality Target
Closing the loop
Modify Care Standards
Data Warehousing, Mining
Clinical Usability
Finding the data
RHIOs!
Community Integration
Information Access
Portals, Context Mgt
MPI, Lexicon, Entity Analytics
Increasing Automation

• Information Linkage

Automation is Key to Measuring Quality
Information Delivery
HL7, IE, HUBs
Reducing Costs

• Departmental Automation

LIS, RIS, Rx, ADT, HIS, CPOE, EMR
Enhancing Pt Safety
Increasing Value
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Health Care in the 21st Century

• During the next decade, the practice of medicine
  will change dramatically, through genetically
  based diagnostic tests and personalized, targeted
  pharmacologic treatments that will enable a move
  beyond prevention to pre-emptive strategies.
• -Senate Majority Leader, Bill Frist, MD
• Health Care in the 21st Century
• New England Journal of Medicine, Jan. 2005

• "I believe we are moving into a remarkable and
  powerful new era in medicine and particularly in
  prescription drugs. I'd refer to it as an era of
  personalized medicine." 
• -HHS Secretary Michael Leavitt
• January 18, 2005

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The global healthcare challenge to improve
quality and productivity in healthcare is driving
initiatives world wide
Globally national health services and departments
are undertaking efforts to improve sharing of
clinical information

and locally many interoperability efforts are
launching in the US
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IBM endorses the Health and Human Services
Decade of Health strategic framework which
gives the industry a starting point on the road
to a national health policy
Goals from the HHS Framework for Strategic Action
July 21, 2004
Inform Clinical Practice Strategy 1. Incentivize
EHR adoption Strategy 2. Reduce risk of EHR
investment Strategy 3. Promote EHR diffusion in
rural and underserved areas
Personalize Care Strategy 1. Encourage use of
Personal Health Records Strategy 2. Enhance
informed consumer choice Strategy 3. Promote use
of telehealth systems
Improve Population Health Strategy 1. Unify
public health surveillance architectures. Strategy
2. Streamline quality and health status
monitoring Strategy 3. Accelerate research and
dissemination of evidence
Interconnect Clinicians Strategy 1. Foster
regional collaborations Strategy 2. Develop a
national health information network Strategy 3.
Coordinate federal health information systems
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Interoperable healthcare networks can improve the
efficiency, cost effectiveness, and safety of
healthcare, while delivering the greatest
possible health benefits and value to consumers
Sample Health Information Exchange Benefits
Public Health
Improved population health
Improved wellness
Improved monitoring and safety
Payers and Employers
Reduced costs
Reduced MLR
Lower absenteeism
Efficiency
Providers
Reduced errors
Improved quality
Efficiency
Other (e.g., Life Sciences)
Faster routes-to-market
Potential U.S. net efficiency gain from use of IT
in health care gt 86B per year Or 5 of total
healthcare expenditures of 1.7 T
Sources Center for Information Technology
Leadership, Partners Health Care, Harvard (2004)
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Forrester recently reported the following as a
list of active community clinical sharing
projects, but we already know that many others
are brewing
From 2005 HIMSS Presentation View From HIMSS
Building Regional Health Information
Networks Eric G. Brown, Vice President Forrester
Research
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While a common vision is developing, the
approaches to clinical information sharing vary
widely
Speed to Value
Grass Roots Sharing
From formation intended to allow for robust
clinical information sharing of different points
eHR components from disparate sources Examples Sa
nta Barbara County Care Data Exchange eHR
sharing across multiple stakeholders with
federated storage of information. Taconic Health
Information Network and Community (THINC)
Physician driven effort to connect office eHRs
with Hospitals. Broad stakeholder
involvement. SAFE Health eHR-lite sharing
across community of Worcester, MA. Joint input
from Fallon HP, Fallon Clinic, and
UMMC. Massachusetts eHealth Collaborative
Broadly focused effort to develop
interoperability model for the State. Still in
planning phase.
Initial goals on delivering more focused
functionality and services to jump start
community sharing Examples The Indiana Health
Information Exchange (IHIE) Query ability of 13
institutions and their medical staffs to
aggregated CDR. Ability to deliver physician
reports electronically. Delaware Health
Information Network (DHIN) Creation of eHR-lite
from available claims data available first in
emergency setting then wider access. Michigan
Health Information Infrastructure MA-SHARE/MedsIn
fo ED Access to prescription fulfillment
information from Pharmacy Benefits Management
firms with plans to include ePrescribing
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We view the RHIO focus from the U.S. Federal
Government as a catalyst to realize the network
effect of information in healthcare
Interoperability Relationship Model
Business Value Productivity
Quality Economy

