Indiana Health Information Exchange The Indianapolis and Beyond

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Indiana Health Information ExchangeThe Indianapolis and Beyond Story

Presented to:South Dakota Health IT Summit

Sioux Falls, SDOctober 8, 2008

Copyright © 2008 Indiana Health Information Exchange, Inc. Page 2

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Agenda

• HIE Landscape • IHIE Background and Governance • Services

– DOCS4DOCS® Clinical Messaging Service– Clinical Repository – Quality Health First

• Customer Support • Discussion


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Health Information Exchange Evolving Landscape


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State of the Field• Health information exchange initiatives are continuing to mature.

– 130 included in the eHI annual survey (self report) – A lot more are getting started – 18 are new – Increased operation in number of HIEs (32 to 42) -

31% increase – DATA IS MOVING – Seeing impact – getting results – reducing costs and

improving care delivery as part of the care process – Business model still is the struggle – Financing – securing

upfront funding is the second largest challenge – 69% of the operational ones reported a positive ROI for

various stakeholders (reducing costs) – More than half of the operational HIEs – labs, radiology is

up this year – still supporting care delivery (CM and alerts) – increasing in population health; and public health surveillance


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Types of Data Exchanged

Types of Data 2007 2006

Labs 34% 26%

Outpatient Episodes 32% 21%

ED Episodes 30% 23%

Inpatient Episodes 28% 23%

Outpatient Lab Results 30% 22%

Radiology Results 26% 20%

Enrollment/Eligibility 26% 27%

Outpatient Prescriptions 25% 19%

From: eHealth Initiative’s 2007 Fourth Annual Survey of Health Information Exchange at the State, Regional and Community Levels, http://www.ehealthinitiative.org/2007HIESurvey/default.mspx


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Most Difficult Challenges (Moderately Difficult and Very Difficult)

Challenges 2007 2006

Developing Sustainable Business Model (56% said “very difficult” in 2007) 91% 80%

Addressing Privacy and Confidentiality Issues (34% said “very difficult” in 2007) 85% 79%

Accurately Linking Patient Data

(25% said “very difficult” in 2007) 81% 86%

Defining Value for Users of the HIE

(43% said “very difficult in 2007) 81% 99%

Securing Upfront Funding

(53% said very difficult in 2007) 80% 90%



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Funding Sources Start-Up vs. Operating

Source Start-Up Operating

Hospitals 54 62

Federal government 44 38

State government 42 35

Payers 33 35

Philanthropic 31 23

Labs --- 21

Public health --- 23

Physician practices ---37



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What Does All this Mean?

• HIEs face substantial challenges, but are demonstrating steady and important progress– Development of a sustainable business model

• Operational HIE organizations have pursued pragmatic, incremental local strategies to engage data sharing partners to build and expand HIE

• Along with federal grants and contracts, state funding has played an important part in advancing early HIE development

• One solution, does not fit all…what is the “burning platform” for South Dakota?


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Courier just dropped off

moreenvelopes

Courier just dropped off

moreenvelopes

Prescription refill request on

fax machine (Right

behind the joke of the day)

Prescription refill request on

fax machine (Right

behind the joke of the day)

Unopened mail

Unopened mail

Printer with results from

one lab

Printer with results from

one lab

“Hey Sally! Where is

Mrs. Jones x-ray?”

“Hey Sally! Where is

Mrs. Jones x-ray?”

Unsorted results

Unsorted results

About to ring with

stat results

About to ring with

stat results

Web portal (from one hospital)

Web portal (from one hospital)


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Indiana Health Information ExchangeGovernance and Services


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Who We Are…Over 36 Million Results Delivered

Indiana Health Information Exchange

• 35 FTEs– 24x7x365 Customer Support– Business Development– Technical/Programming– Physician Liaisons

We are a health information exchange that bridges the gap between paper-based and technology-based medicine to electronically provide patient-

specific, clinical information from various sources at the most critical time: the point-of-care.

