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ONC ‘Deep Dive’ CallWednesday, October 6
AGENDA
Introductions 3 min
Leadership/Stewardship Dr. Chute 3 min
Infrastructure/Meaningful Use Calvin Beebe 10 min
Broadband John Goodman 5 min
Public Health/Schools Mary Wellik 5 min
Deliberative Democracy Dr. Koenig 5 min
Asthma Intervention Dr. Yawn 5 min
Diabetes Intervention Phase 1 Dr. Montori 5 min
Immunization Pilot Dr. Chaudhry 5 min
Sustainability/Payment Reform Dr. Wood 5 min
IntroductionsIntroductions
Leadership/StewardshipLeadership/StewardshipDr. Christopher Chute
3046260-5
Subject Matter Expert WGs
Office of the National Coordinator of Healthcare IT (ONC)
Federal Steering Committee (FSC) - TBN
Eva
luat
ion
Operations
Mayo & Mayo Health System Leadership
Olmsted Medical Leadership
Winona HealthLeadership
SE MN Beacon Governance
MetricsInfrastructure
Quality Academy
Community & PHEngagement
Cross Beacon / ONC Projects
PracticeImplementation
Dept. of Health & Human Services (DHHS)
National Beacon Communities
Comparative Effectiveness
SE MN Beacon Organization
Project Driven teams
MN Congressional
Offices
REOT
CPCCPQOC
SE MN Schools
SE MN Healthcare
SE MN Public Health
Others
Pro
gra
m M
anag
emen
t
Co
mm
un
icat
ion
s
Sta
keh
old
ers
Project Initiation Process
Planning Process
Approval to Execute
Public HealthLeadership
ProjectExecution LPH /
SchoolsHIE
ConnectivityData
RepositoryMini-
deliberativeAsthma Phase 1
Broad-band
Diabetes Phase 1
Immun. Pilot
Community Interest Groups
Infrastructure / Meaningful UseInfrastructure / Meaningful UseCalvin Beebe
High Level Data Flows
A
Sources of
B
C
D
E
F
CCD, Action Plans
CCD, Action Plans
CCD, Action Plans
Surveillance Rpts
Surveillance Rpts
Various Reports
Batch Data / HL7(LIFT managed)
G
A
B
C
D
E
F
G
SE MN Server
Data Flow MappingSource Node Document Flows Other flows
A OMC CCDB,C,D,E,F* CDAE (EMR DB / HL7 2.x)
B MCR CCDA,C,D,E,F* CDAE EMR DB
MHS CCDA,C,D,E,F* CDAE EMR DB
C WHS CCDA,B,D,E,F* CDAE (EMR DB / HL7 2.x)
D PH-DOC* CDAA,B,C,F
E Nurse Portal CDAF, (A,B,C)** TBD
F Repository HL7 2.x A,B,CCross Site Data for EMR/PMS
PMS: Population Management System
Repository Requirements
• Correlate patients, students, and PH cases• Identified & anatomized patient access• Merge & unmerge patient EMR data to
accurately identify patient’s for clinical care.• Support complex access authorization matrix to
protected patient information• Easy access to various authorized data sets for
reporting and analytics requirements• Secure, audited, scalable, cost efficient …
Infrastructure Components
• CONNECT 3.1 (Doc. Exchanges)
– w/ HIEOS Open Source
• MIRTH Connect (Repository Loader)
– Interface Engine Open Source
• SE MN Beacon Data Repository options:A. Regenstrief INPC Open Source
B. Mirth Results Open Source
C. Amalga Microsoft Corp
– Regenstrief & Mayo are evaluating the
use of a common repository data model (A,B)
Activities over 90 Days
• CONNECT Code A Thon Rochester, MN• Mayo Health System Population Mgt.• Mayo Clinic Data Trust Mgt.• Public Health Department Review of PH-Doc• Winona Health Service Deep Dive Review
Plans moving forward• Complete assessment of high level functional & technical
requirements for School Nurse Portal solution.– Determine solution provider (MN-HIE / Mayo)
• Review repository requirements with Regenstrief – Select repository solution for SE MN Beacon project
• Specify & acquire server hardware & software assets.
