CITIZENS HEALTH INITIATIVE · • Incremental steps, not big-bang approach • Openness and...

John K. Evans and Camilla Hull Brown

HIE HIT Work GroupJuly 9, 2008

CITIZENS HEALTH INITIATIVE

22

Interview Feedback• Interviewed 8 people so far; comments

reflect 5 of them• Exciting opportunities• Time for action• Should emphasize HIT and HIE equally• Need health system buy-in• Benefit in getting different initiatives to work

together• More focus on the consumer

Vermont Information Technology Leaders, Inc.

Secure sharing of electronic medical records between

doctors, hospitals, and patients

Gregory Farnum, PresidentJuly 9, 2008

Presented to NH Citizens Health Initiative

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What Is VITL?• A non-profit public-private partnership

located in Montpelier, Vt.• Designated in statute to operate the

Vermont Health Information Exchange • It exists to serve multiple stakeholders,

including patients, practitioners, hospitals and other health care facilities, payers, employers, and state agencies.

5

Mission and Vision• Our Mission: To facilitate the implementation of

electronic health records and health information exchange in Vermont.

Our Vision: Our vision is for a healthier Vermont, where shared health information is a critical tool for improving the overall performance of the health care system. The health care community will work together to achieve new efficiencies through the use of information technology in order to deliver better overall value and care to our citizens.

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How VITL Came to Be

• Started as a project within the Vermont Association of Hospitals and Health Systems

• Founded on the principle that improved data leads to better care, controlled costs

• Vermont’s health care reform effort is another driving force

• Spun off as independent entity in July 2005

6

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VITL Funding• Vermont General Assembly

– $3 million appropriated FY06-FY09• Non-State Grants

– $475,000 RTI privacy and security– $470,000 HRSA federal– $500,000 Community Grant Foundation

• Hosting and Data Services– $600,000/yr. Vermont Dept. of Health– $150,000/yr. Medication History Service

8

Stakeholder Engagement

• Emphasized benefits of data exchange• All stakeholders given a seat at the table• Consensus approach to decision-making• Hospitals willing to participate because they

have much to gain, little to lose (Vermont has low competitive environment among hospitals)

8

9

Governance

• 21-member board representing stakeholder groups– Hospitals, Physicians, Insurers,

Employers/Payers, Consumers, and State agencies

• Now converting “start-up phase” board to smaller, more strategic “implementation phase” board.

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10

Operating Principles

• Incremental steps, not big-bang approach

• Openness and Transparency• Use of national standards (HITSP, IHE

Profiles)

10

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Issues Trying to Solve

• Relieve physician data pain points• Bend the cost curve downward• Reduce duplication, drive out waste and

inefficiencies• Increase effectiveness and quality of

care• Lower barriers to EHR adoption

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12

Vermont’s Strategic Health Information Technology Plan

• Outlines vision, identifies key stakeholders, strategies and objectives

• Puts forth standards for health information exchange in Vermont

• Provides technology architecture overview

• Privacy and security framework

• Public education plan

• Funding, governance, and next steps

13

VITL’s Projects• Statewide Health Information Exchange

Network• Infrastructure for Vermont Dept. of

Health’s Clinical Information System• Electronic health record pilot• Medication history service

Geographic DiversityOf VITL’s Projects

1515

Health Information Exchange• Links hospitals, physicians, and other

stakeholders • Built to national standards• Core components are ready • Allows practitioners to share data• VITL now adding data sources,

connecting users for Phase I -- lab and radiology results delivery to physician EHRs

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HIE Phases

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Core Components

Basic Legal Agreements

Connectivity w/ sitesInterfaces & Security

Phase I

SecureResultsMessaging & BlueprintSupport Core Components

Basic Legal Agreements


Phase II

Advanced Legal Agreements

Specific Privacy Policies


Advanced Functionality(EMPI, XDS, Security) Public

Health &Research

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Medication History Project• Initiated to relieve #1 pain point: lack of good

medication history

• Piloted at two hospitals

• More than 20,000 medication lists generated from pharmacy claims data delivered to emergency physicians since April 2007

