# Presentation: 193766

##  Health Information Technology, Health Information Exchange, and Regional Health Information OrganizationsOverview of What’s Happening Nationally and Within States and Communities Across the U.S. Call with HRSA Grantees from ORHPHosted by Georgia Health Policy Center

- Janet M. Marchibroda
- Chief Executive Officer
- eHealth Initiative and Foundation

## Overview of Discussion

- Background
- Overview of What’s Happening at the National Level
- Review of What’s Happening in States and Communities Across the U.S.
- Key Take-Aways for HRSA Grantees

## eHealth Initiative and Foundation Mission

- Affiliated independent, non-profit, organizations whose missions are the same: to improve the quality, safety, and efficiency of healthcare through information and information technology

## Our Diverse Membership

- Consumer and patient groups
- Employers, healthcare purchasers, and payers
- Health care information technology suppliers
- Hospitals and other providers
- Pharmaceutical and medical device manufacturers
- Pharmacies, laboratories and other ancillary providers
- Practicing clinicians and clinician groups
- Public health agencies
- Quality improvement organizations
- Research and academic institutions
- State, regional and community-based health information organizations

## eHealth Initiative Strategy

- Identify and develop consensus among  **diverse stakeholders** on common principles, policies, and practices for **mobilizing clinical health information** to support improvements in healthcare
**Align national standards **with efforts at the state, regional and community levels

## eHealth Initiative Foundation’s Connecting Communities for Better Health Program

- Currently funded by HRSA/OAT through a cooperative agreement, provides seed funding and technical support to regional and community-based multi-stakeholder collaboratives that are mobilizing information across organizations
- Develops and disseminates common principles, policies and guides to help regions navigate organizational, financial, clinical and technical aspects of health information exchange
- Connecting Communities Online Resource Center
- _[http://ccbh.ehealthinitiative.org/](http://ccbh.ehealthinitiative.org/)_

## eHI State and Regional HIT Policy Summit Initiative

- Currently supporting 10 states in the U.S.
- Funded by state government, philanthropies, some private sector contributions
- Facilitates public-private sector collaboration, bringing state and regional policy-makers, healthcare stakeholders and business community together
- Focus is on
- Stimulating local innovation
- Facilitating collaboration among all stakeholders in healthcare
- Aligning incentives not only with quality and safety but also HIT and health information exchange

## AHRQ National Resource Center for Health Information Technology

- eHealth Initiative Foundation proud partner of AHRQ National Resource Center for HIT which is led by National Opinion Research Center (NORC).  Other partners include:
- Three academic thought leaders:
- Indiana University/Regenstrief
- Vanderbilt University
- Center for Information Technology Leadership / Partners
- Burness Communications: Policy-focused Public Relations
- BL Seamon Corporation: Logistical and coordination support
- Computer Sciences Corporation: Technology design and support services

**Goal: Increase the adoption of health information systems to improve patient safety and quality of care and conduct research on take-up and impacts**

## Understanding the National Agenda around Health Information  Exchange

- Enormous momentum around improving quality, safety and efficiency through clinical exchange within Administration,  Congress, and the private sector
- Key themes
- National standards for interoperability
- Alignment of value based purchasing with HIT infrastructure required to get there
- Government as catalyst
- Public-private sector collaboration

## Signs of Momentum for Clinical Exchange: Activities in Congress

- 11 bills introduced this year, more coming
- Most bi-partisan
- Unprecedented collaboration between the Republicans and Democrats on the importance of leveraging HIT and the *mobilization of information* to address healthcare challenges

## Signs of Momentum for Clinical Exchange: Activities in Administration

- AHIC public-private “community” formed to provide input to Sec. Leavitt re how to make health records digital and *interoperable* and assure that privacy and security are protected
- Four awards emerging from DHHS:
- Standards harmonization process – awarded by ONC to ANSI in Oct 2005
- Compliance certification process for EHRs – awarded by ONC to Certification Commission for HIT in Oct 2005
- Variations in organization-level business policies and state laws that affect privacy and security practices (including HIPAA) – awarded by AHRQ to RTI International in Oct 2005
- Nationwide health information network prototypes – ONC awarded four projects last week covering 12 communities

## Office of National Coordinator for Health Information Technology

- On August 19, 2005 Federal Register announced formal formation of the office
- Purpose: provides leadership for the development and nationwide implementation of an interoperable HIT infrastructure to improve quality and efficiency of healthcare and the ability of consumers to manage their care and safety

## ONCHIT July 2004 Framework for Strategic Action

- Inform Clinical Practice
- Incentivize EHR Adoption
- Reduce risk of EHR investment
- Promote EHR diffusion in rural and underserved areas
- Interconnect Clinicians
- Foster regional collaborations
- Develop a national health information network
- Coordinate federal health information systems

