# Presentation: 541018

## Utah Health Information Network 

- Jan Root, Ph.D.
- Assistant Executive Director
- June 2005, AHRQ Annual Meeting

## UHIN: CHIN to RHIO

- In operation since 1993  (CHIN)
- Community-based; inclusive
- Providers, payers, gov’t
- Statewide network
- Not-for-profit
- Self-sustaining
- Began with what members thought would bring the most value: claims

**Notes:**
(no animation)
Before we received the AHRQ contract, Utah already had had all technical requirements for a RHIO in place. For example, we have statewide operational transaction network for a decade. We only have one existing hub.  All members sign the same electronic commerce agreement.

Community based means the vendors are not in control.  Members are in control. Members are users (hospitals, clinics, clinicians). Members are not vendors.

A single RHIO has significantly reduced administrative costs on security management, business agreements, and IT connection development and update at users’ end, etc.

UHIN has the longest history in the nation as a Statewide, operational, self-sustained RHIO.
MAShare is a pilot, not have a business model yet.
Indianapolis is primarily a hospital network and research based.

## UHIN Does

- Make e-exchange of healthcare data possible:
- Neutral trusted third party
- Develop the IT & Governance infrastructure
- Develop Standards
- Reduce the cost of health care

**Notes:**
No animation

## Go ‘inside’ office
No EMR
No quality of care improvement
No patient safety
No centralized data base
Utah DOH holds this function

UHIN is the pipeline

- No EMR
- No quality of care improvement
- No patient safety
- No centralized data base
- Utah DOH holds this function
- UHIN is the pipeline

**UHIN Doesn’t**

## Current UHIN Coverage 

- 3rd Party Payors’ Claims (450+ payers)
- Medicaid and Medicare
- Hospitals (100%)
- Physicians/Clinics (85-90%)

- Laboratories (100%)
- Local Health Department (100%)
- Mental health centers (100%)
- Chiropractics (90%)

- ~50 million transactions/year
- Gateway is redundant and mirrored

**Current UHIN Coverage **

## UHIN’s Success

- Community decision-making
- Pursue the value, non-profit business model
- Use standards from the beginning
- Make available to all

**Notes:**
No animation

## 1. Community, Community, Community

- Consensus building process
- Every organization has ONE vote as an equal player
- Value-based operation brings partners together
- If we work together, everyone will be rewarded

**Notes:**
No animation
Within each RHIO, there will be competition and conflict. The question is how does the RHIO manage them?  Initially there were concerns that UHIN might be solely driven by IHC or Regence. But it is not. All board members have one vote.  Most decisions are by consensus, not majority rule.  

Network functionalities: details are worked out by the Standards and Technical Committees.  It takes longer, but solutions will work for all members.  Solutions can be reworked multiple times if necessary.

## 2. Value = Business Model

- Where is the money? Example:
- Claim transaction: cost to a payer to bring in a claim
- Paper claim = ~ $8
- Electronic claim = < $1
- UHIN charges = 20¢
- Payer saves ~ $6.80/e-claim
- Community savings
- As a Not-for-Profit RHIO, transaction volume goes up, average cost per transaction goes down for all stakeholders.

**Notes:**
(No animation)
The silver bullet for the administrative side was the claim transaction.   Everyone (payers and providers alike) benefited.  See example on the slide. Providers had lesser but still significant savings.  The community saves as the RHIO passes more messages.  Because the RHIO is non-profit, great transaction volume means the price is lower for everyone.

Clinical Information is more difficult but the principal is the same. Find the savings for the individual endpoints and then work to bring those savings to the entire community.

## 3. Standards, Standards, Standards

- Use standards from the beginning
- UHIN Standards Committee has been the key IT designing body
- Community has donated ~ 1 million hours towards creating standards
- Open standards-setting process for Utah standards
- Actively participated in HIPAA standards development

**Notes:**
(no animation)
Clearinghouses use proprietary standards. It makes it easier for end-points: they don’t have to change.  However, it drives up the costs. The clearinghouse has to ‘do the work’. Crosswalking between different standards (which is a function of clearinghouses) is difficult and costly.