• Payers providing data through PBMs (including BCBSVT, MVP, VT Medicaid)

• Already tangible quality improvements

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Medication History Pilot Results

• On average, 90% of patients give consent

• Matches produced for 70% of consenting patients, on average

• 10% of medication lists showed medications patient did not mention

• Positive anecdotal feedback from providers: faster treatment; better information to base decisions on

19

EHR Pilot Project• Project authorized by Vermont Legislature in Act

70 of 2007 session, funded by $1 million in voluntary contributions from payers

• Independent primary care practices serving low-income populations eligible

• Selected physicians to receive financial and technical assistance – Grants for 75% of cost, up to $45,000 per provider

FTE (18 providers being helped in pilot)

– Physicians to pay no more than 25% of cost 19

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VITL Pre-Screened EHRs

• Allscripts HealthMatics• Allscripts TouchWorks• eClinicalWorks• GE Healthcare Centricity• McKesson Practice Partner• NextGen

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EHR Pilot Project Grantees

• Mt. Anthony Primary Care, Bennington• Bennington Family Practice, Bennington• Mad River Integrative Medicine,

Waitsfield• Brookside Pediatrics & Adolescent

Medicine, Bennington• Northern Tier Center for Health,

Richford

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EHR Pilot Outcomes

• Clinical workflow transformation• Full use of all EHR features

– E-prescribing– Clinical decision support– Clinical messaging– Patient population management

• Data sharing through HIE

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Vermont Health IT FundApproved by the Vermont Legislature

Insurers to pay 0.199% fee on all medical claims

Fee expected to raise $32 million over 7 years

First payments into the fund will be in Oct. 2008

VITL developing plans to expand EHR grant program to assist more independent primary care practices, and to implement next phase of HIE

Information about grant program will be sent to practices as it becomes available.

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New England Telehealth Consortium

• Private broadband network• Funded by $25 million FCC grant• Connecting health care providers in ME,

NH, and VT• 64 sites participating in Vermont

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Working With N.H.

• Vermont and N.H. share an academic medical center, other providers see patients from both states

• Developing similar privacy/security policies would reduce confusion, lower barriers to data exchange

• VITL can provide successful models on medication history, EHR adoption, developing HIE built to national standards

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State Level HIE Consensus Project – May 1, 2008

• Continued expansion and evolution in state-level HIE efforts

• 75% of states have established state-level HIE initiatives/governance entities

• Advanced state-level efforts poised to begin data exchange

• Health care reform, privacy rights and confidentiality protections are drivers

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Independent private/public partnership incorporated (Aug 2005 - Aug 2006)

Independent private/public partnership incorporated (before Aug 2005)

Independent private/public partnership incorporated (after August 2006)

HIE Privacy and Security (HISPC) Initiatives

Last Updated: October 2, 2007

State level HIECurrent trends across statesState-level Census Project:

Current Trends

In New England (National):

1. Early planning: NH (15)

2. Foundational: CT (12)

3. Early Implementation: ME, VT, RI (13)

4. Operating: MA (5)

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Trends and Models across the United States

• Two distinct and key organizational roles at the state level:

• Governance: convening, coordination• Technical operations: owned and/or managed

• State-level HIE governance role is primary:• Ensure HIE develops as a public good• Serves all statewide stakeholders and data needs• Reduces technology investments and other costs

for all participants• Mechanism for coordination of HIE

policies/practices

2929 29

State-level HIE Functions and RolesSLHIE

roleGovernance Technical

Operations

Function Convening Coordination OperatingTasks • Organizational leadership

and structure• Neutral venue for diverse stakeholder collaboration• Support board/business operations for non-profit org

• Information resource for stakeholders and HIE development (Resource Center concept)

•Advocacy for HIE adoption

• Facilitate statewide HIE implementation

•Facilitate alignment with local, interstate, regional, and national strategies

• Promote consistent application of effective statewide HIE policies and practices

