MASSACHUSETTS eHEALTH COLLABORATIVE HIT Symposium July 2006

MASSACHUSETTS eHEALTH COLLABORATIVE

HIT Symposium

July 2006

- 2 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.

MASSACHUSETTS COMMUNITY OF E-HEALTH ORGANIZATIONS

1978 1998 2003

The convener and educational organization, the business incubator

The transactor of administrative (HIPAA transaction) processes

The grid of state-wide clinical utilities

The last-mile to clinician offices

“The Convener”

2004

“The Transactor” “The Grid” “The Last Mile”


MAeHC ROOTS ARE IN MOVEMENT TO IMPROVE QUALITY, SAFETY, EFFICIENCY OF CARE

• Universal adoption of electronic health records

• MA-SAFE

• $50M commitment to heath information infrastructure

• Recognition of “systems” problem

• Company launched September 2004

– Non-profit registered in the State of Massachusetts

• CEO on board January 2005

• Backed by broad array of 34 MA health care stakeholders


34 ORGANIZATIONS REPRESENTED ON MAeHC BOARD

Health plans and payer organizations

• Alliance for Health Care Improvement

• Blue Cross Blue Shield of Massachusetts

• Fallon Community Health Plan

• Harvard Pilgrim Health Care

• Massachusetts Association of Health Plans

• Massachusetts Health Quality Partners

• Tufts Associated Health Maintenance Organization

Healthcare purchaser organizations

• Associated Industries of Massachusetts

• Massachusetts Business Roundtable

• Massachusetts Group Insurance Commission

Non-voting members

• Center for Medicare & Medicaid Services

Hospitals and hospital associations

• Baystate Health System

• Beth Israel Deaconess Medical Center

• Boston Medical Center

• Caritas Christi

• Fallon Clinic, Inc.

• Lahey Clinic Medical Center

• Massachusetts Hospital Association

• Massachusetts Council of Community Hospitals

• Partners Healthcare

• Tufts-New England Medical Center

• University of Massachusetts Memorial Medical Center

Governmental agencies

• Executive Office of Health and Human Services

Healthcare professional associations

• American College of Physicians

• Massachusetts League of Community Health Centers

• Massachusetts Medical Society

• Massachusetts Nurses Association

Consumer, public interest, and labor

• Health Care for All

• Massachusetts Coalition for the Prevention of Medical Errors

• Massachusetts Health Data Consortium

• Massachusetts Taxpayers Foundation

• Massachusetts Technology Collaborative

• MassPRO, Inc.

• New England Healthcare Institute


MAeHC VISION

Improve quality, safety, and affordability of health care through:

• Universal adoption of modern information technology in clinical settings

• Access to comprehensive clinical information in real-time at the point-of-care

Tools for better, more accessible health care…

…incorporated into clinical practice…

Overcome barriers to promote widespread use of EHRs and associated decision support tools

• Lack of capital

• Misaligned economic incentives

• Immature technology standards

…and sustained over time.

Develop operational and financing models to foster and sustain state-wide adoption of such technologies and infrastructures


MAEHC MISSION: CLINICAL IT ADOPTION THROUGH COMMUNITY EMPOWERMENT


PILOT PROJECTS HAVE FOUR MAIN PIECES

• Quality• Cost• Productivity• Etc.

ConnectivityConnectivity

Clinical IT implementation/

support

Clinical IT implementation/

support

EvaluationEvaluation• Quality measurement

• Pilot evaluation

• Clinical access to data

• Data gathering and aggregation

• Communication

• Hardware/software

• Implementation/tech support

• Systems integration

• Workflow redesign

• Decision support

Intra-community connectivity

Management & coordination

Management & coordination

• Joint oversight and decision-making bodies

• Multi-stakeholder governance

ICCC

PSC PSC PSC


MAeHC PROJECT TIMELINE

Activities 2004 2005 2006 2007 2008

ACP-MA summit

MAeHC launch

Community RFA launch

Pilot communities announced

EHR vendor RFP

EHR vendor finalization

Physician recruitment

Implementation

Evaluation

Formal Pilot completion


EVEN $50M CAN’T GET THE LAST 5%

0

20

40

60

80

100

120

140

160

180

200

Initial practices Ineligible Opted out Signed contract

180 22

1499

Most didn’t fit MAeHC definition of community

Main sources of attrition:• Outyear cost• Close to retirement• Too much of a hassle

149158

=94%

participation


DIVERSE ARRAY OF SETTINGS

Offices

0

100

200

300

400

500

600

350

Patient population (000)

95

43 488

0

20

40

60

80

100

120

140

160

180

200

111

41

25177

Small

Med

Large

111

37

27

175

184

48

38

270

0

50

100

150

200

250

300

350

400

450

500

295

85

65 445

PCPs

Specialists

Physicians

Almost 450 physicians……who care for ~500K

patients……in almost 200 offices.