• Data Exchange
• Mapping
• Protocols
• Traffic Management

• Information Sources
• Clinician Offices
• Hospitals
• Labs
• Payers/PBMs
• Pharma
• Patients
• Other

• Information
• Users
• Clinicians
• Hospitals
• Payers
• Pharma
• Public Health
• Patients
• Other

Core Services

• Network Access Management
• MPI
• Pointers to data
• Security
• Lexicon
• Audit
• Help Desk
• Portal

• Information
• Management Functions
• Warehouse
• Analytics
• Reports
• Query

Infrastructure Boundaries Enterprise Local
Aggregate Regional Aggregate Macro
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The ability to aggregate information in a format
that allows analysis across the community can
enable quality measurement and improvement
Data Storage
Identify Patient
Laboratory
Publish Data to Network
Data Management
Access and Display
Financials
Pharmacy
Radiology
Demographics
Clinical Lexicon
Healthcare Collaborative Network
Data Ware- House Marts
Enterprise Master Person Index
Departmental Automation
Information Usage
Data Management
Data Aggregation
Data Collection
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For stakeholders to maximize benefits in the new
ecosystem additional value must be obvious at the
end-user application level
Providers
Payers
Current Exchange Localized by domain or manually
driven
Predictive Modeling
CDR
Primary Care EMR
Medical Management

• eRX
• Lab
• eHR/ eMR
• Messaging
• Ref Auths

Decision Support Protocols
Local Integration
Local Integration
Services-Oriented Architecture
Case / Utilization Management Protocols
Administrative Efficiency
Acute Care HIS
CDR
Disease and Care Management

• Macro Integration Engine for
• Business services
• Message handling
• Security
• Information management
• Application interface

Transaction Engine for Referrals Auth.
Consumers of Care
Patient/MemberPortal
Public Health
Clinical Research
Program Management
Personal Health Record
Local Integration

• Future Exchange
• Real time
• Clinical focus
• Aggregated, and
• Automated

Health/Wellness Information
Biosurveillance
Quality of Care Management
Chat
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There are many entry points to begin realizing
the benefits of Interoperability
What Interoperability enables pick your
starting point(s)
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For interoperability to succeed you must
conceptualize the road map that ultimately will
deliver you to a sustainable operational model in
which stakeholders find clear benefits for
participation
Governance and Strategy
Business and Systems Design
Requirements Definition and Solution Design
Solution Implementation
On-going Operations and Technical Support
Reason for Being Vision Mission Guiding
Principals By-Laws Goals Objectives Success
Criteria
Business Modeling Systems Modeling Business
Plan Financial Plan Systems Plan Macro Design
Policy and Procedure Definition Design Goal
Prioritization Use Case Development Requirements
Definition Micro Design Technology Selection
Build Unit Test Systems Test User Test Roll Out
Repeat for new stakeholders and functionality
Strategic Operations Business
Operations Administrative Operations User
Technical Support Network Operations
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The WebSphere Healthcare Collaborative Network
was developed to support the needs for
information sharing in healthcare and served as
the technical foundation for our demonstration
project among leading US Health organizations

• Key Features
• The IBM WebSphere Healthcare Collaborative
  Network revolutionizes fast and secure data
  collaboration across multiple stakeholders and
  applications.
• IBM WebSphere Healthcare Collaborative Network
  integrates key clinical data from disparate
  applications allowing open standards-based
  exchange, simplifying and automating adverse
  event detection, and enabling faster and easier
  aggregation and analysis of information for
  quality of care management.
• Message Oriented Integration Architecture -
  Secure publish and subscribe Using standards
  based technologies and messaging (HL7, MAGE-ML,
  etc.) connects to existing clinical information
  systems applications, Lab, Pharmacy, and
  Admission/Discharge systems
• Infrastructure for electronic data aggregation
  and correlation (for Datamarts)