Regenstrief Institute

• 95 FTEs– Research and Development– Application Support– Technical Support


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IHIE and Regenstrief

Regenstrief Both / Either IHIE

Concepts / Ideas

Research

Grants

Business Models

Customer Support

Training

Marketing / Sales

Project Management

Data Use Agreements

Application Development

Operations

Implementation

Technology: Development Testing Production Maintenance


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Governance

• IHIE is governed by a Board of 16 organizations representing the major healthcare stakeholders in Indiana. The Board members are chosen to allow for multi-organizational representation of health care stakeholders and to draw upon industry experience.

• The hardest work was establishing trusted organizational models, consensus on goals and requirements, and crafting participation agreements that met the legal, clinical and ownership requirements of each party.

• We have advisory groups that provide guidance and expertise to assist with future development.

• Membership is multi-disciplinary including representation encompassing technical, clinical, customer service and users.

IHIE was founded as a non-profit 501(c)3 incorporated company on February 24, 2004 by a collaboration of fourteen institutions representing hospitals, healthcare providers, researchers, public health organizations, and economic development groups.


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Governance IHIE Board

• BioCrossroads - CEO• City of Indianapolis - Mayor• Clarian Health Partners - CEO• Community Health Network -

CEO• Health and Hospital Corporation

– CEO • Indiana State Department of

Health - State Health Commissioner

• Indiana State Medical Association - President

• Indiana University School of Medicine - Dean

• The Indianapolis Medical Society - President

• Marion County Health Department - CMO

• Regenstrief Institute - CEO• St. Francis Hospital and Health -

CEO• St. Vincent Healthcare - CEO• At large (3)


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GovernanceAdvisory Groups

Advisory Group Description Membership

Steering Committee

Provides general oversight of the clinical messaging project. Focus is on new functionality, issues, and problem resolution.

CIOs from the charter member hospitals and representatives from IHIE and Regenstrief Institute

Application Committee

Provides for the development of community standards, creation of acceptance testing plans, development of training materials, implementation of physician offices, and development of application enhancements.

Members from the interface teams at each of the charter hospitals who are involved in the day-to-day operations of clinical messaging from the service providers

Planning Committee

Identifies and evaluates potential research and other projects on which IHIE & Regenstrief can collaborate.

Executive staff from IHIE and Regenstrief, as well as key project personnel from both organizations

Security Committee

Provides updates as to the security enhancements of the clinical messaging systems, any HIPAA issues we see from this side. Any HIPAA issues are always reported back to these people as they happen.

Security/privacy officers from each of the charter hospitals


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Indiana Health Information ExchangeState Borders Do Not Exist

Crown Point

Dyer

Hammond

Michigan City

Lafayette

West Lafayette

Crawfordsville

Kokomo

Beech Grove

Carmel

Elwood

Indianapolis

Martinsville

Mooresville

Plainfield

Avon

Fishers

Evansville

Michiana Health Information Exchange

Medical Informatics Engineering

Healthbridge


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Three Things to Remember

1. Don’t make it complicated• “Free” the data – get it out of the silos

and establish trust in your community • Aggregate the data and do something

with it

2. Don’t Boil the Ocean

3. Data re-use is the killer application


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DOCS4DOCS Results Delivery


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Health Information Exchange Services

Health Information Exchange

Hospital

Data Data repositoryrepository

Health Health Information Information ExchangeExchange

Network Network applicationsapplications

Server

Labs

Outpatient RX& PBMs

Physician officeAmbulatory

centers (e.g. imaging)

Public health

Services

Hospitals

Physicians

Labs

Publichealth

Payer

• Clinical Messaging• Medication Reconciliation• Shared EMR• Credentialing• Eligibility checking

• Results delivery• Secure document transfer• Shared EMR• Clinical Decision Support• Credentialing• Eligibility checking

• Clinical Messaging• Orders

• Needs Assessment• Surveillance• Reportable conditions• ADE detection

• Clinical Quality Measurement• Claims Ajudication• Secure document transfer

• De-identified, longitudinal clinical dataResearchers

Negotiated Negotiated AccessAccess

Payers


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“One…two…three Strikes You’re Out!”