• Establish CONNECT implementation timelines for each site, work with MN-HIE to obtain security certificates.
• Utilize a mix of SE MN Beacon staff and consulting complete needed development, configuration and implementation of SE MN Repository & CONNECT network
BroadbandBroadbandJohn Goodman
Winona Deep Dive
14
WCTN Partners
Community Partners
A-Vu Media - Project Management- Broadband Projects
Hiawatha Headend Facility- Central Vidyo Servers
Home &Community Options
- Services to the disabled - Remote residential
management
Other Community- Winona County Services
- Winona Housing & Redevelopment- County Jail- Project Fine
Hiawatha Broadband- High Capacity fiber Network
- VPN connections
Video
InternetPhone
Networks
Winona Health- Hospital and Clinics
- Assisted living - Nursing Home
- Home Care- Hospice
Older AdultResidential Services
- St. Anne of Winona - Sauer Memorial- 260 Residents- 70 Diabetics
Primary Partnerswireless
Education- Winona Public Schools (K-12)
- St. Mary’s University- Cotter schools
# of NetworkConnections
80-120
20-40
7-1611-20
8-12
Broadband Technologies
Major technologies employed: – High capacity community based broadband networks– Multimedia pc’s networked with encrypted VPN connections– Proprietary video conferencing technology with custom UI’s– Shared access telemedicine e-suites and kiosks
Key implementation areas requiring assistance in SE MN:– Final design and implementation of the telemedicine e-Suites.– Security requirements to achieve HIPAA compliance for community broadband
locations.– EMR data base access from telemedicine sites.– Medical protocols for initial Juvenile Asthma and Diabetes program
implementation.– Research structure for meaningful use assessment.
Major vendors involved:– Vidyo/Phoenix Systems/ Logitech - Hiawatha Broadband– Cerner - A-Vu Media
Broadband Technologies
Past 90 days:1. Implemented Vidyo central server application at HBC.2. Defined the proposed WCTN and its community partners.3. HCO State License for Remote Monitoring.4. HCO designed medication compliance application for Remote Monitoring
Next 90 days:1. Winona health network plan and Phase 1 implementation.2.Telemedicine prototype with custom UI development project.3. Define initial medical plan for Diabetes and Juvenile Asthma4. Implement HCO medication compliance application
Major risks:1. WH staff time needed for program implementation.2. Unexpected technical issues to develop custom UIs.3. Delays in hiring additional technical staff funded by Beacon.
Public Health / School Public Health / School EngagementEngagementMary Wellik
LPH/School Engagement
Key Stakeholders: Public Health Directors, County Boards, School Boards, & School Nurses
Goal: Beacon provides a unique opportunity for providers and these extended providers to come together in the region to explore alternative models of care particularly in the areas of childhood asthma and diabetes.
Objective: To initiate this relationship, introduce the Beacon program and acquire input into the Beacon provider model network.
LPH/School EngagementLast 90 days:
– Letters to Public Health Directors– Ph-Doc Users group presentations– Public Health Directors Teleconferences w/ media Kits– County Board presentations – all 11 counties– LPH participation in all projects (infrastructure, asthma,
diabetes, etc.)
Next 90 days: – Letters to each school district (~47)– School Board presentations & School Nurse engagement– Refine requirements of school participation & input into
provider network model
Deliberative DemocracyDeliberative DemocracyDr. Barbara Koenig
Deliberative Community Engagement
Overarching Goal:
Deliberative community engagement will allow SE Minnesota BEACON leaders to incorporate community values into project design and governance
Considerations
• Need to balance scientific and technical gains with social concerns -- not just a technical issue, but a social and political one
• Need to address these issues in an open, informed manner, engaging the community before implementation
Deliberative Democracy Examples
• Trial by jury (citizens’ jury)– environmental risk
• Extended to inquiry into contentious issues in science and technology– CDC & MN Dept of Health on avian flu
pandemic planning (resource allocation)
• British Columbia, Canada– Voting Methods
Deliberative Democracy Goals
• Goal is not just to “inform” or “educate” the community
• Not a series of focus groups!
