A Public Utility for Electronically Exchanging Clinical Information in Central

MassachusettsHealthAlliance Hospital Grand Rounds

March 3rd, 2009

Larry Garber, M.D.

Fallon Clinic Medical Director of Informatics

SAFE Health Principal Investigator

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Agenda

Health Information ExchangesWhat are they?Why do we need them?

Review of SAFE Health project

HealthAlliance Hospital’s role in SAFE Health

Current status of SAFE Health project

The future of SAFE Health

EMRs are great, however…

Hospitals don’t easily interface to office EMRs

ERs don’t know your outpatient information30% of ER visits lack important medical

information, half of which are “critical”15% of ER admissions could be avoided if

the ER had outpatient information150,000 preventable ADEs ($8 Billion

nationwide wasted) each year occur at the time of admission due to inadequate knowledge of outpatient medication history

Hospitals don’t easily interface to office EMRs

Your EMR won’t have ER notes or discharge summaries unless you scan them inOnly 6% of small practice EHR’s are

interfaced to hospital information systems2 million adverse events each year are

due to inadequate communication at time of discharge

Most offices don’t have lab and imaging interfaces

Costly to interface to lab and radiology systemsOnly 50% of small practice EHR’s are interfaced to lab systems5-20% of lab and x-rays are ordered redundantly because original results can’t be found40% of Prostate Cancer malpractice cases in MA (2002-2007) were due to failure to transmit/receive test results

Most offices don’t have all of the patient’s physicians in their practice

Visits are split 50/50 between PCP’s and specialistsAverage Medicare patient sees 6.4 different MDs per year25% of prescriptions are not known by the treating physicianPatient data missing 80% of time in one study25% of PCPs lack consult note 4 weeks after outpatient consultation20% of medical errors are due to inadequate availability of patient information

EMRs are great, however…

Without interfaces to the other parts of the healthcare system,

EMRs will fall short of their goal to improve the quality and

safety of healthcare while reducing costs

EMRs are great, however…

Each interface costs $5,000 - $20,000 in hardware, software, and consultant time

A small office EMR should have at least:LabImagingHospitalPharmacyOther physician practices?

Interfaces can double the cost of EMRs

The Solution:

Health Information Exchanges (HIEs)

Rx

Hospital

MD

OtherMD’s

Patients

VNA

DPH

LTC &SNF

Rehab

Payers

Imaging

Lab

HIE

Local Health Information Exchanges

Regional Health Information Organizations (RHIOs)

National Health Information Network (NHIN)

Health Information Exchange (HIE)

Each organization has 1 interface

Central hub onlyroutes clinical data

Only patient demographic data stored centrally

Rx

Hospital

MD

OtherMD’s

PatientsVNA

DPH

LTC &SNF

Rehab

Payers

ImagingLab

HIE

Community Portals and Health Record Banks vs. True HIEs

Clinical data stored centrally and viewed through website (portal)

Often can use CCOW to synchronize user and patient context between EMR and portal

Clinicians have to learn to use two systems

Can’t directly use portal data in EMR (e.g. allergies, medication list, immunization history, etc…)

Personal Health Records (PHRs) vs. HIEs

Clinical data stored centrally

Larger focus on patient access to data (for now)

Less focus on downloads into EMRs or Provider/Ancillary/Payer healthcare transactions (for now)

Over time, the distinctions will blur as HIEs emphasize patient portals, and PHRs/PHPs interface more Providers/Ancillaries/Payers

Patient enrollment is a bottleneck to data flow

The Benefits of HIEs:

All achieved with MDs using their own EHRImproved coordination of carePCP SpecialistInpatient Outpatient

Improved patient safetyImproved quality of careReduced redundant testingFewer hospital daysFewer adverse events (3% reduction)Better medical history on patients in ER (2%

reduction)

“I ran out of one of my pills. Not sure which one. I lost my wife’s note… ”

We can know our patients better than they know themselves

Excellent Patient Service

Other Benefits of HIEs:

Automated public health reporting

Automated bio-surveillance

Quality Measurements/Benchmarks

Facilitates research

Reduces the cost of interfaces

Reduces barriers to adopting EMRs

Value of National HIE Network

$337 Billion savings during 10-year implementation period

$78 Billion savings each year thereafter:$34 Billion to providers/facilities$22 Billion to payers$13 Billion to reference laboratories $8 Billion to imaging centers $1 Billion to pharmacies $0.1 Billion to Public Health agencies

Legislation for HIEs - State

MA Health Care Reform Act of 2008$15M for community-based HIEs and EHRsAll hospitals and community health centers

must implement interoperable electronic health records systems by 2015

Legislation for HIEs - Federal

American Recovery and Reinvestment Act of 2009

$1B in up-front grants for EHR and HIE implementation

Up to $64K for MDs and $11M for hospitals if:using EHR in a meaningful mannersubmits clinical quality measures

EHR is connected to a Health Information Exchange

A Public Utility for Electronically Exchanging

Clinical Information in Central Massachusetts

Secure Architecture For Exchanging

Health Information

Funding for SAFE Health

$1.5 Million Agency for Healthcare Research and Quality (AHRQ) Grant #1 UC1 HS015220 (10/2004 9/2009)

$4.2 Million donated by:Fallon ClinicFallon Community Health PlanHealthAlliance HospitalUMass Memorial Medical Center

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Objective of SAFE Health

Build and operate a health information exchange infrastructure for Central Massachusetts to securely enable real time aggregation and presentation of patients’ health information from multiple different organizations in order to improve patient safety, quality of care, and efficiency of healthcare delivery.