• There were three times where the IHIE project was down on its knees:– Hospital CIO’s – “IHIE competes with individual hospitals IT strategies

to link to physician offices”• How Resolved – Individual hospitals computer system (Cerner, GE,

Eclypsis, Siemens, McKesson) is hospital workflow but all can participate in the city-wide network to reduce cost - PROCEED

– Hospital CFO’s – “I do not see any significant ROI and recommend to CEO’s not to proceed”

• How Resolved – ROI study shows hard dollar costs about the same as current cost, many tangible (soft) cost savings. Hospital CEO vision is that IHIE is the infrastructure for future healthcare initiatives and cost savings – PROCEED

– IHIE – “Funding – Have plan, have community buy-in, no money”• How resolved – join Bio Crossroads and Regenstrief Initiative to obtain

initial grant funding - PROCEED

Almost

^


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DOCS4DOCS Service (Push)

• IHIE’s DOCS4DOCS clinical messaging service takes text reports (e.g. lab, pathology, radiology, transcription, cardiology) from their source information systems and delivers those results to physicians associated with the source organization (medical staff or non-medical staff) via any of three methods: – Into “DOCS4DOCS”, a web-based “inbox” that is accessible via

the hospital portal or other IHIE portal – Via fax (if they insist)– Directly into the physician practice EHR

• We deliver only what the customers tell us they want us to deliver.


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Results Delivery History

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

Q1 20

05

Q2 20

05

Q3 20

05

Q4 20

05

Q1 20

06

Q2 20

06

Q3 20

06

Q4 20

06

Q1 20

07

Q2 20

07

Q3 20

07

Q4 20

07

Q1 20

08

Q2 20

08

Q3 20

08

Fax

IHIE Poral

EMR


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Sustainable With Results Delivery

• Basic Conceptual Principles of HIE Sustainability– HIE is a business– Leveraging of High-cost, High-value assets– No Loss Leaders– Independent Local Sustainability– Natural Monopoly– The Need for Scale– Avoidance of Grants for Operational Cost


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Interdependency of HIE Components

Layer I: Including Interface Engine, Community Trust, …

Layer II: Including Mapped/Normalized Data…

New Value-added

ServiceLayer III: Including Repository Services…

New Value-added

ServiceMedication Profile

Public HealthSurveillance

Clinical Messaging

Clinical Quality

Services

Ambulatory Results Review

ED Abstract and Results

ReviewNew

Value-added

Service

Inpatient Results Review

Value-added services that can be built upon the HIE investment

A layer of necessary investment

In the beginning, HIE assets are interdependent and how assets, once created, can be leveraged to deliver additional services.


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Community-Wide Clinical Repository Indiana Network for Patient Care

Page 27

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Clinical Repository Background (Pull)

• Securely aggregates and connects patient information electronically outside an individual healthcare organization. Provides an abstract that contains the most accurate, up-to-date information available a patient, regardless of treatment location.

• Available at over 130 locations in Indianapolis area, including ED and ambulatory

• Data on over 6 million patients.• Used by approximately 15,000 active users.• One study indicated the repository results in $26 savings per ED

visit. • Other participants include:

– National and regional laboratories– Local imaging centers– All four homeless care systems– Public health departments (county and state)


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Clinical Repository Data

• 16 million registration events

• 41 million orders

• 1 billion coded results

• 25 million text reports

• 9 million radiology reports

• 12 million drug orders

• 750,000 EKG tracings

• 140 million radiology images


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Indiana Network for Patient Care Data Sources – Growing Beyond Central Indiana

• Hospitals – Over 20 hospitals including the 5 major hospital systems and

other hospitals in the Indianapolis-area

• Payors

• Labs and local imaging centers

• Public health departments (county and state)

• Ambulatory Physician Practices – Approximately 1/3 of ambulatory physicians


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Participants’ AgreementThe Participant Controls the Use of Their Data

• How can participants share health data to treat patients?

• Who may have access to personal health information for treatment purposes?

• What information is to be stored on the network?