• Facilitate collaborative development of public policy options and ongoing health care reform efforts

• Infrastructure -> statewide MPI, RLS• Applications -> clinical messaging, EHR via ASP • Services -> Implementation guides, clinical data standardization, central

3030

Scope of State-wide HIE Efforts

DelawareVermontMaineCalifornia

TechnicalOperations

In-Between

Michigan Connecticut New York

KansasArkansas

Governance: Convene & Coordinate

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Trends and Models across the United States

• State-level HIE governance entity is a public-private partnershipentity:

• Role between state government and the health sector and industry

• Involves state government, but independent of state government

• State governments play important roles:• Designating authority to a state-level HIE governance entity• Providing resources: start-up and ongoing• Leveraging public programs, policy levers to create incentives

for HIE

• Statewide technical approaches can vary and will likely evolve:• Size, market characteristics, resources• Stages of development

32323232

3 Prevailing Organization 3 Prevailing Organization Models:Models:

1. State government leads with involvement of public/private sector

2. State-level HIE is an independent PPP focused exclusively on the Governance Role

3. State-level HIE is an independent PPP focused on Governance and Technical Operations roles

3333

State-level HIE Organizational Frameworks and Functions 1/2008

Governance Technical & Governance

State State Government Led

Independent Public/Private Partnership

Independent Operating

MAMINYCAINMEVTRIFLKYWA

XXX

XXX

XXXXX

X = currently operating X = foundational/early implementer

34343434

State Health Information State Health Information Network Network –– New YorkNew York

(SHIN(SHIN--NY)NY)

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State Health Information Network – NY (SHIN-NY)

• Key Principles:• HIT itself will not result in value: alignment with

clinical practice redesign; support services for clinicians; new models of prevention, quality-based reimbursement and patient engagement strategies

• Clinical, quality and public health priorities must drive HIT adoption and common actions among public and private health care sectors

• Major HIE building blocks – organizational, clinical/quality, technical – must co-evolve and advance together in order to realize value

• Cross-sectional interoperability needed to support policy alignment, value realization for clinicians and sustainable transformation

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• Organizational Strategy:• Regional Health Information Organizations (RHIOs)• Community Health Information Technology Adoption

Collaborations (CHITAs): community collaboration of ambulatory care clinicians and affiliated providers defined as acare coordination zone with a mission to advance adoption and use of HIT tools, especially EHRs, for clinicians at the point of care

• New York eHealth Collaborative (NYeC): public-private partnership collaborating to: drive consensus on HIT policies and standard implementation approaches; provide technical assistance and provide governance and policy framework

• HITEC: a multi-institutional collaborative among institutions in NY state charged with providing evaluation services for awardees: Cornell, Columbia, Univ of Rochester, SUNY Buffalo and SUNY Albany

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• Funding:• 2005: $52 million to 26 grantees• 2008: $106 million to 19 grantees

• 19 projects ranging from $1-10 million each

• Awards for technical infrastructure:• Statewide Health Information for NY: 8• Clinical Informatics Services: 3• Electronic Health Records 8

• Awards for clinical priorities:• Implementing EHRs linked to Medicaid: 12• Public Health: 10• Connecting New Yorkers to their clinicians: 5• Quality Reporting: 4• Clinical Decision Support: 2

38383838

Michigan Health Michigan Health InformaionInformaionNetwork (Network (MiHINMiHIN))

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HIE Priorities in Michigan• Medical Trading Area (MTA) driven• Conduit to Care report• Health Information Security and Privacy Collaborative

(HISPC)• HIT Commission• HIE related grants: FCC Rural Health Pilot; Medicaid

Transformation

• 2007/2008 funding:• $ 6.4 million• Seven initiatives: 5 planning and 2 implementation• $ 1 million to MSU and MPHI for HIE Resource

Center• $ 2.0 million for new planning or implementation

efforts

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Michigan’s Regional HIEs

Marquette General (Implementation)

North Central Council of the MHA

Alliance for Health

Central Michigan University

Greater Flint Health Coalition

Capital Area Health Alliance (Implementation)

SE Michigan

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Core of MIHIN Roadmap

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National: The trend of statewide efforts is to closely integrate regional initiatives with the statewide HIE initiative. Large and complex states are not starting with a statewide HIE approach.