Using standards means that the end points must do the work to bring their systems up to speed: it is more work up front.  However, it is cheaper in the long haul.  

UHIN standards are set by the community.  UHIN staff encouraged the community to participate in the creation of the national HIPAA transaction implementation guides: Utah largely got what it needed in those implementation guides.

Many new standards and implementation guides need to be created. RHIOs should make it a priority to participate.  

## 4. Adoption for ALL

- Goal: Bring value to everyone
- Get everyone on board (low cost)
- Everyone can play the same game (use standards)
- Approach: low-tech and simple
- Technical requirements are minimal
- Baseline software offered to providers
- Free product
- Simple send/receive reports

**Notes:**
(no animation)
RHIOs must shoot for a high overall volume of message to be economically viable. In addition, RHIOs need to be community solutions which means the entire community (on a voluntary basis).  RHIO solutions should be geared towards allowing everyone who wants to participate to be able to do so
	reduce technological barriers (use standards, use simple, low-tech solutions
	offer baseline products if necessary to get low-end users in the game.  Baseline products do not complete with existing practice management or EMR systems.  They are report tools to send/receive information; no data management. 
	make it low cost: only need to meet operation costs

## Moving into Clinical

- UHIN vision always included clinical exchanges
- From the RHIO’s perspective:

- Health data is health data is health data

- Goal: Bring value driven, non-profit business model to clinical exchanges

**Notes:**
(no animation)
UHIN’s vision has included exchanging clinical information from the beginning. “Health data is health data is health data”.  UHIN moves health data.

UHIN began to actively explore e-prescribing in 1998. Effort was derailed first by Y2K and then by HIPAA implementation (took everyone’s resources for about 3 years).

Our goal is to bring the same not-for-profit business model to clinical exchanges; we want to reduce the cost of health care; improve health care and reduce the burden of government; i.e., a continuation of our original mission.

The national discussion around RHIOs and NHII is very helpful in moving UHIN’s agenda forward.  We began in 1993 with a dial-up system: very inexpensive (by today’s standards).  UHIN’s current gateway is Internet based: much more expensive.  The AHRQ funding is instrumental in allowing UHIN to build a state-of-the art secure high performance gateway and community infrastructure.

## RHIOs

- What should a RHIO be?
- Only clinical exchanges?
- Following slides are UHIN’s vision of a RHIO

**Notes:**
(no animation)
RHIOs are an emerging idea.  The problem was first attempted to be solved in the 1990’s with the CHINs (Community Health Information Networks).  RHIOs are the latest attempt to break the communication barriers that impede quality care and drive up health care costs.

RHIOs must be viable businesses; must serve the communities they are rooted in.

## RHIO – Clinical X

- PBM

**RHIO – Clinical X**

**DOH**

- Payers

- Other orgs

- Clinicians

**Clearinghouse**

- Providers

**Clinics**

- Provider

**Payers**

**Laboratories**

**RxHub**

**Banks**

**RHIO**

- Clinics

- Payers

**Clinicians**

- PBM

**Billing Services**

- Pharmacies

**NHIO**

**RHIO**

**RHIO**

** ****Hospital – Hospital**

**Pharmacies**

**Pharm Hub**

**Integrated health care system**

- Clearinghouse

**Notes:**
Wait (title comes up)
Click
An example of what an existing RHIO does (Indianapolis - hospital to hospital ED data exchanges)