• How may the personal health information be used for research purposes?

http://www.regenstrief.org/medinformatics/inpc


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Silos of Information

Electronic Medical Electronic Medical Record SystemRecord System

Data delivered Data delivered to to

immunization immunization registryregistry Jane Receives Jane Receives

Immunizations and other Immunizations and other care (measurements, labs, care (measurements, labs, diagnoses, etc) @ Clinical diagnoses, etc) @ Clinical

PracticePracticeData delivered Data delivered to EMRto EMR

ImmunizatioImmunization Registryn Registry

Jane Receives Jane Receives Immunizations @ Health Immunizations @ Health

DepartmentDepartment


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Silos of Information



Registry Web Registry Web InterfaceInterface

EMR EMR InterfaceInterface

??????????????????????

“Amid all the discussion, Indiana may be mentioned more often than any other state as a model for how to develop a successful HIE.”– For the Record, September 2007


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Consolidating the Silos



Patient ID: 123LMNOPPatient ID: 123LMNOPName: Jane Doe Name: Jane Doe DOB: 01/01/04DOB: 01/01/04SSN: N/A SSN: N/A Address: 555 Johnson RoadAddress: 555 Johnson RoadCity: IndianapolisCity: IndianapolisState: IndianaState: IndianaZIP: 46202ZIP: 46202

Patient ID: 6789XYZPatient ID: 6789XYZName: Jane Ellen DoeName: Jane Ellen DoeDOB: 01/01/04DOB: 01/01/04SSN:123-45-6789SSN:123-45-6789Address: 555 Johnson Address: 555 Johnson RoadRoadCity: IndianapolisCity: IndianapolisState: IndianaState: IndianaZIP: 46202ZIP: 46202

Global Global Patient IndexPatient Index

Concept Concept DictionaryDictionary

Global ID:Global ID: 4567845678Name: Name: Jane Ellen Doe Jane Ellen Doe Lots of Demographics..Lots of Demographics..MRF1 ID: MRF1 ID: OU81247OU81247MRF2 ID: MRF2 ID: 45643564564356PH MRF ID: PH MRF ID: 123LMNOP123LMNOPMRF3 ID:MRF3 ID: 6789XYZ6789XYZ

DTaP Dose Count:DTaP Dose Count: 30936-930936-9HIB Dose Count:HIB Dose Count: 30938-530938-5IPV Dose Count:IPV Dose Count: 33555-433555-4VZV Dose Count:VZV Dose Count: 30943-530943-5MMR Dose Count:MMR Dose Count: 30940-130940-1HepB Dose Count:HepB Dose Count: 30937-730937-7

Jane Doe’s Immunizations:Jane Doe’s Immunizations:

3/1/043/1/04 DipTetaPurDipTetaPur3/1/043/1/04 HemInfBHemInfB3/1/043/1/04 PolioVirPolioVir3/1/043/1/04 HepaBHepaB

Jane Ellen Doe’s Shots:Jane Ellen Doe’s Shots:

5/1/045/1/04 DTaP ImmDTaP Imm5/1/045/1/04 HIB ImmHIB Imm5/1/045/1/04 IPV ImmIPV Imm7/9/047/9/04 DTaP ImmDTaP Imm7/9/047/9/04 IPV ImmIPV Imm

30936-30936-9 9 30938-30938-5 5 33555-33555-4 4 30937-30937-77

30936-30936-9 9 30938-30938-5 5 33555-33555-4 4 30936-30936-9 9 33555-33555-44


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Consolidating the Silos





St. Vincent St. Vincent MRFMRF

Clarian Clarian MRFMRF

Wishard Wishard MRFMRF

Community MRFCommunity MRF

Public Health Public Health MRFMRF


IUMG MRFIUMG MRF



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The clinical repository can tell the story when the patient cannot…

Dr. Watson

Dr. Thomas’ office

ED visit data (free-text chief complaint)

Registration Records (demographics)

Radiology Reports

Discharge Summaries

Operative Notes

Pathology Reports

Medication Records

EKG Reports

Laboratory Data

Inpatient and outpatient hospital encounter data demographics

Coded diagnoses and procedures for hospital admissions and ED visits

Ambulatory encounter (visit) data

• Patient presented at emergency department complaining of ‘having trouble’ with his heart.