Regional HIE Approach: Michigan is the 8th largest state, so one HIE for the entire state will not work or be accepted. Therefore, the regional emphasis is a critical aspect of any Michigan approach.

Statewide HIE Approach: Michigan will be comprised of multiple Regional HIE initiatives that may have different architectures and capabilities. A state-level organization can facilitate exchange of data between the Regional HIEs.

Future State of MI Health Information Network (MiHIN)

43434343

Delaware Health Information Delaware Health Information Network (DHIN)Network (DHIN)

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State of Delaware (DHIN)• Population of Delaware – 875,000• Medical Society of Delaware – 1800 physicians• HIE org effort over 10 year period• Governance

• Statewide HIT infrastructure; multi-stakeholder• More to fill in

• Functionality• Clinical messaging and results delivery• Next stage is inquiry of data across orgs (snap shot)

• First state-wide infrastructure to exchange data

45457/9/2008 HIE 5

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Delaware Health Information Network Milestones

• Funding:• Launch $5M

• 2005 – Delaware Health Care Commission awarded a 5 year Federal Contract from the Agency for Healthcare Research and Quality

• 2006 – Augmented with $2M from the State of Delaware Bond and Capital Improvements Budgets

• 2006 – State funds matched with $2.1M from community based partners. Key Partners

• Christiana Care Health System• Beebe Medical Center• Bayhealth Medical Center• Labcorp• Delaware Physician participants (No utilization fee to physicians)

• October 2006 – Vendor award to Medicity and Perot Systems with implementation in 2007

Agenda #4

NH Report on HIT Status (Patrick) – 25 minHospital Association and UNH Surveys ePrescribing Statistics Telehealth UsageDiscussion Barriers to HIT (Camilla and John)

• Funding• Knowledge Transfer

Hospital Association and UNH Surveys

New Hampshire Hospitals’ Use of

Information Technology

Kathy A. BizarroExecutive Vice President

New Hampshire Hospital Association

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Survey of Hospital IT Use

Survey conducted in summer of 2005AHA (American Hospital Association) Survey on Hospital Adoption and Procurement of Health Information Technology was used.National results are excerpted from AHA’sfinal report “Forward Momentum: Hospital Use of Information Technology” (2005)

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Hospital Participation

19 of the 26 acute care community hospitals participated in the New Hampshire survey.More than 900 hospitals participated in the American Hospital Association survey (19%).Representative sample of all hospitals by size and location.

51

IT Areas ReviewedIT AdoptionTypes of IT UsedElectronic Health Records (EHRs)Computerized Physician Order Entry Systems (CPOE)Users of EHRs and CPOELocal/Regional sharing of patient informationCapital and Operating investment in ITBarriers to IT Implementation

52

IT AdoptionNH Hospitals are actively considering, testing

and using IT for Clinical Purposes100% 100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Yes

Critical Access Hospitals (9) Urban Hospitals (10)

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IT Adoption

NH Hospitals have adopted IT in Non-Clinical Areas

100%

89% 89%

67%

100%

90%

80% 80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Patient Accounts Patient Scheduling Pharmacy Supply Mgt Medical-Surgical Supply Mgt


