# Presentation: 100421

## 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

## Regional Approaches: Assumptions

- There is lost value because of an inability to coordinate the exchange of information across a patient’s 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

## 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

## A Process

## Starting Points

- Medicaid
- Uninsured
- Employers
- Plans
- Hospitals
- Physician practice groups
- Pharmacies and pharmaceuticals
- Federal initiatives and CMS regulations

- Each starting point represents a “burning platform” capable of fostering a guiding coalition to attain improvements

## Defining Roles

- The convener
- Setting the ground rules; governance
- The financial transaction infrastructure
- Claims infrastructure; efficiencies; trust; revenues
- The clinical data exchange infrastructure
- Safety, efficiency, efficacy, outcomes
- The last mile
- Enabling health care professionals – physicians, retail pharmacies, home care, nursing homes
- Empowering patients and their families

***Source: Massachusetts model – Halamka, Tripathi, et. al***

- Roles for various parties have to be defined to assure effective operation and demonstration of value

## Models

- 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

- Different architectural models have arisen in different areasas a result of need, capability, and circumstances

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

## Picking the Model: SW Tennessee

- 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

- Current emphasis of the SW Tennessee work is focusedon the convener and the clinical data exchange.

## Technology: Low Entry Costs and then Evolvesee: http://www.volunteer-ehealth.org/AHRQ/technology-overview.htm

**Technology: Low Entry Costs and then Evolve****see:**** ****http://www.volunteer-ehealth.org/AHRQ/technology-overview.htm**

- Exchange receives data & manages data transformation

- Mapping of Data
- Parsing of Data
- Standardization of Data
- Queue Management

- Data is published from data source to the exchange

- Participation Agreement
- Patient Data
- Secure Connection
- Batch / Real-Time

- 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

## Emergency department utilization shows that information exchange among providers will benefit the care of patients in the region’s emergency rooms.

- 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

***Emergency Department Activity***

- Sources:
- 1 – Data supplied by Memphis Managed Care 07/2003-07/2004

***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.***

*Benefits*

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

- The exchange of data among the core healthcare entities has potential to reach $24.2 million in savings.

| Financial  Measures | Dollar Savings
(millions) |
| --- | --- |
| Reduced inpatient hospitalization | $5.6 |
| ED communication distribution | $0.1 |
| Reduced IP days due to missing Group B strep tests | $0.1 |
| Decrease in # of duplicate radiology tests | $9.0 |
| Decrease in # of duplicate lab tests | $3.8 |
| Lower emergency department expenditures | $5.5 |
| Total Benefit | $24.2 |

- If data is exchanged across all facilities within the three-county region, the overall savings has potential to reach $48.1 million.

***Overall Benefit***

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

## Operations

- 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

- Over time, operations move from a “project” to a largelyregional organization

## Evolution

- 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

- It is a race to identify the value so that a community canmake informed decisions about health care

## 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

## Common  National Themes

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