Trends in Health Information Exchange and Implications for Public Health

Trends in Health Information Exchange and Implications for Public Health

June 12, 2013

- 2 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.

The inverse-square law of health information exchange


HIE is maturing

• Focused on “the noun”• Assumed hierarchy of HIEs

- State- and regional-level HIEs feeding into a National Health Information Network

• Assumed repository-style architectures with rich applications

HIE 1.0 hie 2.0• Focused on “the verb”• No organized hierarchy of HIE

organizations- No “National Network”- State-level HIEs highly varied

and locally driven- Greatest growth in “private HIEs”:

vendor- and ACO-driven• Wide variety of integration approaches


What is driving this transition?

Limited successes of the prior model

Bottom-up demand -- systems are not interoperable because not enough customers asked for interoperability

• Meaningful Use incentives• Value-based purchasing• Market expectations about standards of care• Younger provider expectations about use of technology• Consumer expectations about use of technology

Supply-side• EHR certification requirements – common denominator important in a

fragmented industry• Technology advancements in cloud services, mobile, broadband, storage,

patient-matching capability, etc


HIE Building Blocks

Content and vocabulary standardsDocumentation standardizationAnalytics definition synchronization

Interfaces to connecting systemsSecurity and transport standardsPhysician/facility directory

Patient-matchingMedical record indexingConsent managementData access and use contractsClinical portals (patient/provider)

Amount of central orchestration required

Acc

ount

able

car

e ca

pabi

lity

MU

cap

abili

ty

EHR functions

Message & document delivery

Registries & Repositories

Case management and patient access

Measurement & Reporting

Population, Risk, and Financial Management

Enterprise Integration & Management

HIT/HIE Uses Functional requirementsBusiness models

Cross-system query

Business process harmonization


Data Needs Vary With Business Goals

Independent actors

IDNAccountable care entities

IPA/PHO

Enterprise Integration & Management

• Business integration

Measurement & Reporting


Case management, and patient access


• Business alignment

• Team-based care• Patient

engagement

EHR functions


EHR functions


EHR functions


EHR functions

Message & document delivery • Become

electronic• Fill in gaps in care

transitions


Cross-system query


Cross-system query


• Performance mgmt

• Population mgmt• Utilization mgmt• Case facilitationCross-system query

Case management & patient access




hie 2.0 comes in many shapes and sizes

Transaction-specific national level (e.g., Surescripts)

State-level and regional collaborative HIE organizations

Vendor-specific (e.g., Epic, eClinicalworks)

Point-to-point (e.g., LabCorps, hospital labs)

Enterprise-level HIE organizations (e.g., “private HIEs”)

National level collaborative HIE organizations (e.g., Healtheway)

Level of external coordination needed

Point-to-patient

Level of highest growth


hie 2.0 comes in many shapes and sizes (2)

• Ability to export and import structured data

• Incorporate in EHR and usable for all EHR analytic and decision support functions

• Ability to export and import clinical documents

• Attach to patient record and viewable

• Ability to provide view into another clinical system at point-of-care

• No exchange of data or documents

Data integration Document integration Visual integration

Growing increasingly common to solve immediate need without interfacing and application workflow redesign

Growing rapidly and likely to increase even more with maturation of directed exchange capabilities

Essentially not happening, except:

• Specific transaction streams such as eRX and labs

• Within EHR network, such as Epic and eCW

• Sophisticated implementations such as Healtheway


National-level HIOs are most comprehensive HIE implementations, but still quite thin

• Over 20 participants (4 federal) as of September 2011• Over 90,000 transactions conducted• HIE solution based on NHIN standards enabling send/receive and

query/retrieve• DURSA covering complete set of exchange patterns

• Five provider organizations (Geisinger, Kaiser, Mayo, Intermountain, Group Health)

• Complete solution based on NHIN standards enabling send/receive and query/retrieve


State-level collaborative HIE activity high in certain areas

42 remaining HIE activities had fewer than 1,000 monthly transactions

State HIE Grantee Monthly

transactions Indiana 351,070 Texas 215,005 New York 101,748 Kentucky 92,387 South Carolina 50,515 Delaware 37,245 Oklahoma 32,015 Colorado 22,665 Mississippi 12,909 Nebraska 3,459 Tennessee 3,254 Maryland 3,223 Maine 3,211 New Jersey 1,601 Utah 454 Kansas 302 Minnesota 208 New Mexico 165 Rhode Island 130