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SAFE Health Architecture

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High Level Design GoalsNo central clinical data repositoryOne central demographic repository (EMPI)Preservation of data and transaction ownershipMinimize duplicate data from multiple sourcesSecure and auditable; Protect patient privacyScalable and high performanceInteroperable with other local health information exchanges and the NHINNo rip and replace – leveraging existing systemsIntegrate seamlessly into varied physician workflowsMinimize cost

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Levels of Participation – current & planned

Portal access – web browser access to display patient informationPractice management system integration – medical summary prints out automatically when patients arrive triggered by ADTEHR integration – One or two-way integration with existing information systems to display patient information while in those systems and supply data to the SAFE Health network. Clinical information supplier– Ancillary systems that receive orders and provide results, or health insurance carriers that only feed patient data to SAFE Health network.

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Privacy and SecurityUser Authentication – performed by each entity

Patient Authorization Opt-in consent for “Pulls”Ordering/Referring/Authoring/CCd provider for “Pushes”Privacy Notice covers “Pushes” as well as release of

demographics to Core Server

Encryption - HTTPS

Audit trails – maintained within each Local SAFE Health server as well as the Core Server

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Patient Opt-in Consent AutomationWhen patient who has been at more than one participating entity, arrives at a participating entity and a consent form hasn’t authorized all of the entities that the patient is registered at yet, a consent form automatically prints on the registration clerk’s local printer.

Consent is to authorize a participating entity to both disclose as well as view patient information

Patients can authorize any or all of the current entities participating in SAFE Health, or they can authorize all current and future healthcare providers in the state of Massachusetts

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Patient Opt-in Consent AutomationPatients can authorize their medical insurance carrier(s) to provide information to SAFEHealth, but these payers can not view information.

Consent only needs to be signed once at one organization to authorized any or all entities

Consent can be revoked from any or all entities for future disclosures and viewing, but past disclosures cannot be revoked.

Patients cannot refuse to participate in the “Push” of results to ordering/referring/ authoring/CCd MD

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Patient Opt-in Consent AutomationAfter the consent form is signed, a clerk clicks on patient’s name in the worklist to acknowledge that form was or was not signed and which entities were authorized, triggering clinical data to be exchanged between these authorized entities and imported into the local EHRs

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Current Status of SAFE Health

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Current Status of SAFE Health

SAFEHealth went live on June 24th, 2009!

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Current Status (continued)

For any patient that presents to the HealthAlliance Hospital Leominster Campus ER or Fallon Clinic Leominster or Fitchburg sites that chooses to participate, regardless of PCP site or health insuranceHealthAlliance Hospital Leominster Campus ER provides Fallon Clinic with ER Summaries

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Current Status (Continued)Fallon Clinic provides visit notes with:Medication ListAllergiesProblem ListImmunization HistoryCode Status and Advance Directive StatusPCP and phone numberVital SignsRecent Lab and Radiology Results

No confidential notes

What do ER Doctors Want to See?

34 Shapiro JS, Kuperman G, et al. J Am Med Inform Assoc. 2007;14:700–705.

Phase 1

Phase 2

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Future Plans for SAFE HealthIntegration with any hospital, physician practice/group, or other provider in the region that wishes to participateIntegration with any imaging center, reference lab, or other ancillary service in the region that wishes to participateIntegration with any health insurance carrier that is willing to provide patient information to the SAFE Health network

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Potential Physician Concerns

Potential Physician ConcernsWill I be overwhelmed with too much data?

If the same data comes from 2 sources, will I see duplicates?

Will the data be incorporated into my EHR so I can use it to defend my decisions in court if necessary?

Will the incorporated data be in a discrete data format that matches my EMR so I can do decision support with it?

Potential Physician ConcernsWill my staff and I be overwhelmed getting consent to use the HIE from each patient?

Will it be too easy for patients to transfer their care to competing practices?

Will it be easier for lawyers to access my records? Can they case-find through the HIE?

Summary

Clinical data sharing has great potential to help us and our patients with:QualitySafetyEfficiencyServiceImplementation of an EMR

SAFE Health is a low-cost, secure Health Information Exchange for our region

Questions? www.SAFEHealth.org

Larry Garber, MD LGarber@MassMed.org

Rx

Hospital

MD

OtherMD’s

Patients

VNA

DPH

LTC &SNF

Rehab

Payers

Imaging

Lab

HIE

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