## ONCHIT July 2004 Framework for Strategic Action

- Personalize Care
- Encourage use of PHRs
- Enhance informed consumer choice
- Promote use of telehealth systems
- Improve Population Health
- Unify public health surveillance architectures
- Streamline quality and health status monitoring
- Accelerate research and dissemination of evidence

## AHRQ Focus on Health Information  Exchange

- Over $150 million in grants and contracts for HIT
- Over $100 million supporting approx 110 grants in 38 states – **approximately 50% focus on health information exchange**
- Contracts to six states to help develop statewide **health information exchange** networks – CO, DE, IN, RI, TN, UT - $29 million over five years
- National HIT Resource Center: collaboration led by NORC and including eHealth Initiative, CITL, Indiana University, Vanderbilt and CSC - $18.5 million over five years

## CMS Focus on Health Information  Exchange

- Section 649 – Pay for Performance Demonstration Programs – link payment to better outcomes and use of HIT – launched in early 2005 – some aspects related to standards-based HIT
- Quality Improvement Organizations providing technical assistance for HIT in small physician practices through eighth scope of work – **health information exchange** will be needed to report measures
- Section 646 “area-wide” demonstration just announced in September 2005 – **health information exchange** will need to be implemented to get there
- Physician Voluntary Program Reporting Program regarding quality of care begins January 2006 – **health information exchange** will support population of measures

## Overview of Activities at State, Regional and Local Levels

## Why Focus on Communities?

- Wide-spread recognition of the need for health information technology and exchange/ interoperability at the national level
- While federal leadership and national standards are needed, *healthcare indeed is local* and leadership is needed at the state, regional and community levels across the country
- Need for collaboration and development of consensus on a **shared vision, goals and plan** is needed among multiple, diverse stakeholders at the *state and regional level* in order to get this work done

## What is Health Information Exchange?

- Health information exchange provides the capability to electronically move clinical information between disparate healthcare information systems while maintaining the meaning of the information being exchanged.
- The goal of health information exchange is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care.

## Why Health Information Exchange?

- U.S. healthcare system highly fragmented....data is     stored —often in paper form—in silos, across hospitals, labs, physician offices, pharmacies, and insurers
- Public health agencies forced to utilize phone, fax and mail to conduct public health surveillance, detection, management and response
- Physicians spend 20 - 30% of their time searching for information...10 - 81% of the time, physicians don’t find the information they need in the patient record
- Clinical research hindered by paper-based, fragmented systems – costly and slow processes

## Value for Patients

- The true promise of coordinated care along the entire care continuum, and improved relationships with all care givers
- The ability to better manage their personal health information and records
- The ability to improve the physician-patient dialogue and relationship

## Value for Clinicians

- Doing well while doing good
- Gaining a deep understanding of their individual, group and practice’s performance in delivering quality care to patients
- Initiating and tracking QI programs
- Better management and coordination of their patients’ care

## Value for Purchasers and Payers

- Real-time, relevant, fair, and equitable information on the quality of services delivered by all clinicians
- Ability to better engage employees and their family members in managing their care

## Survey of Over 100 State, Regional and Community-Based Initiatives

- 109 respondents from 45 states and the District of Columbia
- Covered aspects related to goals, functionality, organization and governance models, information sharing policies, technical aspects, funding and sustainability

## Key Findings from Survey

- Health information exchange activity is on the rise....there are more efforts, and those that are out there are maturing
- Of the 109 health information exchange efforts in the survey:
- 40 are in the implementation phase and
- 25 fully operational
- Nine were fully operational in 2004

## Stage of Health Information Exchange Programs

**12%**
** **
- Recognition of the need for HIE among multiple stakeholders in your state, region, or community

**Stage 1**

**Stage 2**

**Stage 3**

**Stage 4**

**Stage 5**

**14%**
- Getting organized
- Defining shared vision, goals, & objectives
- Identifying funding sources
- Setting up legal & governance structures

**15%**
** **
- Transferring vision, goals, & objectives to tactics and business plan
- Defining needs and requirements
- Securing funding

**37%**
** **
- Well under-way with implementation – technical, financial, and legal

**12%**
** **
- Fully operational health information organization
- Transmitting data that is being used by healthcare stakeholders
- Sustainable business model

**11%**
** **
- Demonstration of expansion of organization to encompass a broader coalition of stakeholders than present in the initial operational model