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Healthcare leaders backed the HCN demonstration,
to enable rapid sharing of health data and
improved bio-surveillance, which included federal
agencies and nationally recognized institutions
Healthcare Collaborative Network (HCN) Solution

• Enables rapid detection and response to adverse
  healthcare events including bio-surveillance
• Creates lower cost capabilities for collecting,
  aggregating, analyzing and reporting clinical
  information at near real time
• Establishes a common electronic healthcare
  information highway that supports government,
  non-profit, and private industry needs

Initial goals
Leverage Acceptable Data Sharing Protocols
NY Presbyterian Hospitals Vanderbilt University
Medical Center Wishard Memorial MedStar Health
CDC CMS FDA
Demonstration participants
IBM
Promote Clinical Reporting Standards
MedStar hospitals connected are Franklin
Square Hospital Center Good Samaritan Hospital
Harbor Hospital Center Union Memorial Hospital
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HCN Architecture
Key Design Elements

• Components Portal, Broker, Gateway
• Leverages legacy systems
• HCN uses existing open data standards and a
  non-proprietary implementation approach (e.g.
  ICD, CPT, LOINC, via HL7)
• Meets highest security standards (authentication,
  encryption, HIPAA)
• As soon as a health topic is satisfied all
  information available on the related patient
  event can be shared

EHR
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Specific examples of HCN in practice give a
picture of how organizations can benefit

• Clinical Data Repository Population (EHR)
• Aggregate electronic health records from multiple
  sources for patient care
• For intelligent data warehouse population
• Quality of Care Analysis
• Prompt identification/notification of patients
  for whom care departs from established care paths
  
• Development of best practice guidelines for
  specific patient populations facilitated through
  easier aggregation and analysis of outcomes
  across disparate systems
• Evaluation of the practices pattern for specific
  patient population to support outcomes
  assessments
• Detection of Adverse Drug Events
• Evaluation of drug effects relative to outcome
  indicators like lab values
• Patient with prescription for Coumadin exhibiting
  International Normalized Ratio (INR)/ Prothrombin
  Time lab result greater than 8
• Monitoring across larger populations for lower
  frequency adverse events
• Public Health Alerts
• Rapid notification of sentinel events related to
  direct diagnosis of public health concerns
• Rapid notification of syndromic indicators which
  could warrant deeper epidemiologic investigation
  as precursors of outbreaks

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Across the healthcare ecosystems HCN supports the
needs of many stakeholder relationships

• Hospitals - Internal collaboration for
• Research/ Outcomes Analysis/ Quality Improvement
  Studies
• Adverse Event Detections
• Hospitals and Payers
• Improved coordination for case management
• Improved identification of disease management
  candidates
• Support for quality incentive programs
• Hospitals and Pharmaceutical Researchers
• Identification of candidates for clinical trials
• Post market population analysis
• Compliance observation for outcomes analysis
• States (and Local) - Public Health Reporting
• Bio-surveillance/ Situational awareness
• Health/disease management program candidate
  evaluation, outcomes analysis and resource
  planning
• Population monitoring

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HCN is ready today to enhance the capabilities
for collaboration among various stakeholders in
support of improved quality and reduced medical
errors

• Summary of HCN solution benefits
• Enables monitoring groups (e.g. Local health
  jurisdictions, FDA, CMS, CDC) to improve
  detection and response time for bio-surveillance,
  adverse drug reactions, quality of care, and
  disease outbreaks
• Enables rapid ability to aggregate and share data
• Enhances ability to judge quality of care
• Facilitates and improves efficiency of mandatory
  reporting and collaboration with business
  partners
• Provides a secure environment for clinical data
  transmission using SSL and the highest level of
  encryption
• Leverages existing applications minimizing
  barriers to implementation