BrocktonNewburyport

N. AdamsAll

BrocktonNewburyport

N. AdamsAll

BrocktonNewburyport

N. AdamsAll


HIGHLAND PRIMARY CARE KICK-OFF

Docs link up to new record styleBy Jennifer Heldt PowellTuesday, March 14, 2006

The end of the paper trailBy Ulrika G. Gerth/ [email protected], March 17, 2006

Setting a new record: Local doctors pilot electronic patient history system By Stephanie Chelf Staff Writer


PHYSICIANS “GOING LIVE”, BY COMMUNITY

0

50

100

150

200

250

300

350

400

450

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Total

# MDs

2006 2007

North Adams(55)

Newburyport(81)

Brockton(305)

9 7 5 19 21 33 25 24 27 67 121 9 64 1 7 1 441


THE GRID AND THE LAST MILE

Inter-community connectivity

MA-SHARE

Intra-community connectivity


THE NEXT PHASE: CONNECTING PHYSICIANS

Health Information Exchange

Patient permission

Privacy and security

Clinical utility

Sustainability


NORTH ADAMS HEALTH INFORMATION EXCHANGE

ehr ehr ehr

ehr

ehr

HIS

eCR eRef

ePatient

Patient portal

Patient-specific functions

• Appointment requests• e-visits• Clinical summary• Other

Patient-centric clinical summary

• Medications• Labs• Allergies• Problems• Other

eReferrals• Secure-messaging between care-givers• Tracks and matches outbound/inbound referrals, and outbound/inbound consult reports

Physician portal


DRIVERS OF BUSINESS SUSTAINABILITY

Low

Clinical data fields in eHealth Summary

Structured, codified data Unstructured, text

High

Patient opt-insClinical usefulness

Low High

Physician adoption

Labs Medications Problems Allergies Medical/family history

Notes

Business sustainability threshhold


PRIVACY APPROACH SUMMARY (I)

MAeHC and communities need to decide what patient notification or consent we will require for data exchange in community pilots

• Not required for stand-alone EHRs

• Will be required for data exchange across legal entities

Data exchange already happens today

• Current exchanges happen by fax, phone, mail, email, and remote access

• Community network could change the scale but probably not scope of that exchange (ie, same type of information will be exchanged but more often)

• With no “person-in-the-loop”, electronic data access may seem more risky, whether it is or not


PRIVACY APPROACH SUMMARY (II)

Even though we’re just changing the transport vehicle, we can’t rely on existing notifications and consents to cover exchange over the new network

• MAeHC commitment to transparency will necessitate some form of patient notification or consent about new network

• Furthermore, we can’t assume that current entities have gotten patient consent that conforms with MA consent laws– very likely that many have not

Notification about the network is not enough – MA law argues for some form of affirmative consent BEFORE disclosing data across legal entities

• HIPAA Notice of Privacy Practices does NOT count for MA consent

• MA consent requires affirmative consent for disclosure of clinical information, and a second affirmative consent for disclosure of sensitive information

Question before us now is how to get patient consent in a way that is ethically and legally robust and operationally sound


ENTITY-BY-ENTITY OPT-IN (REPOSITORY MODEL)

Jane Jones

Patient visits clinical entity for care and is provided option at first visit to opt-in all clinical data from EACH entity

Patient visits clinical entity for care and is provided option at first visit to opt-in all clinical data from EACH entity

1

Visit

YY Y YN

2

Patient chooses which entity’s records to make available to network

Patient chooses which entity’s records to make available to network

Consent

Jane Jones

3

Name-location index published for entities who have gotten consent

Name-location index published for entities who have gotten consent

Publish

Physician views data prior to or during patient visit

Physician views data prior to or during patient visit

4 Retrieve

Community Network

Jane Jones eCommunity RecordJune 9, 2006

Visit historyxxxxxx

Active problem listxxx Dr. Jane Brody

Current medicationsxxx Seacoast Cardio

Current allergiesxxx Dr. Jane Brody

Recent laboratory resultsxxx AJ Hospital

Recent radiology resultsxxx AJ Hospital

Otherxxx XXX


Adoption

EVALUATION PROGRAM WILL SUPPORT THREE KEY PILOT PROGRAM OBJECTIVES

• What are the most significant adoption barriers?

• What are the best ways to overcome them?

• What are the costs (direct and indirect) of adoption of IT?

• What are the benefits?

• How are the costs and benefits distributed across payers, providers, government, patients, ancillaries, etc?

• How much money will be required to implement statewide?

• What is general framework of incentives to implement and sustain the model?

• What are the most effective management strategies for implementing and sustaining in communities?

• What are the most effective organization models and tactics for implementing and sustaining statewide?