• Standard treatment for heart attacks: blood thinners.

• Before embarking on treatment path, physician checked the repository for additional information on patient.

• Repository showed head scan performed at another hospital 3 weeks ago. Patient recovering from head injury.

• Repository helped physician determine best course of care to avoid complications.


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Abstract Example


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Results Review Example


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Quality Health First® Program


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Quality Health First


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Quality Health First ® Program Background

A disease management, preventive care and reporting service providing pt-specific and population-based management reports, clinical alerts and reminders, as appropriate either participating physicians and health plans.

• Enables improved clinical decisions by combining clinical data, medical and drug claims and point-of-care data to monitor patients’ health and wellness.

• Employers Forum of Indiana instrumental in program design.

• Involves physicians, employers, and health plans and implemented and managed by IHIE


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QHF Quality Improvement Measures

• Asthma Treatment• Children’s Health• Diabetes Care• Heart Health• Mental Health• Women’s Health


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Customer Support


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IHIE Customer Service & Application Specialists

• Support of DOCS4DOCS application - 24x7x365 Customer Support– Implementation

• Acceptance Testing and Piloting• Workflow review and analysis

– Communications • Marketing• Practice Verification

– Training • Initial and on-going physician office and hospital training• Follow-up • Account maintenance for Data Providers and Practice Locations

– Operations / Maintenance • Help Desk (for example, password resets and result delivery issues• Scrub provider files and maintain.

– Provides the most accurate and up-to-date provider and practice information

• Monitor non usage of inboxes• Monitor inactive end user accounts

One-stop Issue Resolution / Seamless One-Call Policy Physician Offices Call IHIE, Not the Data Providers.


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Customer Support Team

9 FT Employees• 1 FT Customer Service Manager• 4 FT Customer Service/Help Desk• 4 FT Application Specialists

Supporting • 10,000 providers = 3,400 offices• 37 data providers• 6,000 application users• Average 20 incoming call per day; most common

– “forgot my password”– “why didn’t I get this result”


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Customer Support – Time Spent

% of time

38%

28% 2%

15%

10%

Provider File: clean up, marketing, verification

Training

Travel

Follow up

Help Desk


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Provider File Maintenance

• The average provider file from a facility has 3,000 providers– On average it takes 7 minutes to research one provider, if all

the information is accurate. Verify address, phone, fax, providers, other staff, POC, delivery needs, office flow

• What we find that is NOT accurate– Providers who are deceased / no longer in practice– Moved and are not listed with the correct practice– No longer practicing in the state– Expired license– They practice at multiple locations– Contact numbers and addresses are invalid


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Discussion


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Three Types of Business Risk an HIE Needs to Manage

Operating Risk

Execution Risk

Market Risk

How the company is structured, and the details of its basic logistics in order for it to carry out its plan successfully

To what extent the market for the HIE’s services is ready for its adoption, what barriers or obstacles if any exist, and how well the marketing plan meets market needs and obstacles

Ability of the HIE’s team to actually execute, given the complexity of the endeavor and their track record at rolling out such products and services


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Lessons Learned…

• Technology is just one piece– How is it implemented matters!

• Provide incremental value to the stakeholders– Small steps (don’t try to boil the ocean)

• Customer support is crucial– Communicate with customers often (data providers and users)

• Expect the unexpected– Interfaces change often and without notice

• Hospitals must shut-off delivery processes– Change in culture for internal departments

• Concentrate on value and satisfaction


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If I Had a Crystal Ball…IHIE 2010

• Acquired new data sources– Medicaid / Medicare data

– Additional hospitals, labs, other data sources

• Connected to other HIEs– Inside and outside of IHIE

– National participation (NHIN)

• Continued participation in the Indiana Health Information Commission (IN state-wide group)

• Further work with quality and population-based initiatives

• Extended IHIE into a new entity to market and implement our HIE solutions to other HIE communities outside of Indiana.


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Questions

Emily Welebob, RN, MS

Indiana Health Information Exchange

VP, Strategic Development

[email protected]

Phone: 317-644-1725

Health & Medicine

Indiana Health Information Exchange The Indianapolis and Beyond