## RHIO

**DOH**

- Payers

- Clearinghouse

- Other orgs

- Clinicians

**Clearinghouse**

- Providers

**Clinics**

- Provider

**Laboratories**

**Banks**

**RHIO**

- Clinics

- Payers

**Clinicians**

**Billing Services**

- Pharmacies

**NHIO**

**RHIO**

**RHIO**

**Pharmacies**

**Pharm Hub**

**RHIO – Clinical X**

** ****Hospital – PBM**

**Notes:**
Wait (title comes up)
Click

An example of what an existing RHIO does (MA-SHARE: hospital ED to PBM – drug look ups)

## RHIO

**DOH**

- Payers

- Clearinghouse

- Other orgs

**Clearinghouse**

- Providers

- Provider

- PBM

**Payers**

**Laboratories**

**Banks**

**RHIO**

- Payers

**RxHub**

- PBM

**Billing Services**

**NHIO**

**RHIO**

**RHIO**

**RHIO – Clinical X**

** ****E-Prescribing**

**Notes:**
Wait (title comes up)
Click

An example of what an existing RHIO does (Rhode Island – e-prescriptions)

## RHIO

**RHIO**

- Payers

- Clearinghouse

- Other orgs

**Clearinghouse**

- Providers

- Provider

- PBM

**Payers**

**Banks**

- Payers

**RxHub**

- PBM

**Billing Services**

**RHIO**

**RHIO**

** ****Public Health Reporting**

**Integrated health care system**

**Notes:**
Wait (title comes up)

An example of what a RHIO could do in the area of public health.  All public health reporting could be through a single pipeline.
Click
Labs could automate reporting of lab results for reportable diseases.

Click
All facilities, clinics and clinicians could automate and streamline their reportable diseases.  All registries and reporting from hospitals could be automated and standardized.

click
Pharmacies could automate reporting to the state controlled substances data base.  The data base could be queriable in real time and made available to both pharmacies and prescribers.

Click
All national reporting could be done via the RHIO.

## UHIN

- PBM

**UHIN**

- Clearinghouse

- Other orgs

**Clearinghouse**

**Laboratories**

**RxHub**

**Banks**

**RHIO**

- PBM

- Pharmacies

**NHIO**

**RHIO**

**UHINet**

** ****Administrative Exchanges**

**Pharmacies**

**Pharm Hub**

**Integrated health care system**

** ****+**

**Notes:**
Wait (title comes up)
Click
UHIN does all the medical HIPAA transactions.

Click
+ - UHIN also routes data to the Health Department to support the immunization and hospital discharges data bases

## RHIO

**RHIO**
**(UHINet)**

**Notes:**
Wait (title comes up)

UHIN’s vision of a RHIO:  It should do it all.

 (click) Administrative
(click) Clinical
(click) Public Health Reporting
(click) Connect to NHIO and other RHIOs

Why?  
Greater volume means lower cost for all users
The value of the single connection increases for each user as more and more data flows through it.

## Physician to Hospital

| TO 
FROM  | Physicians | Hospitals | Health Plans | Public Health | Pharmacies | Laboratories | Consumers |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Physicians | Referrals and consultations
CCR | Admissions information; pre-natal reports;
CCR | Medical nec; Workers Comp notes; P4P  
Claims; claim status; eligibility, prior auths
Formularies, current drugs; pharm. ben.
 | Case reporting;
Queries to Controlled Substance Data Base | E-prescriptions;
refills, renewals,
Prior auth notice;  | Questions about tests and results | Lab results, reminders disease mgt reminders refill/renewal reminders,  |
| Hospitals | Results,; Discharge notes; lab results, Rx, admissions;  ED labs and Rxs transc.; dictation;  CCR | Patient transfers; CCR | Claims, claim status, eligibility, prior authorizations
Drug look-ups | Case reporting;
RODS
Vital records
Tumor registries | Drugs reconciliation; 
E-prescriptions; | Questions about tests and results |  |
| Health Plans | Pharmacy eligibility, formularies, current drugs ; pharmacy benefits; remits; claim status; eligibility, prior auth responses | Medical necessity;
remits; claim status; eligibility, prior authorizations responses | Subrogation, coordination of benefits | Case reporting? | Eligibility resp; medication history; medical history remits; | Questions about tests and results | Benefits information |
| Public Health | Notices of disease outbreaks;
Notices of changes in reportable diseases | Notices of disease outbreaks;
Notices of changes in reportable diseases | Notices of disease outbreaks | Reports of disease outbreaks (to CDC); bioterrorism | Response to controlled substances data base queries | Notices of changes in reportable diseases |  |
| Pharmacies | E-prescriptions;
refills, renewals,
Prior auth requests; questions about prescriptions; fill status | Drug reconciliation; fill status? | Pharmacy eligibility; claims; medication history; medical history | Reporting and queries to Controlled Substance Data Base | Prescription transfers | Questions about tests and results | Refill and renewal management |
| Laboratories | Results, responses to queries, test status updates | Results, responses to queries, test status updates | Answers about tests and results | Reportable diseases reporting | Results, responses to queries, test status updates | Q/A re: tests and results; test status updates | Results |
| Consumers | eVisits, appointment scheduling, refills & renewals | Admission/ appointment scheduling | Benefits questions, complaints |  | Refills & renewals |  |  |

