Health Information Information Exchange Exchange in t

Michael Weiner, MD, MPH

Alissa Russ, PhD

David Haggstrom, MD, MAS

C t en er of E ll xce ence on I l ti mp ementing E id v ence‐B 

as

Department of Veterans Affairs, Veterans Health Adm

Health Services Research and Development Service 

Richard L. Roudebush VA Medical Center, Indiana

Kenneth Boockvar, MD, MS

James J. Peters VA Medical Center, Bronx, N

HSR&D Cyberseminar • 24 September 2012

The views expressed in this presentation are those of the au

and do not necessarily represent the views of the Department of Ve
Agenda for Today

• Understand Understand the need for health informatio

informatio

exchange (HIE)

• Learn about health information information organizatio

organizatio

• Learn about current approaches to HIE• Learn about insights from end users• Gain appreciation of frameworks, measures

research

• Questions and discussion

• Not on agenda: comprehensive review, resu

evaluation, extensive extensive technical technical details details
Veterans make transitions in 

• There are no closed systems of care• About half of Veterans Veterans receive receive care outside outside VA (estima

(estima

• More than 80% of older Veterans (65+) also have Med• 25% have at least two non‐VA federal federal health plans

VA insurance (Non‐VA insuraNo insurance ( 

Kizer KW, JAMA 2012; 307 (8):789‐90.

Shen Y et al., Med Care Res Rev 2003; 60 (2):253‐67. 
Medicare‐eligible Veteran

with outpatient use (1999

Hynes DM et al., Med Care 2007; 45 (3):214‐23. 
Medicare Advantage in Veter

(2009)

Trivedi AN et al., JAMA 2012; 308 (1):67‐72. 
Medicare Advantage in Veter

(2009)

• Dual enrollment i d ncreased

by 90% to 924,792 from

2004 to 2009

• VA paid $13 billion for

Medicare Advantageenrollees over 6 years

Trivedi AN et al., JAMA 2012; 308 (1):67‐72. 
Meaningful use of electro

health record (EHR) syste

• Using EHR technology to improve care, coo

and security, while engaging patients

• Stage 1 (2011‐2012; encouraged): capture a

data

• Stage 2 ( ; 2014 req ) uired : advance clinical p

• Stage 3 (2015): improve outcomes
Meaningful use of electro

health record (EHR) syste

• Using EHR technology to improve care, coo

and security, security, while engaging engaging patients patients

• Stage 1 (2011‐2012; encouraged): capture a

data

• Entry of basic patient data• Electronic prescribing with decision supp

• Ability to exchange structured health in

• Additional options

• Stage 2 (2014; required): required): advance advance clinical clinical p

p

• Stage 3 (2015): improve outcomes 
Meaningful use of electro

health record (EHR) syste

• Using EHR technology to improve care, coo

and security, while engaging patients

Eligible providers and hospitals

must electronically transmit and security, while engaging patients

• Stage 1 (2011‐2012; encouraged): capture a

data

summary in at least 10% of

transfers or referrals.

data

• Entry of basic patient data• Electronic prescribing with decision supp

• Ability to exchange structured health inf

• Additional options

• Stage 2 (2014; required required): advance advance clinical clinical p

p

• Stage 3 (2015): improve outcomes 
What is health information information exch

exch

“The electronic movement of health‐reinformation among organizations organizations acco

acco

nationally recognized standards”

• Includes clinical clinical and administrative administrative d• Organizations are often diverse and

competing

The National Alliance for Health Information Technology <http://healthit.hhs.gov/defining_key_h

Dixon BE et al., J Am Med Inform Assoc 2010; 17 (3):295‐301. 
Governance and standards can

support medical decisions and car

• The public‐private

support medical decisions and car

Health Information

Technology Standards

Panel formalized HIE

standards

• Continuity of Care

Document (CCD)summarizes a patient’s

medical status

• Newer groups and

approaches have

evolved
Nationwide Health

I f ti n ormation

Network (NwHIN)

