Health Information Exchange and the National Agenda

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Health Information Exchange and the National
Agenda May 2008 Kelly Cronin Director,
Programs and Coordination Office of the National
Coordinator for
Health Information Technology (ONC)
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HIE and the National HIT Agenda

• Where are we?
• Challenges
• Overcoming the barriers
• Moving toward a connected network of networks
  the NHIN
• Trial implementations
• Accreditation and certification
• Develop the business case
• Where do we go from here?

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Key Health IT Components to Enable Transformation
A Robust, Interoperable, Health IT Environment
that brings together

• Electronic Health Records (EHR)
• Personal Health Records (PHR)
• Population Health Information (Public
  Health, Quality Improvement, Research)

• Standards (Data, Technical and Security)
• Interoperable Health Information Exchange Network
• (Nationwide Health Information Network -
  NHIN)

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Pieces of the Puzzle Necessary for Transformation
of Health and Care through HIT
Governance
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Status of HIE Findings from eHI Survey

• 125 initiatives reported on stage of development
  in the 2007 survey
• 20 are just getting started (stage 1 or 2)
• 68 are in the process of implementation (stage 3
  or 4)
• 32 are operational (stage 5, 6 or 7)
• 5 are no longer moving forward
• 15 fewer participating than in 2006
• 32 HIEs exchanging data (Stages 5-7)
• 25 dependent on grants (or dont know)
• 75 rely on results delivery (but other sources
  important as well)

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Funding Sources for RHIOs in 2007
Funding Source Overall Advanced
Hospitals 24 58
Public Payors 21 38
Physician Practices 16 46
Laboratories 13 33
Private Payors 10 46
Philanthropic 9 29
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Services Offered in 2007
Service Overall Advanced
Results Delivery 30 75
Clinical Documentation 27 63
Enrollment or Eligibility Checking 26 54
Consultation/Referral 21 54
Alerts to Providers 19 48
Disease or Chronic Care Management 18 32
Disease Registries 14
QI Reporting for Clinicians 12
Reminders 12 33
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32 Operational Initiatives Sources of Revenues
Funding Source 2007 2006
Hospitals 58 54
Payers Private 46 19
Physician Practices 46 33
Payers Public 38 18
Laboratories 33 42
Federal Government 29 17
Philanthropic Organizations 29 21
State or Local Government 21 26
Purchasers/Employers 17 0
Pharmacies 13 11
Pharmaceutical Companies 4 6
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State Level HIE - An Evolving Landscape
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Major Challenges for All HIE Initiatives
Challenge 2006 2007
Developing Sustainable Business Model 88 91
Securing Funding 88 80
Defining Value for Users of the HIE 89 81
Privacy 79 85
Engaging Clinicians 80 82
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Challenges Sustainability of HIE

• No silver bullet to get to viable business model
• Need to be market savvy and develop HIE services
  that meet a customer need and deliver value
• No obvious demand for HIE with current
  reimbursement system
• But an increasing number of RHIOs are in the red
• Successful RHIOs are inducing demand by providing
  services that demonstrate value
• Know your customer dont build it and expect
  they will come
• Need business acumen and good market research to
  develop a viable, marketable services
• Social capital is essential for effective
  governance and sustainability

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Challenges Value Proposition

• Needs to be defined according to type of service
  and from each stakeholders perspective
• i.e., results reporting for hospitals
• Are the costs and benefits of each
  function/service for each stakeholder different
  at a regional and state level?
• Some providers, employers or plans might only
  have a regional interest
• Data suggests that hospitals are deriving value
  more often than other stakeholders
• Employers seem least likely to be engaged

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Value from a higher level perspective

• Health information exchange can
• Produce cost savings from decreased redundancy
• In duplicated care
• In the costs of data sharing
• Enable quality improvement and Medicare payment
  reform by making clinical (not just claims) data
  available for performance measurement and
  reporting
• Support public health and emergency preparedness
  including situational awareness and response
  management

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What is the problem we are trying to solve?

• Market forces have not realized the potential of
  electronic health information exchange
• Fee for service payment system provides no
  incentives to share data
• Cost savings dont accrue to those who need to
  invest
• Proprietary, one to one, relationships are easier
  to create technically and legally
• Public health does not get the data it needs
  its viewed as a government, not a private sector
  responsibility
• The tipping point for participating in data
  exchange has not been achieved

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Different models for exchanging health information
Network Type Examples Example Benefits Biggest Challenge
Organizational Integrated delivery systems, hospital chains Effort of exchanging data internally is aligned with business outcomes Extra-organizational exchange is needed for care provided in other organizations
Geographic RHIOs, jurisdictional HIEs Non-proprietary exchange Struggle to achieve sustainable business models
Personally Controlled Health data banks Microsoft, Google, Intel Consumer access to, and control of, health information Based on point to point connections, have challenges in supporting provider data access
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Collaborative Governance Needed Across
Jurisdictions

• With varying approaches to HIE, multi-stakeholder
  governance is needed at the regional, state and
  national level
• There is currently no coordination of HIE
  governance across jurisdictions to eventually
  reach interoperability on a technical and policy
  level
• Some state level governance entities coordinate
  with RHIOs but not all
• No explicit coordination exists between national
  and state level governance
• National governance has been informal through
  AHIC and Secretary Leavitts leadership
• No oversight mechanisms exist to ensure
  accountability of HIE
• State governments are increasingly interested in
  accountability and mechanisms to protect
  consumers
• Accreditation and model data sharing agreements
  could support trust among stakeholder involved
  with HIE and protect consumer interests

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Some Solutions to Challenges

• Improve business case at regional, state and
  national level
• Stakeholder specific value propositions
• State and federal policy changes
• Advance governance of HIE
• Establish national level governance
• Promote effective governance models at state
  level
• Consider oversight mechanisms such as
  accreditation to support interoperability of
  policies/data sharing agreements
• Identify and adopt common standards and
  specifications for health information exchange

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Where are we going?