• Seeks genuine discussion among representative community members, and,
• Citizens make non-binding recommendations about implementation, governance, & long-term community oversight
Deliberative Democracy Goals
• Not simply to let different perspectives or points of view be expressed, but,
• To make real trade-offs and compromises, encouraging the formulation of recommendations to guide interventions and EHR data use
Large Group Deliberation
Small Group Sessions
Deliberative Community Engagement
Past 90 Days:– Dependency: County Board Endorsements– Logistics of engagement activities (2 part structure)– Developing content & speaker guides– Coordination with public affairs/communications
Next 90 Days (4 Community Discussions):– Oct 30: Rochester – (Seat of Olmsted County) – Oct 31: Winona – (Seat of Winona County) – Nov 13: Red Wing – (Seat of Goodhue County) – Nov 14: Austin – (Seat of Mower County) – Based on above, plan “full engagement” for spring 2011
Deliberative Community Engagement
Key Features of Initial Events:
• Representative sample of disinterested lay participants
• Involve “local conveners”
• Professional moderators
• Expert stakeholders available (as consultants)
– Privacy, Promise of enhanced EHR, etc.
Asthma InterventionAsthma InterventionDr. Barbara Yawn
Asthma Intervention Initiation—Clinical Transformation
Milestones: – Established cross-region asthma focus project team– Identify initial asthma intervention (begin with AAP)– Discuss longer term asthma intervention requiring widespread
EHI support
Next 90 days: – Identify schools and health care facilities willing to participate.– Identify appropriate AAPs and methods to share
– Identify champions in schools and healthcare sites
• Risks– Lack of time and interest by clinical staff– Failure to identify appropriate contacts such
as parent champions– Declaring victory too soon
Asthma Data and performance metrics
• Milestones completed– Sent in baseline data from 3 sites– Began discussion with MN Community Measures– Considered patient reported metrics
• Milestones next 90 days– Develop intervention related metrics– Develop outcome metrics– Develop community acceptable patient reported
metrics
Asthma data and Performance metrics
• Risks– MN Community Measure denied request for
research exemption– Reluctance to require another clinical
endeavor without clear results to suggest this will make a difference in outcomes
– People still living in their silos
Diabetes InterventionDiabetes InterventionDr. Victor Montori
Patient centered diabetes care
Goals To know - at any time - what is the quality of life and
functional status (along with disease control metrics) of patients (described by their demographic and health literacy characteristics), in SE MN.
To implement tailored patient decision aids to enhance patient involvement in clinical decisions about primary and secondary prevention of cardiovascular events.
Patient centered diabetes care
Approach – health measuresCollect health literacy, health-related quality life and functional
status information at the point of care (public health nurse visit, clinics and hospitals) and at the point of existence (home, workplace).
Using these data will enable:• The SE MN Map of Diabetes Control, Health and Function• Stratification of patients by patient-reported and disease-
control measures and health literacy for prioritized/tailored interventions
Patient centered diabetes care
Approach – decision aidsImplement the following patient-tailored decision aids into the
Beacon-integrated electronic environment, for use during patient-clinician interactions of different types:
- Statin Choice (primary prevention)
- Aspirin Choice (primary prevention)
- Diabetes medication cards (A1c target + drug selection)
- AMI Choice (secondary prevention)
Capture use and outcomes in usual clinical settings across the continuum of care
Patient centered diabetes care
Deliverables/Milestones (Phase 1) 2010
Sep - Constitute cross-region diabetes group
Oct - Resourcing & planning
Nov - Design health + literacy metrics (PRO), decision aids (DA)
2011
Feb - Pilot implementation of PRO collection and DAs
Mar – Check ease, rate of use; data quality; iterate and scale up
Later - Display diabetes map, assess correlations, evaluate impact of DAs and other interventions on health and function
Elements of success (or its opposite)
Dependencies– Phased technology infrastructure– Engagement of public health and other partners
Potential Collaborations - Center for innovation, KER UNIT, Healthcare delivery
research program, Beacon partners
Risks – Constrained resources, tight timelines, large community.– Inadequate evaluation
Patient centered diabetes care
Immunization PilotImmunization PilotDr. Rajeev Chaudhry
Mayo Clinic Immunization PilotData & Performance Measurement
• Goal: Pilot to utilize HIT to improve Influenza and Pneumonia vaccination delivery for patients with Asthma and Diabetic patients in primary care practices.