• Standards, services, and

poli i c es enabling HIE via

Internet

• NwHIN Exchange: collaborators exchanging informat

• Participants

• Federal and public‐health entities

• Integrated delivery networks

• Private organizations

• Health information organizations

• Transitioning to HealtheWay, a public‐private part
Examples

of exchangeable informat

• Information source

L k

• Healthcare pro

• Language spoken I i ti

• Personal information

• Problem list

• Immunizations

• Insurance prov

Problem list • Medications

• Advance directives

• Allergies

Medications

• Plan of care• Pregnancy stat

• Problem list

• Progress notes

• Discharge summaries

• Procedures• Vital signs

• Discharge summaries • Diagnostic Diagnostic resu

resu
The health information information organiza

organiza

• Oversees HIE• Uses nationally nationally recognized recognized standard

standard

• Provides interop y, erability, security, a

confidentiality

• Ensures authi i or zation of those who 

information

American Health Information Management Association 
Health information organiza

• In 2009, U.S. had about 197 regional h

information organizations

• 45% operational, covering 14% of hosp

3% of ambulatory ambulatory practices practices

• 33% financially viable• U.S. government

provided startup funding

Adler‐Milstein J et al., Ann Intern Med 2011; 154 (10):666‐71. 
Indiana Health Information Exchang

• Statewide network with “virtual record”• Operates Operates largest largest HIE in the U S. .

• Over 12 million patients, 19,000 physicians, 90 

110 other healthcare organizations ( g lon ‐term 

rehabilitation facilities, clinics, imaging centers, 

health centers)

• 3 billion pieces of clinical data: 80 million radio

50 million text reports, 750,000 EKGs; discharge

summaries, operative notes, path l o ogy reports

medication records

• Encounters Encounters from 90% of care provided provided at Indianap

Indianap

hospitals

• Over a million million health transactions transactions daily• Partners with Regenstrief Institute at Indiana Unive
HIE should consider

consumers’ preferences

• New York survey ( ) N=170• 67% were comfortable with HIE process of automatic 

storage

• Primary care doctor should have emergency access w

permission (93%)

• M t os want:

• Permission before routine viewing by primary car

(64%)

• Ability to see who has viewed their information (8

• Ability to stop electronic storage of data ( ) 84%

• Ability to stop all viewing (83%)

• Ability to select which parts are shared (78%)

• 51% would trust practice to regulate security and pri

Dhopeshwarkar RV et al., Ann Fam Med 2012; 10 (5):428‐34. 
Virtual Lifetime Electronic Record 

• Announced by President Obama in 2009• For streamlined transitions of patients and their

administrative and medical records, starting with m

service

• Five capability areas defined by functionality

• VLER C bilit apability Area 1 ("VLER H lth“) ealth“) cht d ar ered D 

Interagency Program Office to pursue interoperabi

private‐sector providers

• Integrated electronic health record will use HIE to 

care for individuals served by DoD, VA, other agen

Social Security Administration)

• Intended benefits: continuity, quality, timeliness, s

redundancy
VLER: 13 active sites; more on t

• Sites

• VA and DoD: Hampton, Puget Sound, San Diego, • VA only: Altoona, Asheville, Buffalo, Charleston, 

Junction, Indianapolis, Minneapolis, Richmond, S

• O t p ‐in process

• Veteran completes authorization form (N=52,76

• Veteran Veteran s’ identity identity is authenticated authenticated• Authorization form is validated and entered into 

• NwHIN Exchange Exchange Partner Partner may require require additiona

additiona

• Correlation (matching) of patients across systems

• NwHIN Exchange Partner systems try to match V

identity to their records

• Missing SSN, absence of visits, and other factors 

matching

• Evaluation underway 
User interface for clinicia
Computerized Patient Record System 
List of Data Sources

Double dagger

indicates non‐VA

sources of data
S

F

d

strptio


Aggregated view

• For VA data, date ranges can be specified specified for various various t• For non‐VA data, date ranges can be specified only fo
Clinical Notes
Clinical 

d 

eta
Initial usage

• Physicians, physician assistants, nurses, phar

mental‐health providers use the system

• 5% of matched Veterans have had at least on

disclosure to a VA clinician

• Veterans Veterans may not have had encounters encounters

• Clinicians might choose not to view data, o

unaware

• Similar access to Tennessee study (6.8%)• Even low usage may lead to improved care 

• Outbound disclosures are also occurring

Frisse ME et al., J Am Med Inform Assoc 2012; 19 (3):328‐33.
Technical dimensions

• Consider Consider benefits benefits and risks relative relative to usua

retrieving NwHIN documents is faster than 

requests requests to hospitals hospitals and waiting waiting for replies replies

• Timeouts and other delays can slow data re• For multiple reasons, documents are retriev

demand, rather than being locally cached

• Need for usability: "the extent to which a p

be used by specified users to achieve specif

with effectiveness, efficiency and satisfactio

specified context of use"