54

Types of IT-Bar CodingNH Hospitals that have Fully or Partially Implemented

Bar Coding

78%

33%

11%

33%

0%

60%

30% 30% 30%

60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

a. laboratory specimens b. trackingpharmaceuticals

c. pharmaceuticaladministration

d. supply chainmanagement

e. patient ID


55

Types of IT-Bar CodingNH Hospitals that are Considering

Bar Coding

11%

56%

78%

44%

89%

30%

50% 50%

60%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

a. laboratory specimens b. trackingpharmaceuticals

c. pharmaceuticaladministration

d. supply chainmanagement

e. patient ID


56

Other Types of IT

NH Hospitals that have Fully or Partially ImplementedOther Technologies

22%

0%

11%

38%

0%

36%

0%10%

20%30%40%50%

60%70%80%

90%100%

a. Use of Telemedicine b. Use of Radio Frequency ID C. Physician Use of PDA


57

Other Types of IT

NH Hospitals that are Considering Other Technologies

56%44%

33%

13%

100%

27%

0%10%20%30%40%50%60%70%80%90%

100%

a. Use of Telemedicine b. Use of Radio Frequency ID C. Physician Use of PDA


58

EHRsNH Hospitals that have Fully or Partially Implemented

Electronic Health Records

33% 33%

0%

67%

80% 80%

50%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

a. Access to current medicalrecords

b. Access to medical history c. Access to patient f lowsheets

d. Access to patientdemographics


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33%

22%

78%

44% 44%50%

60%

100%

80% 80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

e. Clinical – guidelines &pathw ays

f. Access to PACS g Order entry – Lab h. Order entry – Radiology i. Order entry – Pharmacy


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33%

78%

56%

22% 22%

11%

90% 90% 90%

60%70%

20%

0%10%20%

30%40%50%60%70%

80%90%

100%

j. Results review –Consultant Report

k. Results review –Lab

l. Results review –Radiology Report

m. Results review –Radiology Image

n. Results review –Other

o. Patient supportthrough home-

monitoring, self-testing, and interactive

patient education


61

Users of EHRsNH Hospitals with 50% or greater staff use of EHR functions

22% 22%

33%

80%

90%

60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

a. Physicians b. Nurses c. Other clinical staff


62

CPOENH Hospitals that have Fully or Partially Implemented

Computerized Physician Order Entry functions

11% 11%

33%

11%

40% 40%

50%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

a. Access to current medicalrecords

b. Access to patient flowsheets

c. Access to patientdemographics

d. Real time Drug interactionalerts


63


Computerized Physician Order Entry Functions

0%

22%

11% 11%

0%

50%

30%

40%

30%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

e. Back end Druginteraction alerts

f. Order entry –Pharmacy

g Order entry – Lab h. Order entry –Radiology

i. Report review – imagereview


64


Computerized Physician Order Entry Functions

22% 22%

11%

0%

50% 50% 50%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

j. Results review – Consultantreport

k. Results review – Lab k. Results review – Other o. Patient support throughhome-monitoring, self-testing,

and interactive patienteducation


65

Users of CPOENH Hospitals with 50% or greater staff use of

Computerized Physician Order Entry functions

11% 11% 11%

30% 30% 30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

a. Physicians b. Nurses c. Other clinical staff


66

Local/Regional SharingNH Hospitals participate in local/regional arrangements

to share electronic patient specific healthcare information

78%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


67

SharingNH Hospitals participation in local/regional arrangements


33% 33%

0% 0% 0%

60%

30%

0% 0%

20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Private practice physicianoff ices

Laboratories Free-standing imagingcenters

Retail pharmacies Long-term care facilities


68

SharingNH Hospitals participation in local/regional arrangements


11%

0%

33%

22%

0% 0%

30%

0%

20%

40%

10%

20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Public HealthDepartment

School Clinics Other Hospitals Payers Pharmacy BenefitManagers

Other:


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Funding Sources for ITNH Hospitals Use Multiple Sources

for Funding of Health Information Technology Systems

89%

100%

11% 11%

22%

80%

100%

20% 20% 20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Operations Budget Capital Budget Grants Loans Bonds


70

Capital Investment-last yearPercent of Capital Expenses devoted to Health Information

Technology by NH Hospitals in past year

3%

15%

59%

4%

30%

60%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

CAH - Low

CAH - Median

CAH - High

Urban - Low

Urban - Median

Urban - High

71

Capital Investment-next 3 yearsPercent of Capital Expenses devoted to Health Information

