Health Information Exchange:Myths, Mirages and Reality

Donald P. Connelly, MD, PhDUniversity of Minnesota

September 8, 20082008 AHRQ Annual Conference

Information Gaps in the Emergency Dept.

Gaps are frequent - 32% of visits

Gaps are consequential Very important or essential 48% Somewhat important 32% Prolong the ED stay Increase costs

Redundant testing & repeated MD assessments

Stiell A et al. CMAJ 2003; 169:1023-8.

Rationale for sharing an abstract instead of the entire record

Contents are bounded & defined Patients “get it.” They understand the value of a

concise clinical abstract for themselves and their providers

Avoiding sensitive content means easier consenting & wider use

A better first step for a public wary of confidentiality breaches

While not the entire record, clinicians endorse the abstract as having high clinical value

The abstract’s succinctness is preferred by some emergency room physicians

Interoperability across vendor platforms should be easier

“My Emergency Data” Abstract

Patient Information Contact Information Primary Care MD &

Clinic Advance Directives Current Problem List Current Medications Allergies Immunizations Surgical History Family Medical History Alcohol and Tobacco use

Our setting The Twin Cities’ healthcare delivery

market is highly concentrated into a few large healthcare systems (i.e., an oligopoly)

Our project’s health system partners are: Allina Hospitals and Clinics Fairview Health Services HealthPartners

Each partner system has adopted Epic as its primary EMR vendor

The highway mirage

Heightened privacy concerns and changing laws

Minnesota privacy law is especially stringent Patient consent is required for nearly all

disclosures, including treatment Limited exception to consent requirement

Medical emergency Record movement within “related” health care entities

Written consent (signed & dated) is required

Heightened privacy concerns and changing laws (continued)

Minnesota’s new 2007 privacy law facilitated HIE Allowed representation of consent Apportioned liability for inappropriate disclosure Defined record locater service (RLS)

RLS clause presumed a centralized model Global opt-out option is required Partners’ EMR software doesn’t appear to comply

Litigation leery lawyers Interstate clinical information transfer is

even more problematic

Slow and circuitous uptake of interoperability standards

Continuity of Care Document (CCD) standard approved in slow-to-develop SDO compromise in early 2007 AHIC endorsed HITSP’s recommendation of the

CCD standard EHRVA included CDA/CCD in their

interoperability roadmap The EMR vendor’s interoperability business

model continues to evolve A single-vendor dominant, universal-sharing

model Working with CCD for multi-vendor sharing

The great EMR-PHR debate

MN HIE (Minnesota’s Health Information Exchange)

Participation in MN HIE’s formation was important to ensure a public-private solution

Proof of concept using e-prescribing history was demonstrated early

Commitment to use MN HIE to transport abstract made last fall

Pilot use of MN HIE scheduled near end of grant period and limited to e-prescribing

Broad acceptance, sustainability and privacy remain as key challenges

Healthcare systems respond to external drivers

Local healthcare competition has heightened over the past few years

Profitability is in a down cycle in our local competitive, low margin setting

Four of our six healthcare system board members have moved on including one of our strongest advocates for “It’s the patient’s data”

Electronic information sharing very strong in terms of administrative claims data sharing but still nascent for clinical data

North Dakota Capitol Building

Crossing the wide Missouri

Grandma’s house

Changing culture, work, & relationships takes time

Privacy is a societal issue – citizens, legislators, and stakeholders are now engaged

Interoperability standards are new and need some evolution

The business case for clinical information sharing must be made. Use it to solve real problems and demonstrate its value

This all takes time. Have patience. You can’t do it all.

HIE takes collaborative effort

Acknowledgements The many dedicated and committed

participants from Allina Hospitals and Clinics Fairview Health Services HealthPartners University of Minnesota

Our project’s Board members AHRQ This project was funded in part under Grant Number UC1

HS016155 from the Agency for Healthcare Research and Quality, US Department of Health and Human Services.