International Organization for Standardization, ISO 9241.
Insights from End‐Users

Findings

from other HIE systems

Alissa Russ, PhD

VA HSR&D Center of Excellence on Imp g lementing Evidence‐Base

Richard L. Roudebush VA Medical Center

Indianapolis, Indiana
3 studies:

1. Hincapie AL, Warholak TL, Murcko AC, Slack M, M

Physicians' opinions of a health information exch

Med Inform Assoc 2011;18:60 2011;18:60‐5

2. Gadd CS, Ho YX, Cala CM, et al. User perspectives 

usability usability of a regional regional health information information exchang

exchang

Med Inform Assoc 2011;18:711‐6.

3. U tl ner KM, J ho nson KB, L i orenz NM. H lth ea i f 

n or

exchange technology on the front lines of healthc

workflow workflow factors factors and patterns patterns of use. J Am Med I

Assoc 2011.
1. Hincapie Hincapie et al. 2011

Focus groups:

• Arizona Medical Information Exchang• 29 physicians

Findings:• Workflow variation• HIE useful to prevent prevent ‘doctor shopp

shopp

• Helps avoid duplicate testing
1. Hincapie Hincapie (cont d) (cont’d)

Identified Challenges:• Limited data availability (e.g.,

immunizations, mental health) health)

• Difficulty finding data

• Workflow efficiency

• Some physicians physicians relied on others to r

r

information
2. Gadd et al. 2011

Cross‐sectional survey

• MidSouth eHealth Alliance

• Quest o a e i nnaire for User Inte act o r i n Sat s ac

isfac

• 151 respondents: physicians, nurse pract

physicians assistants, nurses, others

Findings:• 3 usability factors were positive predictors 

• Overall reaction

• Learning

• Functionality
2. Gadd (cont d) (cont’d)

Findings (cont):

• Consolidating data in HIE, rather than agg 

ggr

may facilitate implementation and use

• Focus on meeting meeting basic expectations expectations of HI

• Usability may be more important than ‘tru

Identified Challenges:

• Need to improve design and navigation of HIE
3. Unertl et al. 2011

Qualitative study

• MidSouth eHealth Alliance Alliance• 6 emergency departments, 8 ambulatory clinics• Direct observations, interviews interviews

Findings:

• Workflow varied by site and end‐user’s role

• HIE used for:

• Pt medical history

• Discharge summaries

• Track completion and results of external pro

biopsies

• Verifying patient input• Referrals
3. Unertl (cont d) (cont’d)

Identified challenges:• “Fragmentation of information

information

• EHR system at their site• EHR systems from associated •Data from information excha• Paper forms
Summary from end‐use

End‐users:• Find value in HIE

• Likely use a core set of data from HIE

• Need more than just ‘more informatio• Desire systems that will consolidate d

all sources
Health information exchan

Frameworks, Measures, Rese

David A. Haggstrom, MD, MAS

VA HSR&D Center of Excellence on Imp g lementing Evidence‐Base

Richard L. Roudebush VA Medical Center

Indianapolis, Indiana
Evaluation framework

Dixon BE et al., J Am Med Inform Assoc 2010; 17 (3):295‐301. 
Evaluation framework

VA clinical outcomes are not

yet known.

Dixon BE et al., J Am Med Inform Assoc 2010; 17 (3):295‐301. 
Randomized controlled trial of 

among providers providers of care for H

Design: randomized at patient levelSetting: 6 infectious disease clinics paired with 9 ancilla

community‐based settings providing HIV case managem

Participants: 254 patients with HIV

Intervention: HIE for 2 years/patient

Outcomes:

Medical records: HIV viral loads, CD4 counts, antiretrovi

prescriptionsPatient surveys (0, 12, 24 months): hospitalizations, emedtt epar ment use, quality of life (M di l (Medical O t u comes St du Results: no statistically significant differences (ARVs slighLi i i m tat on: small amount of i f n o exch d ange , no direct H