**Stage 6**

## Key Findings from Survey

- The key driver moving states, regions and communities toward health information exchange is
- Perceived provider inefficiencies (77% of all respondents)
- Rising healthcare costs also seen as important driver (60% of all respondents)

## Key Drivers for Health Information Exchange

## Key Findings from Survey

- Organization and governance structures are getting more formalized and shifting to multi-stakeholder models with the involvement of providers, purchasers and payers
- 60% of advanced stage are incorporated
- 70% are non-profit models

## How are HIE Efforts Organized?

## HIE Efforts are Forming Legal Structures

## Key Findings from Survey

- Organization and governance structures are getting more formalized and shifting to multi-stakeholder models with the involvement of providers, purchasers and payers
- Providers continue to play the most dominant role but see an increase in others: health plans (28%), local public health departments (45%), QIOs (35%), employers (22%), patient consumer groups (29%)

## Who’s Involved?

## Key Findings from Survey

- Organization and governance structures are getting more formalized and shifting to multi-stakeholder models with the involvement of providers, purchasers and payers
- Clear shift towards leadership by neutral, multi-stakeholder entity (55%)

## Who is Leading These Efforts?

## Key Findings from Survey: What are They Doing?

- Primary focus continues to be on supporting care delivery
- Clinical documentation
- Reminders
- Results delivery

## Health Information Exchange Initiatives: What Are They Doing? 

## Key Findings from Survey: What are They Doing?

- Advancements in functionality to support improvements in quality and safety are evident. In addition to traditional uses to support care delivery, a number are now expanding functionality
- 32% currently providing disease or chronic care management services (with additional 21% expecting to within six months)
- 27% are currently supporting quality performance reporting efforts (with additional 18% expected within six months)

## Growing Focus on Disease Management, Quality Reporting

## Key Findings from Survey: What are They Doing?

- Health information exchange efforts are delivering *more information* and increasingly *using standards* for data delivery
- More than 50% are exchanging or expecting to exchange outpatient and inpatient episodes, lab results, ED episodes, pathology and enrollment and eligibility
- 76% of advanced stage are using HL7 as messaging standards and 41% are using LOINC for laboratory reporting

## Most Significant Challenges

## Most Difficult Challenges

- Securing upfront funding- 91% of all respondents cited “securing upfront funding” as either a very difficult or moderately difficult challenge.
- Developing a sustainable business model- 84% of all respondents cited “developing a sustainable business model” as a very difficult or moderately difficult challenge.

## Most Difficult Challenges

- Engaging health plans- 74% of respondents perceived the engagement of health plans as a very difficult or moderately difficult challenge.
- Accurately linking patient data- 80% of respondents indicated that accurately linking patient data was a very or moderately difficult challenge.

## Key Findings from Survey

- Funding sources for both upfront and ongoing operational costs still rely heavily upon government funds
- 46% of all respondents cited federal government contracts as current revenue source
- 48% of advanced stage cite federal government as source for ongoing operations

## Federal Government Still Key Funding Source

## Federal Government Still Key Funding Source

## Key Findings from Survey

**But alternative funding sources for ongoing sustainability are beginning to emerge**.
- Advance payments from hospitals (38%)
- Physician practices (33%)
- Public health (19%)
- Labs (15%)
- Payers (15%), and
- Purchasers (9%)

## New Models for Sustainability Emerging

## Emerging Guiding Principles

## So What Does the Survey and Our Many Experiences Tell us?

- Second annual survey of states, regions and communities engaged in health information exchange
- eHealth Initiative Connecting Communities Program in cooperation with DHHS
- Learning community
- Seed funding
- Development of common principles and tools
- eHealth Initiative State and Regional HIT Initiative – supporting 10 states
- Facilitates public-private sector collaboration, bringing state and regional policy-makers, healthcare stakeholders and business community together
- Focus on facilitating collaboration, developing shared vision and incremental roadmap, aligning incentives to support state or regional health and healthcare goals

## Characteristics of Successful Health Information Exchange Initiatives

- Governed by a diverse and broad set of stakeholders within the region or community
- Develop and assure adherence to a common set of principles and standards for the technical and policy aspects of information sharing - addressing the needs of every stakeholder
- Develop and maintain a model for sustainability that aligns the costs with the benefits of HIE; and
- Use metrics to measure performance from the perspective of: patient care, public health, provider value, and economic value.