Technology Investment over the next three years

10%

25%

45%

5%

30%

50%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

CAH - Low

CAH - Median

CAH - High

Urban - Low

Urban - Median

Urban - High

72

Operating Expenses-last yearPercent of Expenses allocated to Health Information

Technology in the past year by NH Hospitals

0.60%

1.25%

2.00%

1.50%

2.25%

2.90%

0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50%

CAH - Low

CAH - Median

CAH - High

Urban - Low

Urban - Median

Urban - High

73

Operating Expenses-next 3 yrsPercent of expenses to be spent on hospital IT operations

0.7%

1.7%

2.0%

1.5%

2.7%

3.1%

0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5%

CAH - Low

CAH - Median

CAH - High

Urban - Low

Urban - Median

Urban - High

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Significant Barriers to Hospital IT Adoption

0%

0%

8%

8%

17%

0%

8%

17%

8%

8%

0%

0%

0%

0%

33%

33%

0%

33%

33%

44%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Other barriers:

Inability to cost-effectivelymaintain HIPAA compliance

Legal barriers to investment anddevelopment

Fear that technology will becomeobsolete too quickly

Acceptance of technology byclinical Staff

Availability of well-trained IT staff

Inability of technologies to meetneeds

Interoperability of hardware andsoftware with current systems

Ability to support ongoing costsof hardware and software

Initial cost of IT investment

Urban Hospitals (10) Critical Access Hospitals (9)

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Items Considered Somewhat of a Barrier to Hospital IT Adoption

23%

25%

8%

17%

17%

42%

42%

42%

58%

75%

19%

33%

22%

67%

22%

33%

56%

56%

67%

56%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Other barriers:

Inability to cost-effectivelymaintain HIPAA compliance

Legal barriers to investment anddevelopment

Fear that technology will becomeobsolete too quickly

Acceptance of technology byclinical Staff

Availability of well-trained IT staff

Inability of technologies to meetneeds

Interoperability of hardware andsoftware with current systems

Ability to support ongoing costsof hardware and software

Initial cost of IT investment

Urban Hospitals (10) Critical Access Hospitals (9)

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Key FindingsHospitals in NH are committed to ITWide variation between hospitalsCapital and operating expenditures may prove to be a barrierTraining of clinicians and other staff needs to be reviewedOverall, NH is on par or exceeds national trends for IT adoptionStill more to be done!

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Kathy A. Bizarro, FACHE

Executive Vice President / Federal Relations

New Hampshire Hospital Association

(603) 225-0900

[email protected]

78Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE

NH Clinical Use of Technology Survey

• Mixed mode (web & mail) survey of physicians and other health care professional in NH

• Questionnaire replicates other surveys conducted in Florida and Vermont

• Worked with Governor’s Office, professional societies, and insurers to contact potential respondents to encourage response

• 600+ completed surveys in 2006


Sample Demographics

• Type of Professional– Primary Care: 23%– Pediatrics: 8%– OB/GYN: 10%– Specialty: 25%– Allied Health Care Professional: 12%– Other: 21%

• 52% male, 47% female• Average age - 49• 13% in solo practice, 72% 2-25 clinicians, 15%

25+


Overall Findings

• Doctors and other health care professionals are technologically sophisticated personally, but have not fully implemented current technology into their practices.– Particularly hesitant to use e-mail with patients

• Electronic Health Records (EHR) are being used by less than half (46%) of doctors and other patient care givers– Biggest barrier to increased use is cost.


Overall Findings

– Biggest barrier to increased use and adoption is cost

– Of providers who use an EMR, 45% have used them for 3 years or less.