**Physician to Hospital**
**Medical necessity; Admissions; pre-natal reports**
**current drugs;**
**CCR**

**Hospital to Physician**
**Results; Discharge notes; lab results, ED admissions;  ED labs and prescriptions transcription; dictation;  CCR**

**Public Health**
**Reportable diseases**
**Real-time; reduce public health burden; notice of disease outbreaks**

**Pharmacy/PBMs**
**E-Prescriptions; **
**Formularies**

- Doing It All

**Health Care Providers to Payers**
**Claims, eligibility inquiries; claim status; lab results; CCR**

**Notes:**
Wait (Do it all fades in and out)
Another way to look at doing it all.  RHIOs are only successful if they are many-to-one connections shipping many types of messages.

Click – Physician to hospital examples
Click – Hospital to physician examples
Click – Health care providers to payers
Click – Pharmacy examples
Click – Public health examples

## UHIN and DOH

- Goal: Create a single pipeline for health care entities to move many kinds of data including public health data to ease burden of reporting.

**Notes:**
(no animation)
Is it the Utah Department of Health’s goal to assist providers in reducing the cost of doing health care and improve and quality of care by participating in the expansion of a single pipeline for administrative, clinical, and public health reporting data exchanges.  

## Major Challenges

- Public perception of loss of privacy / control
- Physician concerns about privacy
- Building a business case
- No killer app for clinical
- Must build a collection of messages
- Need uniform privacy law across the nation

**Notes:**
(no animation)
1. Public Perception: 
Public fear that “Cop will see it” or “My father will know”.  This could kill the RHIOs
Public doesn’t know the types of health exchanges that  exists already. Any discussion of exchanging clinical information may be met with fear.  Need to educate the public.

2. Uniform Privacy Laws
HIPAA provides important legislation and regulation to protect privacy. But HIPAA is a floor, it sets minimum privacy standards. Many states have their own privacy law that are stringent that HIPAA. Inconsistent privacy policies among states cause legal difficulties in exchanging data cross states. 

3. Competition
Health care needs to move to a model where health care entities compete on their core business competencies and not to compete on how data is exchanged.  The creation of RHIOs can solve the data exchange blockade and create a higher quality health care system.

4. Standards: National standards need to be created and adopted for connectivity, security, authentication, and a host of messages to ensure interoperability at a national level

## Competition 
Community doesn’t compete on exchanging information
Compete on core services
Standards 
RHIOs  adopt community message and connectivity standards
Builds trust
RHIOs participate in national message and connectivity standards setting process 

- Community doesn’t compete on exchanging information
- Compete on core services
- Standards
- RHIOs  adopt community message and connectivity standards
- Builds trust
- RHIOs participate in national message and connectivity standards setting process

**Major Challenges**