Proeschold‐Bell RJ et al., J Public Health Manag Pract 2010; 16 (6):521‐8. 
Early Randomized Controlled 

in an Emergency Emergency Department Department 

Design: randomized at patient levelSetting: large, longitudinal EHR system from an urban ho

physicians at either of 2 emergency departments with la

Parti i c pants: 16,374 i i ntervention; 16,094 controls

Intervention: information to ED physician both as printe

by means of online access to EHR s stem yOutcomes: charges, hospital admissions, repeat emergeemergency emergency physicians physicians’ satisfaction satisfaction with the information informationResults: decreased charges by $26/encounter at one ho

effect at the other hospital

• No differences in admission rates or repeat emerge

• Problem lists, medications most useful

Discussion: mark de d ff i erences in workfl / f ows informatio

across sites

Overhage JM et al., Annals of Emergency Medicine. 2002; 39 (1):14‐23. 
Recent impact of HIE on emergenc

• Design: matched case‐control study

p g 

• Setting: all major emergency departments (12) in Memphis, TN

• Participants: 15,798 HIE cases (12,120 patients)

15 798 , non‐HIE controls controls (13 832 , patients patients)

• Cases (exposures): emergency visits with HIE access (Aug 2007 

• Controls: emergency visits with no HIE access ‐ matched by age

care delivery site, discharge diagnostic code, primary payer

• Outcomes:

• H it l ospital adii m ss ons from the emergency dtt epar ment• Admissions for observation• Laboratory testing• Head CT, body CT• Chest x‐ray, ankle x‐ray• Echocardiograms

Frisse et al., JAMIA, 2012 
Recent impact of HIE on emergenc

• HIE d t a a were accessed in 6 8%. of emergency vi it s s

• 11 emergency departments directly accessed only H

browser

• Decrease in hospital admissions• Increase in head CT and chest x‐ray

• 12th emergency department relied more on printed 

• Decrease in hospital admissions

• Significant decreases in head CT, body CT, and lab 

• Financial summary

• HIE access was associated with annual cost saving

million

• Net of annual operating operating costs, HIE access reduced reduced 

by $1.07 million

• Hospital Hospital admission admission reductions reductions accounted accounted for 98% 

reductions

Frisse ME et al., J Am Med Inform Assoc 2012; 19 (3):328‐33. 
Lessons from empiric empiric resea

resea

• Amount of information exchanged is

important metric

• Access to transaction transaction data improves improves s

s

of study design

• Mixed methods important to understa

implementation

• Evidence suggests downward pressure 

costs

• Important to stakeholders• Quality important, too
HIE in emergency care: “who, what, an

• Mixed methods:

• Cross‐sectional audit log data

• Overall usage trends

• User logon statistics

• Data types accessed by users

• Semi‐structured interviews

• Direct observation in emerg y enc departments activ

• Results:

• Higher rates of access for (1) return visits, (2) sites 

underserved, (3) patients with high levels of comor

providing access to clerks, RNs, & MDs

• Providers noted retrieving additional history (29%)

repeat tests (20%), comparing new to retrieved res

avoiding hospitalizations (3%)

Johnson KB et al., J Am Med Inform Assoc 2011; 18 (5):690‐7. 
“A Novel Set of Proposed Metr

Electronic Quality Reportin

• A lit t era ure review id tifi d entified quality met ir c sets f

ambulatory care

• Ambulatory Ambulatory Care Quality Quality Alliance Alliance (AQA)• National Quality Forum (NQF) ambulatory care measu

• National National Committee Committee Quality Quality Assurance Assurance (NCQA) Health

Health

Effectiveness and Data Information Set (HEDIS) measu

• Two rounds of quantitative quantitative rating of individual individual m

m

• 36‐member national expert panel validated ratin

final metric set

• Metrics were developed de novo to capture addi

expected effects of EHR systems (reduced utilizat

Kern LM et al., Jt Comm J Qual Patient Saf 2009; 35 (7):359‐69.

expected effects of EHR systems (reduced utilizat
Conceptual framework

Outpatient clinical encounter(s) 

Electronic d

Traditional receipt of

Clinical Data by aHealth Care Provider

(no HIE)

Kaushal et al.

Electronic receipt of

Clinical Data by aHealth Care Provider

At th Pit f C

Electronic d

capture

Clinical data residing

elsewhere 

MedicalDecisionMaking

HIE

transaction(s)

At the Point of Care

(HIE)

Information‐ processing Study question: HIE goodness of fit?

Provider(Interdependence)

‐Sociodemographics

‐Type of provider(s)

Patient

Amount of clinical (Complexity)

data available

elsewherecapacity

McDonald et al.