## Emerging Guiding Principles

**Approach for Getting Organized**
- Convening by trusted, neutral party
- Important to engage all of the stakeholders in your region or community: practicing clinicians, hospitals, laboratories, community health centers, pharmacies, health plans, employers, patient groups, public health, and the state and local government
- Very, very important to understand your shared vision, goals and objectives, and principles for working together
- Migrating from loose affiliation to organized legal structures

## Emerging Guiding Principles

**Approach to Organizing the Work**
- HIT adoption and health information exchange will require local / regional collaboration; a “national or state-wide, one-size-fits-all” approach will not work
- Incremental; no “big bang” approach
- Value—to various stakeholders is critical here
- How does this link with your region’s or community’s healthcare goals?
- Build on what exists....
- Minimally invasive with limited disruptions

## Emerging Guiding Principles

**Approach for Technical Aspects**
- Build in your policies for information sharing as you build your technical architecture!
- Need information environment that facilitates and structures connectivity - adherence to precisely defined, uniform technical standards, common policies, and common methods
- Connectivity built on the Internet and other existing networks
- Environment is private, secure
- Minimally invasive approach – leverages existing systems - no “rip and replace”
- Accurate patient identification based on uniform and standardized methodologies....record locator services created and controlled regionally or within other sub-networks, to help authorized parties learn where authorized and pertinent information is housed

## Emerging Guiding Principles

**Engaging Practicing Clinicians in the Changes Required**
- Innovation and investment will be needed to support small physician practices in migration
- Reduce burden of multiple reporting systems (health plans, employers, regulators, public health)
- Build reporting into current work-flow
- Improve trust through certification processes
- Realign incentives to promote adoption

## Emerging Guiding Principles

**Sharing Burden and Benefits**
- Must create value for all participants, both globally and for each stakeholder interest
- Must address the highly competitive environment
- Look for incremental value gains – projects that will immediately return value – as you move towards your longer-term goal

## Emerging Guiding Principles

**Financing and Sustainability**
- Recognize that value of HIT accrues to many stakeholders, including clinicians, health plans, hospitals, purchasers, patients and public health
- Incentive amounts offered should be meaningful
- Purchaser or payer sponsors of the incentive program should represent a meaningful proportion of the clinician’s patient panel
- Any applications covered by the program should be “interoperable” and standards-based

## Emerging Guiding Principles 

**Financing and Sustainability....**
***Coordination and collaboration within the region or community is critical.*****  **
- Physician practices ordinarily contract with a large number of purchasers and payers.
- Incentives offered by a small number of purchasers or payers generally are not effective
- Reduce the potential for the “free rider” effect
- Most of the data required to deliver care within physician practices resides somewhere else (hospital, lab, pharmacy, health plan, etc.)

## Emerging Guiding Principles 

**Financing and Sustainability: **
**Rapidly emerging interest in aligning quality improvement initiatives with the HIT and health information exchange infrastructure required**

## Aligning Incentives with
Quality capabilities
Physician HIT capabilities
Health information exchange capabilities

- Quality capabilities
- Physician HIT capabilities
- Health information exchange capabilities

- eHI’s Parallel Pathways: Aligning Incentives with Quality *and* HIT

**Quality and Value**

-         **Quality **
**Expectations**

**Physician **
**Practice HIT**
**Capabilities**

**Health Info **
**Exchange **
**Capabilities**
** **

**Financial **
**Incentives**

## Aligning Quality Expectations with HIT and HIE Capabilities

- Reporting of Outcomes

- Implementation of HIT

- Time

- Incentives

- L

- H

- _Phase 1_

- _Phase 2_

- _Phase 3_

**Quality self-assessment**
**HIT implementation**
**Chart data reporting**
**HIE formation**

**Use of HIT**
**e-reporting of outcomes**
**QI initiatives**
**HIE operational**

**Continued QI**
**Full e-reporting of outcomes**

## Key Take-aways

- Health information technology is here and interoperability is the name of the game
- Rapid changes in policy at the national, state and local levels
- Every stakeholder group is trying to figure out how this fits within their strategy
- National standards are emerging to support interoperability- stay in tune with them...build them in as they get defined

## Key Take-aways

- Value-based purchasing will be here soon....keep this in mind as you proceed
- Engaging your purchasers and health plans is critical...without them you don’t have a sustainable business model
- Remember that most of healthcare is delivered by small physician practices...engage them, and engage them early

## Key Take-aways

- Most important thing is to **stay focused** ...build your incremental roadmap based on value.... **at the end of the day, value is the only thing that matters**
- Mobilizing health information is going to **dramatically improve the quality and safety of healthcare in the U.S.**

- Janet M. Marchibroda
- Chief Executive Officer
- eHealth Initiative and Foundation
- _[www.ehealthinitiative.org](http://www.ehealthinitiative.org/)_
- 1500 K Street, N.W., Suite 900
- Washington, D.C. 20005
- 202.624.3270
- Janet.marchibroda@ehealthinitiative.org