37 remaining HIE activities had no query-based transactions

State HIE Grantee Monthly

transactions Indiana 14,532,368 Colorado 5,011,816 New York 3,322,812 Minnesota 1,680,124 Vermont 889,700 Delaware 827,483 Washington 138,422 Michigan 98,976 Maryland 48,655 Ohio 35,359 Rhode Island 29,627 California 28,439 Alaska 3,701 Utah 2,482

3.2 million directed exchanges per month

14 million directed exchanges per month

Directed transactions Query transactions

200K+ directed exchanges per month

Source: ONC HIE Dashboard


EHR vendors with high penetration generating large amount of vendor-specific HIE traffic

• Large majority of customers (200+) participating in query-based exchanges

• Currently CCD/CDA query-based exchange is ~2.2 million records for ~385K unique patients per month

• Volume doubled over previous year

• Does not include HL7 directed exchange transactions

• 16,743 providers using query-based exchange

• ~2.5 million new CCD records made available on query exchange hubs or sent directly to referral providers per month

• Processed over 75+ million lab result records in 2012

• ~1.5 million query-based exchanges per month

• ~58.5 million directed exchange transactions per month (including HL7 lab result delivery)

Source: Epic, eClinicalWorks, Cerner


Lab Market Is Highly Fragmented

60%

33%

7% 116,634 physician office laboratories

5,604 commercial labs

8,807 hospital labs

• Quest: ~30%• LabCorp: ~20%• Only Quest and LabCorp cover the

entire US• Next largest, Spectra, covers 1/3 of US

counties and county-equivalents

% of labs conducted

• Fragmentation may be increasing as hospitals increase lab business to offset revenue decreases in other areas

• Fragmentation makes it difficult to generate collective action for a national lab network like Surescripts

• Meaningful Use is the only industry-wide force driving standardization of lab results delivery

• High fragmentation of lab market makes it difficult to measure progress of electronic transactions

• ONC is now fielding national lab survey

Source: Quest Diagnostics 2009 Annual Report; CMS CLIA Update July 2012


Large fraction of lab results delivery still via fax and paper

10%

90%

HL7 interfaces

Paper/fax delivery

~585 million lab results delivered by Cerner customers per month

• Progress in electronic results delivery tied to EHR penetration

• Interface implementation is significant barrier to progress – lack of standardization and competing priorities

• MU Stage 2 may not be enough of a spur to significantly increase electronic delivery from hospitals – does not require electronic delivery and standardization of electronic delivery is menu set item

% lab electronic lab results

Source: Cerner Corporation


Large fraction of lab results delivery still via fax and paper

62%

38%

HL7 interfaces with ~600 labs

Not interfaced with ~6800 labs• ~3,400 fax• ~3,400 paper, portal, etc

Analysis of 29 million lab result records received by athenahealth customers

• athenahealth has unique data because they track ALL lab result reports delivered to their customers

• Small number of labs account for majority of electronic results

• Effort required for interface deployment is barrier both on the lab side as well as on EHR vendor side

• athenahealth completing about 15 new lab interfaces per month

• Large practices have higher lab interface rate (68%) than small practices (56%) who get lower priority from labs -- commercial labs do not cover cost of interfaces to small practices

% lab electronic lab results

Source: athenahealth


Large gap in LOINC-mapping capabilities

24%

76%

Only 1 lab sends LOINC-encoded results

~599 labs send results with proprietary codes

Analysis of 29 million lab result records received by athenahealth customers

• Vast majority of labs do not send LOINC-encoded results

• 1 national lab does, another national lab can but currently does not because has not been asked to

• Large commercial labs capable of LOINC-encoding, however, vast majority of hospitals are not and will take significant effort to get them there

• MU Stage 2 may not provide enough of a spur given difficulty of effort, allowed variation in state public health requirements, and competing priorities