‐Disease‐Comorbidity

yp p ()

‐Number of provider

referrals

Type of clinicaldata available

elsewhere

Information‐processing requirements
Ambulatory measures of under

PREVENTIONColorectal cancer screening Colorectal cancer screening up-to-date (age 50 date (age 50–80)% of women 40–69 years of age who had a mammogram to screen for breast cancer% of patients 50–64 years who received an influenza vaccination% of patients 65 years and older who received an influenza vaccinationDIABETES% of pts18–75 years of age with diabetes whose most recent HbA1c level during the m9.0%% of pts 18–75 years of age with diabetes who had one or more HbA1c lab tests durinASTHMA% of patients 18–56 years of age who were identified as having persistent asthma and prescribed medication during the 12-month period

CARDIOVASCULAR DISEASE

% of patients w/ atients w/ischemic ischemic vascular disease vascular disease (diagnosis diagnosis) who have documentation of u

have documentation of u

another antithrombotic during the 12-month measurement period (medication)% of patients with ischemic vascular disease whose most recent LDL-C had a result of 

CONGESTIVE HEART FAILURE CONGESTIVE HEART FAILURE% of patients with CHF (diagnosis) who also have paroxysmal or chronic atrial fibrilla

prescribed warfarin therapy (medication)

MENTAL HEALTH

% of patients 18 years of age and older who had a of patients 18 years of age and older who had a follow-up visit up visit within 30 days after 

within 30 days after 

inpatient mental health stay (including hospitalizations for depression, schizophrenia, atand personality disorders)OSTEOPEROSIS

% of patients aged 50 years and older with fracture of the hip spine or distal radius wh

of patients aged 50 years and older with fracture of the hip, spine, or distal radius wh

energy x-ray absorptiometry (DXA) measurement ordered or performed or pharmacolog

(procedure)

Kern LM et al., Jt Comm J Qual Patient Saf 2009; 35 (7):359‐69. 
De novo metrics (including ove

Bl d T t Blood Tests

How many tests were already completed for a patient that are less appropriate repeat interval] old at the time of the 2nd test?

 Creatinine (10 days); Sodium (10 days) Creatinine (10 days); Sodium (10 days) Total cholesterol (6 weeks); HDL (6 weeks) ; Hemoglobin A1c (12 wee Thyroid stimulating hormone (6 weeks); Liver function tests (ALT/AST)  Hemoglobin (10 days); Ferritin (8 weeks)Imaging TestsX-rays, ultrasounds, CT scans, and MRIs ordered over a 1-year p• how many represent tests for which results were already completed for 

h 60 d ld h i f h 2 d no more than 60 days old at the time of the 2 ? nd test?

Cardiac TestsStress tests, echocardiography, and cardiac catheterization ordereperi do• how many represent tests for which results were already completed for 

no more than 90 days old at the time of the 2nd test?

• Other measure domains: discharge medication docum

referrals, follow‐up after discharge, ambulatory care s

Kern LM et al., Jt Comm J Qual Patient Saf 2009; 35 (7):359‐69. 

hospitalizations, readmissions
Additional resources
Conclusions about HIE rese

• Conceptual frameworks can inform resear

consideration of...

• Patient factors and provider factors• Information characteristics• Clinical decision‐making role

• B th o underuse & overuse of medi l ca servi

potentially effected by HIE

• Need to consider impact of HIE in multiple 

• Emergency department• Ambulatory care/primary care• Specialty care• Inpatient care
Summary

• In the U.S., HIE has shown early signs 

benefit for health care

• VLER is improving, expanding, and eva

its HIE program

• Need to address address technical technical issues, issues, usab

usab

patients’ preferences, and sustainabil

• M h uc research is need d! e
Credits and thanks

• Tim Cromwell, Jamie Bennett• C l o ene Byrne, N l e son H is ng, L i o s Ol

Elaine Hunolt, Eric Pan, Karl Banty,

Nathan Botts, Lauren Mercincavage

• Omar Bouhaddou

• Brian Dixon• Darrell Baker, Bryan Mitchell
Questions

• Questions now?• Questions later?

• Mike Weiner <michael.weiner4@va.gov michael.weiner4@va.gov>• Alissa Russ <alissa.russ@va.gov>• D id av H t aggs rom <d id h t @ david.haggstrom@va

• Ken Boockvar <kenneth.boockvar@va.go