• What projects and efforts are advancing HIE?

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State-level Health Information Exchange Consensus
Project

• State-level HIE governance role is primary
• Ensure that HIE develops as a public good
• Serves all statewide stakeholders and data needs
• Reduces technology investments and other costs
• State-level HIE governance entity is a
  public-private partnership entity
• Sits between state government and the health
  sector and industry
• Involves state government, but independent of
  state government
• Addresses public and private sector interests,
  blends investments
• Mechanism for coordination of HIE policies and
  practices
• State governments play important roles
• Designating authority to a state-level HIE
  governance entity
• Providing resources start up and ongoing
• Leveraging public programs, policy levers to
  create incentives for HIE
• Statewide technical approaches can vary and will
  likely evolve
• Size, market characteristics, resources, stages

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State-level HIE Leadership Forum

• In 2008, a forum will be established for all
  states to share information among peers who are
  responsible for leading state level efforts to
  advance HIE
• Enable peers to learn from each other and share
  progress, challenges, and creative ways to
  advance statewide agendas
• The forum will foster better understanding and
  coordination of many related but separate
  projects to advance HIE including HISPC, HITSP,
  NHIN, CCHIT, and AHIC 2.0

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State Alliance for e-Health

• Examination of Financing, Accountability and
  Oversight Models to Sustain Health Information
  Exchange
• To inform Governors and State Legislators about
  the various models for financing and ensuring
  accountability
• A key financial consideration appropriate role
  for states in providing oversight and support
• Final report to the Alliance in August 2008

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The AHIC Successor Why Change?

• Continuity of leadership is needed to sustain the
  momentum gained over the past 24 months
• Government transition occurs every four years
• Uncertainty under new leadership places momentum
  at risk
• Sustainable business model is needed to support
  perpetual operation
• Congressional appropriations are a cyclical model
• Decisive action is needed keep pace with large
  scale innovation and transformation
• Government is necessarily a deliberate process

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AHIC 2.0 What It Will Do

• Provide continuity -- accelerate and coordinate
  current AHIC interoperability initiatives
• Provide strong leadership in
• determining priorities
• harmonizing interoperability standards
• certifying products and systems to those
  standards
• overseeing and facilitating the NHIN
• establishing criteria for assuring
  interoperability, privacy and security
• Construct and champion a balanced view
• that takes into account the needs of all
  stakeholder groups

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NHIN Trial Implementations

• Awards to 9 state regional Health Information
  Exchanges (HIEs) and another 6 grants to other
  entities
• Forming the NHIN Cooperative to implement, test,
  and demonstrate core services by September 2008
• Support of consumer access controls
• Lookup and retrieval of clinical information
• Exchange of patient summary records
• Test implementations of the first 7 priority
  scenarios
• Lab result reporting medication history
  exchange quality and public health, etc.
• Expanding to include other types of HIEs, such as
  
• Multi-community Integrated Delivery Systems
• Health plans
• Health data banks

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NHIN Business Model

• Contract awarded to nine HIEs for trial
  implementations of inter-HIE connectivity
• Contract requirement to develop business model
• Emphasis on HIE-to-HIE sustainability.
  Considerations may include
• What are the business drivers for inter-HIE
  connectivity?
• Sourcing of core services (in-house, outsource,
  some services being provided by a state-level
  HIE, etc.)
• Costs to obtain core services
• Source of funds for start-up costs and ongoing
  funding options
• What is the value proposition for each
  participant in the transaction?
• How does cost and benefit distribution work for a
  transaction that has participants residing in
  more than one HIE?

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Other Federal Activities Addressing Sustainability

• Six state HIE initiatives with State and Regional
  Demonstration Project contracts from AHRQ are
  informing business model development using the
  eHI Value and Sustainability Model
• AHRQ sponsored case studies of stakeholder
  engagement in HIEs and the impact on
  sustainability
• Thirteen state Medicaid agencies are using their
  Centers for Medicare and Medicaid Services
  Medicaid Transformation Grant awards to advance
  HIE efforts within their states.
• State-level HIE Consensus project will address
  the Value Proposition for each Stakeholder
  participating in a state-level HIE

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Important Next Steps to Advance Sustainable HIE

• Coordinated research agenda
• NGA, eHI, AHIMA, HHS, and other partners work
  together to answer key questions
• State and federal policy development to support
  sustainability
• Commonwealth report called for mandates for
  providers to participate in interoperable
  networks
• AHIC 2.0 established - national governance
• State Forum established to facilitate state level
  approached to HIE governance

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The Ultimate Reason for Health IT
Health IT is a key enabler for us ALL to get
The quality of health we want and deserve The
quality and value of health care services we
demand
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For More Information
www.hhs.gov/healthit