% LOINC-encoded labs

Source: athenahealth


HIE Activity Mushrooming Across the Region

NEHEN

North Adams

Baystate SafeHealth

Newburyport

RIQI

VITL

NYeCBeverlyWinchester

Holyoke Emerson

Sturdy

BerkshireHealth

South Shore

NH-HIO

Cape Cod Health


Current state of the market favors a network of networks connected via a single statewide open HISP supported by centralized project management

Illustrative example

Berkshire Health SystemNEHEN

SafeHealthMD

MDMD MD

Fallon Clinic UMass Memorial

PKI/certificate mgmt

Webportal

Provider/entitydirectory

Auditlog

MD MD

MDMD

MD

MD

BIDMCPartners

Direct gateway services

EOHHS NwHIN

MassHealth

DPH

Atrius


Data Aggregation Process Steps

Clinical sources Transport Management and analysis Reporting and data access

MDs

MDs

MDs

MDs

HHHH

Data requirements

RX

Labs

Vitals

Problems

Patient

Provider

Payer

etc

Remediation and Improvement

Key questions:• How well-defined are reporting/analysis needs, and corresponding data requirements? Will source-

level remediation be required?

• How many clinical sources will be included? What is integration strategy and timeline for disparate EHR systems?

• Which transport option? What are pros/cons of each?

• Are there unique data management and analysis requirements?

• Who will be accessing reports and data? Are there unique reporting and/or data access requirements?

• How will reporting/analysis integrate with business and care processes?


BIDCO QDC

BIDCOQDC

Electronic reporting• MU, PQRS, AQC, etc

Data management• Report viewing• Case tracking

Data extraction• Queries• Pre-defined data marts

Documentation & Extraction

Transport Validation & Analysis

User Access

Management Info System• User information• Utilization analysis• Other

Current status:• 5,611,698 care event C32 records• Covers 614,829 unique patients• Covers 2,506 unique providers

576,765

Cumulative records 2013 YTD (828,339)

231,218

20,356


AHI QDC

AHIQDC


Documentation & Extraction

Transport Validation & Analysis

User Access

Current status:• 760,923 care event C32 records• Covers 155,740 unique patients• Covers 300+ unique providers

Pod 1


Pod 2


Pod 3

31,504

Cumulative records 2013 YTD (278,587)

50,416

87,934

13,061

84,507

11,165


Current Data Frequency Count

Problem

s

Proced

ures

Total R

esult

s

Medica

tions

Immun

izatio

nsVita

ls0

10,000,000

20,000,000

30,000,000

40,000,000

7,336,740 1,817,738

34,671,028

7,639,148 2,366,770

26,239,285

Total Clinical Element Counts

Problem

s

Proced

ures

Total R

esult

s

Medica

tions

Immun

izatio

nsVita

ls0

2,000,0004,000,0006,000,0008,000,000

1,217,776 366,286

8,261,178

1,595,983 581,209

5,983,886

Unique Clinical Element Counts

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

26,189,415

7,251,404

44,036,490

25,315,817

400,37115,051,849

Total Clinical Element Counts

Problem

s

Proced

ures

Result

s

Medica

tions

Immun

izatio

nsVita

ls0

10,000,000

20,000,000

30,000,000

6,729,434 5,854,982

25,951,710

5,854,982 311,2448,356,400

Unique Clinical Element Counts

BIDCOAHI


Implications for Public Health

Heterogeneity will be the hallmark of HIE activity in the coming years

Multi-layered HIE modes seem to be developing as business practices mature• “B2B”-style patterns to move documents around with little to no centralized coordination

– Direct and Directed Query• “Supply-chain” style patterns with deep integration among very closely aligned entities

seeking centralized orchestration for rich applications to support complex uses

Aggregation at the edge• HIE as conduit for aggregation rather than as repositories themselves

Alignment with Meaningful Use• MU Stage 2 includes higher standards for clinical content• Aligning with and/or “piggy-backing” on MU and ACO capabilities is most likely path to

scaleable model for rich, longitudinal data to meet variety of public and population health purposes


www.maehc.org

Micky Tripathi, PhD MPPPresident & CEO

[email protected]

http://www.maehc.org/

mailto:[email protected]

Documents

Trends in Health Information Exchange and Implications for Public Health