• Baseline data for one primary care practice:– Asthma Influenza rate = 53% Asthma Pneumonia vaccination rate = 38%– Diabetic Influenza rate = 55% Diabetes Pneumonia vaccination rate = 75%
• Scope:
1. To test utilization and efficacy of a newly developed population based HIT system ( advanced registry--Amalga) for improving delivery of immunizations for asthma and diabetic patients
2. To test utilization and efficacy of a newly developed point of care Clinical Decision Support System (GDMS) to improve practices to deliver vaccinations for patients seen in the clinic with Asthma and Diabetes
3. To learn from the pilot the primary care practices needs for HIT to advance the care of patients with chronic conditions.
Mayo Clinic Immunization PilotData & Performance Measurement
Past 90 days:– Identified baseline metrics for asthma and diabetes patients using HIT across SE MN practices– Completed development of a point of care decision support system (GDMS) to identify patients with
chronic conditions and provide decision support for providers for adult patients who need vaccinations during any visit in practice
– Completed development of a population management system (Amalga) to identify population of patients who are due for vaccinations for a primary care practice. Integrated the system with state registry.
– Initiated planning for a pilot with current HIT for vaccination needs for patients with Asthma and Diabetes for 2010 flu season
Next 90 days:– Initiate pilot at one practice with current HIT – Employ PDSA cycles to optimize processes of care and also to enhance the HIT for SE MN Beacon
population management – Invite all practices in SE MN to initiate pilots during current flu season with their existing HIT – Study impact of HIT on delivery of vaccinations to at risk population– Identify opportunities to enhance HIT ( SE MN repository for population management and reporting) and
processes of care for vaccinations delivery– Test utilization of patient portal to notify patients and provide online access for care– Study patient preferences for notification, access and vaccination delivery
Mayo Clinic Immunization PilotData & Performance Measurement
• Risks:
– Inadequate vaccination supply
– Lack of adequate access at practices to accommodate the patients who need vaccinations (access for patients, convenience, hours of operation for vaccination administration)
– HIT unable to serve the needs of practices at both point of care and population level
– Inability to reconcile vaccination information from other sources (e.g. retail vaccination administration and other practices)
– Capacity of practice to utilize new HIT and incoporate process redesign
– Lack of standardization of processes among practices
– Patient Portal ability to alert patients and provide online access
Clinical Transformation
• Types of resources are available:– Study impact of HIT on care delivery ( Health Care Policy and Research)
– SE MN Beacon team for sharing pilot results (lessons learned etc.) with partner practices
– Quality academy for multi disciplinary teams that need training
• Provider landscape:– Group practices ( Mayo Clinic Rochester , Mayo Clinic Health System, Winona Health,
Olmsted Medical Center)
– Public Health
• Next 90 days:– Immediate goals are to apply processes and HIT point of care clinic decision support
systems and population management systems in primary care practices that will impact immunization rates
Sustainability/Payment ReformSustainability/Payment ReformDr. Douglas Wood
Sustainability & Payment Reform
Experience:• Minnesota has now implemented coordination of care payments for practices that have been
certified by the state dept. of health as health care homes (started 7/1/2010)• Minnesota has implemented baskets of care, or episode based payment, for several conditions,
including pediatric asthma and pediatric preventive services, effective 3/1/2010• Next Minnesota payment reforms will come in 2012 (in planning now)
Engaged partners: • Minnesota has an active effort underway in the Health Care Access Commission (work groups
appointed by the legislature) to evaluate additional payment models to incorporate into exchange (s) by 2012; this includes legislators, large systems, health plans, physicians, large businesses
Milestones:• No new payment reform implementations have occurred in the past 90 days, nor are planned in
the immediate next 90 days.
Risks:• Biggest current risk for payment reform in Minnesota is the November election, where all state
office holders and the entire legislature are up for election; the outcome could influence direction of state implementation of health care reforms
BEACON WEBSITE
www.semnbeacon.org