Value

Replication

Efficacy vs EffectivenessEfficacy vs Effectiveness


WHAT IS ROI?Physician Office Example

Return on investment

(ROI)=

Benefits

Costs

• Quality of care

• Error rate

• Patient satisfaction

• Liability exposure

• Investment cost

• Investment time

• Ongoing cost

• Revenue loss

• Physician/staff dissatisfaction

Easier to measure Harder to measure

• Cost saving

• Time saving

• Revenue increase

• Physician/staff satisfaction

Easier to measure Harder to measure

• Quality of care

• Error rate

• Patient satisfaction

• Liability exposure


MAeHC QUALITY DATA WAREHOUSE

1. Breast Cancer Screening 2. Colorectal Cancer Screening 3. Cervical Cancer Screening 4. Tobacco Use # 5. Advising Smokers to Quit 6. Influenza Vaccination 7. Pneumonia Vaccination 8. Drug Therapy for Lowering LDL Cholesterol# 9. Beta-Blocker Treatment after Heart Attack 10. Beta-Blocker Therapy – Post MI 11. ACE Inhibitor /ARB Therapy# 12. LVF Assessment# 13. HbA1C Management 14. HbA1C Management Control 15. Blood Pressure Management# 16. Lipid Measurement 17. LDL Cholesterol Level (<130mg/dL) 18. Eye Exam 19. Use of Appropriate Medications for People w/ Asthma 20. Asthma: Pharmacologic Therapy# 21. Antidepressant Medication Management 22. Antidepressant Medication Management 23. Screening for Human Immunodeficiency Virus# 24. Anti-D Immune Globulin# 25. Appropriate Treatment for Children with Upper 26. Appropriate Testing for Children with Pharyngitis

1. Breast Cancer Screening 2. Colorectal Cancer Screening 3. Cervical Cancer Screening 4. Tobacco Use # 5. Advising Smokers to Quit 6. Influenza Vaccination 7. Pneumonia Vaccination 8. Drug Therapy for Lowering LDL Cholesterol# 9. Beta-Blocker Treatment after Heart Attack 10. Beta-Blocker Therapy – Post MI 11. ACE Inhibitor /ARB Therapy# 12. LVF Assessment# 13. HbA1C Management 14. HbA1C Management Control 15. Blood Pressure Management# 16. Lipid Measurement 17. LDL Cholesterol Level (<130mg/dL) 18. Eye Exam 19. Use of Appropriate Medications for People w/ Asthma 20. Asthma: Pharmacologic Therapy# 21. Antidepressant Medication Management 22. Antidepressant Medication Management 23. Screening for Human Immunodeficiency Virus# 24. Anti-D Immune Globulin# 25. Appropriate Treatment for Children with Upper 26. Appropriate Testing for Children with Pharyngitis

CLINICAL MEASURES FOR PHYSICIAN PERFORMANCEAQA Recommended Starter Set


WHY DON’T WE JUST LET THE MARKET TAKE CARE OF THIS?

Current system pays for quantity, not quality

Physicians not trained or compensated to reduce fragmentation of care

Few if any incentives to reduce inefficiency, which rations care away from the under-served

No obvious place for consumers to voice their concerns about quality, safety, and protection of privacy

We have a societal interest in how implementation happens

• Bad systems and/or bad implementations offer little, if any, value

• Collective action and public goods barriers will prevent effective interoperability

“In the long run, we’re all dead....”

27

LEVELS OF HEALTH INFORMATION EXCHANGE

Level Description Examples

1 Non-electronic data Mail, phone

2Machine-transportable data

PC-based and manual fax, secure e-mail of scanned documents

3Machine-organizable data

Secure e-mail of free text or incompatible/proprietary file formats, HL-7 message

4Machine-interpretable data

Automated entry of LOINC results from an external lab into a primary care provider’s electronic health record

No PC/information technology

Fax/Email

Structured messages, non-standard content/data

Structured messages, standardized content/data


TECHNICAL STANDARDIZATION IS ONLY THE BEGINNING...

Percent

0

10

20

30

40

50

60

70

80

90

100

Source: Center for Information Technology Leadership, MAeHC calculations

19%

Fax/email

5%

Structured messages

76%

Standardized content

• Technical coordination• Policy coordination• Process coordination• Community coordination

• Technical coordination• Policy coordination• Process coordination• Community coordination


EARLY LESSONS LEARNED...

This can get done on a large scale, and it can get done collaboratively

Building the program is more difficult than originally anticipated

• Fixed cost that we can leverage going forward

The market is shifting – getting attention of vendors somewhat harder than before

Affordability isn’t the only barrier to physician adoption

Starting the conversation creates a community – already seeing synergies

Where are we offering greatest value?

• Funding

• Practice catalyst – facilitators/navigators

• Community catalyst – wholesale vs retail

• Forcing HIE


...SUGGEST SOME LESSONS ABOUT HOW TO EXTEND THE MODEL IN THE FUTURE

Community is an effective level of organization (“wholesale vs retail”)

• Self-defined, cohesive.

• Accept accountability for its members, apply peer pressure, and appeal to local pride

• Efficient to serve logistically

• Natural unit for establishing health information exchange

Central coordination and active intervention are key success factors

• Reduced costs for hardware, software, implementation

• Dramatic reduction in failure rate

• Speedier rollout and recovery of physician productivity

• Application of best practices to realize the systems’ potential

The Golden Rule applies (“whoever has the gold makes the rules”)

• Direct funding increases compliance with best practices, including standardization, structured data capture

• Minimizes “paving over the cow-paths”

• Enables community-wide benefit of HIE


www.maehc.org

Micky Tripathi, PhD MPPPresident & CEO

[email protected]

Documents

MASSACHUSETTS eHEALTH COLLABORATIVE HIT Symposium July 2006