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IBM believes the service oriented architecture
model the bus is best to meet the needs of
multi-stakeholder solutions
Patient ID. Results HC Data Entry Clinical
Msgs Collaboration
Patient ID. Ins. Financial Health Status Clinical
Msgs Alerts Collaboration
Medical Mgmt Quality Programs Collaboration
Physicians Portal (PCP)
Patient Portal
ER Doc Portal

Consumer Portal
Provider Portal
Payer Portal
Enterprise Service Bus
MED
Location Services
Partners

• Directories
• Patient
• Provider
• Location

Context Management
CDR
Security
Provider Systems
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The Enterprise Healthcare Service Bus can offer
stakeholders basic as well as enhanced functions,
both clinical and technical

• Business Services
• Authentication and Access Control
• Patient Index and Cross Reference
• Location Services
• Decision Support Engine
• Risk Modeling Engines
• Repository Consumer or Provider
• Workflow and Context Management
• MED Medical Entities Dictionary
• NLP Natural Language Processing
• Business Partner Connections
• Lab
• Pharmacy
• Eligibility
• Audit Logging
• Monitoring, Reporting, and Alerting

• Technology Foundation
• Integration Engine
• Industry Specific Connectors and Data Handlers
• HL7, CDA, CCR
• DICOM
• XML
• ebXML
• EDI
• Connectors
• JDBC
• FTP, SMTP
• ODBC
• Text, etc.
• CIT System application adapters
• Mapping, Transformation, De-Identification -
  Pub/Sub
• Applications supporting services (e.g. EMR,
  Clinical Messaging, eRX, Decision Support)

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IBM is extending this model through the
development of the Integrated Healthcare
Infrastructure (IHII)
IHII ArchitectureClinical Affinity Domain
Rural Practice
Large Healthcare Enterprise
Hospital Information System
Enterprise Service Bus
IHE XDS Standard


PC or Browser
Enterprise Service Bus




DocumentRepository
DocumentRegistry
DocumentConsumer
DocumentSource
PIX
Portal
RIS
HIS
Summarization(EHR Extract)
CentralizedStorage
Annotation
Locator
Workflow
MPI Server
RHIO (shared infrastructure)
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Expectations for realizing the goal of
interoperability need to balance the input of
People, Process and Technology

• Technology
• Spend more time up front on appropriate design to
  mitigate implementation churn
• Technology for this solution can be complex -
  think component and standards based to facilitate
  integration
• Assure technical design captures the network
  goals but can be componentized to allow for
  manageable phases
• Hire skilled and technically knowledgeable
  resources to manage projects AND day to day
  operation or a technology partner to provide same

• People
• Committed leadership from primary stakeholders
• Make communications a cornerstone of your
  operations - among stakeholders and the community
• Establishment of realistic goals and a plan to
  progressively add value to stakeholders as
  functionality matures
• Define clear and measurable success criteria
• Dont take short cuts especially on foundational
  governance tasks
• Be as inclusive as possible without getting
  unwieldy

People
Process
Technology

• Process
• Clearly define how decisions will be made for the
  initiative and the organization
• Set conservative operating budgets (sunny day vs
  rainy day planning)
• Be realistic about attaining financial targets.
  Sustainability will come from making the numbers
  work for your community
• Address legal and policy issues early as
  challenges to design but not deal breakers

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IBM has made much progress helping our clients
achieve interoperability through various stages
InterOperability
Consortium
IntraOperability
BioSurvelliance / Public Health
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Conclusion
Dont loose sight of the big picture
Governance and Strategy
Business and Systems Design
Requirements Definition and Solution Design
Solution Implementation
On-going Operations and Technical Support
and strive to adopt a disciplined but adaptive
approach to achieving your vision
"Far better to dare mighty things, to win
glorious triumphs, even though checkered by
failure, than to take rank with those poor
spirits who neither enjoy much nor suffer much,
because they live in the gray twilight that knows
not victory, nor defeat. - Theodore Roosevelt -
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Summary Discussion
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Mark McCourt Global Solutions Sales
Leader Clinical Interoperability IBM Healthcare
Life Sciences Office [phone] mobile (520)
247-3042 Email mmccourt_at_us.ibm.com
http//www.ibm.com/solutions/healthcare