Volunteer eHealth Initiative

a regional demonstration project

Mark Frisse, MD June 8, 2005 Washington, DC

Funding: AHRQ Contract 290-04-0006; State of Tennessee; Vanderbilt University This presentation has not been approved by the Agency for Healthcare Research and Quality Portions of this presentation derive from a planning engagement conducted with Accenture

SW Tennessee Project

Establishing complete secure access to critical health information for all consenting patients seeking care in 3 counties (over 3 years) Create a more effective health information infrastructure across providers and payers Identifying major technical, policy, and regulatory barriers to a more consumer-focused health care delivery system Assure complete privacy and confidentiality Performing a rigorous cost-benefit analysis $5 Million AHRQ Funding; $7 million state funding; $750k VU funding

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Regional Approaches: Assumptions

There is lost value because of an inability to coordinate the exchange of information across a patients lifetime Such coordination begins at the local and then the regional level Coordination among all regional stakeholders requires new organization and governance approaches Such approaches can capture this additional value and distribute it to stakeholders in an equitable way Such approaches can evolve from the status quo and not be stymied by efforts to forestall change
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Where is the Value?

More informed decision making by providers and consumers Lower health delivery costs to payers esp. Medicaid, and employers Better management of test utilization More efficient management of pharmaceuticals Secure messaging to physician practices and other care settings Aggregating pay-for-performance or quality data Consumer-driven health care services
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A Process

Starting Point

Defining Roles

Picking a Model

Operations

Evolution

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Starting Points Each starting point represents a burning platform capable of fostering a guiding coalition to attain improvements

Medicaid Uninsured Employers Plans Hospitals Physician practice groups Pharmacies and pharmaceuticals Federal initiatives and CMS regulations
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Defining Roles Roles for various parties have to be defined to assure effective operation and demonstration of value

The convener

Setting the ground rules; governance

The financial transaction infrastructure

Claims infrastructure; efficiencies; trust; revenues

Safety, efficiency, efficacy, outcomes

The clinical data exchange infrastructure

The last mile

Enabling health care professionals physicians, retail pharmacies, home care, nursing homes Empowering patients and their families
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Source: Massachusetts model Halamka, Tripathi, et. al

Models Different architectural models have arisen in different areas as a result of need, capability, and circumstances

Collaboration communities NY, Oregon, Colorado Broad, community-based Mass., Santa Barbara Transaction networks Utah, Mass. Plan-based proposed in multiple states Hospital-clinic-initiated - Indiana

All models should, over time, converge on a core set of community stakeholders and value propositions

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Picking the Model: SW Tennessee Current emphasis of the SW Tennessee work is focused on the convener and the clinical data exchange.

Convener State, local government => Driven by Medicaid costs The financial transaction infrastructure Left to the market and plans The clinical data exchange infrastructure Modeled on a hybrid version of the Indianapolis work The last mile Left to the market and plans E-prescribing is driven by choice
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Technology: Low Entry Costs and then Evolve

see: http://www.volunteer-ehealth.org/AHRQ/technology-overview.htm
Volunteer eHealth Initiative Data Bank Health Care Entity Internal Systems
Publish Data

Vaults
Identifier Information - Patient Identifier numbers - Facility identifier - Patient name - Date of birth - Gender - Social security number Data - Demographics - Lab - Transcribed reports - Pharmacy - Orders

Regional Index
Person 1 Composite Information Person 2 Composite Information Person 3 Composite Information Link 1 Link 1 Link 1 Link n Link n Link n FAX Server

Hospital

Publish Data

Clinic

Identifier Information - Patient Identifier numbers - Facility identifier - Patient name - Date of birth - Gender - Social security number

Parsing/Integration Engine

Data - Demographics - Lab - Transcribed reports - Pharmacy - Orders

Record Locator Service

Record Access Service

Web User

Pharmacy

Publish Data

Identifier Information - Patient Identifier numbers - Facility identifier - Patient name - Date of birth - Gender - Social security number

Data - Demographics - Lab - Orders

: :

Printer

Laboratory

Publish Data

Identifier Information - Patient Identifier numbers - Facility identifier - Patient name - Date of birth - Gender - Social security number

Data - Demographics - Lab - Orders

Person n Composite Information

Link 1

Link n

Data is published from data source to the exchange Participation Agreement Patient Data Secure Connection

Exchange receives data & manages data transformation Mapping of Data Parsing of Data Standardization of Data

Organizations will have a level of responsibility for management of data Issue Resolution Data Integrity Entities are responsible for managing their Data

Data bank compiles and aggregates the patient Data at the regional level Compilation Algorithm Authentication Security

User Access

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Batch / Real-Time

Queue Management

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Benefits

Emergency department utilization shows that information exchange among providers will benefit the care of patients in the regions emergency rooms.
Emergency Department Activity

Approximately 11% of the three-county population used the Emergency Department more than once a year
99% of the patients treated were seen in two or more Emergency Departments On average patients used the Emergency Department five times a year 7% of the patients used the Emergency Department more than 10 times in a year Information sharing will enable clinicians in the emergency departments access to emergency department history across the region as well as other clinical care settings to provide the patient with the most appropriate care.
Sources: 1 Data supplied by Memphis Managed Care 07/2003-07/2004

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A data exchange across the core healthcare entities can achieve significant dollar savings over a five year period.
Overall Benefit

The exchange of data among the core healthcare entities has potential to reach $24.2 million in savings.
Dollar Savings (millions) $5.6 $0.1 $0.1 $9.0 $3.8 $5.5 $24.2

Financial Measures Reduced inpatient hospitalization ED communication distribution Reduced IP days due to missing Group B strep tests Decrease in # of duplicate radiology tests Decrease in # of duplicate lab tests Lower emergency department expenditures Total Benefit

Notes: 1 Core healthcare entities include: Baptist Memphis, Le Bonheur Childrens Hospital, Methodist University Hospital, The Regional Medical Center (The MED), Saint Francis Hospital, St. Jude Childrens Research Hospital, Shelby County/Health Loop, UTMG, LabCorp, Memphis Managed Care-TLC, Omnicare

If data is exchanged across all facilities within the three-county region, the overall savings has potential to reach $48.1 million.
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Operations Over time, operations move from a project to a largely regional organization Goal is to move toward complete regional ownership with Vanderbilt technologies as an initial vendor A regional oversight group manages the effort the MidSouth eHealth Alliance Core technology and evaluation group in Nashville as sub-contractor to state Program management office is in Nashville presently Developing on-site group in Memphis area

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Evolution It is a race to identify the value so that a community can make informed decisions about health care

Must conduct enough work to fully document the costs and benefits of comprehensive information exchange e.g, core medical history Challenge is to complete work before the value is carved up by disparate initiatives Threats to sustainability will require greater commitment from employers, other payers, and plans Growth to patient care settings will require greater consumer involvement VU technologies are to help understand and define a market, not dominate by first mover advantage When market defined (several years), software will have been componentized and all put out to bid
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Common Lessons

Many ways to achieve some connectivity Trade-offs between quick wins and long-term market solutions No way to achieve comprehensive interoperability Secure messaging (e.g., sending lab reports and discharge summaries via email) pays Disagreement over value how much and when Emergency departments - ROI for hospitals? Governance & compelling value propositions are critical Incentives are not aligned for participants Low tech very effective, but difficult to reach the small medical practice with advanced clinical systems Some national issues e.g., pharmacy & lab information Trust takes coercion or time preferably a little of both

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Common National Themes

Organization and governance Legal agreements Security Privacy Technology models Value Financing Sustainability Growth and extension

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