Use of Computers / Technology

98% 97%92%

99% 97%

55%46%

16%

0%

20%

40%

60%

80%

100%

Have accessto computer

at office

Internetaccess at

office

Other staffuse

computers

Computersused in scope

of practice

Have accessto computerwhen needed

Have website forpatients

Use EMR Use Registryor Disease

ManagementSoftware


Functions of Technology

77%

64%57%

39%30%

0%

20%

40%

60%

80%

100%

Billing ChargeCapture

Drug Interactions Claims Submission e-Prescribing Electronic OrderEntry


How Sophisticated a Computer User Are You?

14%

37%34%

13%

2%

-10%

10%

30%

50%

VerySophisticated

Sophisticated Neutral Unsophisticated VeryUnsophisticated


Satisfaction with Office Computerization

36%39%

11% 11%

3%

-10%

10%

30%

50%

Very Satisfied SomewhatSatisfied

Neutral SomewhatDissatisfied

VeryDissatisfied


Use e-mail to communicate with patients?

Yes; 30%

No; 70%


Should Patients have Access to Own Electronic Medical Records?

Yes, Definitely; 16%

Yes, Probably; 42%

No; 42%


New Hampshire Connects for HealthStatewide Assessment Project

• Conducted 34 key informant interviews with New Hampshire health care stakeholders in April and May of 2006

• Interviewed stakeholders from state government, hospitals, physician groups, community health centers, mental health, home health, public health, health plans, employers, and academic medical centers

• UNH/eHI documented assessment and incorporated into the briefing paper with feedback from the steering committee


Assessment Project: “What We Heard”

• Project Goals and Approach– Lack of understanding of health information exchange

(HIE) among participants

– Reported HIE to be a collaborative effort based on comprehensive, standards-driven data to reduce error, enhance safety, and promote quality

Implication: Need for further dialogue and discussion between stakeholder groups in order to gain a greater understanding and knowledge of HIE and its implications, values and benefits.


“What We Heard”• Leadership and Vision

– HIT viewed as important vehicle towards solution of health care issues such as patient safety, quality of care, access and cost

– Participants strongly stated the need for a statewide infrastructure, one that would allow interconnectivity with a national health information exchange


– Public/Private Collaboration with multi-stakeholder representation to provide oversight and guidance

• Citizen’s Health Initiative (CHI) viewed as leadership body for spearheading discussions and facilitating development of strategic plan in the near term

“What We Heard”

Implication: Development of statewide vision and infrastructure design necessary to provide guidance, continuity and consistency towards achieving the maximum level of interconnectivity across the state.


“What We Heard”• Barriers to Adoption and Implementation of

Health Information Technology and Health Information Exchange1. Interoperability

> Lack of common standards and terminology allowing the communication and exchange of information between various stakeholders and systems> Difference in software utilization

“A number of organizations have already committed to certain technology for some time, true HIT infrastructure refers to adherence to standards what are they going to be? What will be the safeguards?”


2. Access to the Internet> Lack of availability and limited access to

broadband in Northern NH

“Level of technology by community is widely different.”

“Regional collaboration will be critical.”

“What We Heard”


3. Financing> Leaders cited capital investment, staff training,

and cost of program maintenance and patient awareness as areas of concern

“Money is not the be all or end all.”

“What We Heard”


4. Privacy and Security> Variation in interpretation of HIPAA specifically in

regards to what information can be shared> Exchange of data between various providers and

facilities of concern

“Why should providers spend money on this when nobody has answered the privacy concerns?”

“What We Heard”

Implications: Common standards and terminology are essential forcommunication and exchange of information between various stakeholders and systems. Sustainability and viability of health information exchange analysis is needed. Work from RTI subcontract will have major impact on privacy and security concerns.


Conclusions (cont)

• Barriers can be resolved, but have to be mindful of and leverage existing regional initiatives and HIT implementations – do not want to “recreate the wheel”

• Regional collaboration will be critical to a statewide process.

• There is variability of technology across NH –we need to dig deeper in access issues and available technologies.

ePrescribing Statistics

Core Components

ePrescribing has three core quality improvement and efficiency components:

• Medication history. This information may come from a variety of sources, including electronic medical records, pharmacy claims data, or from prescriber-to-pharmacy transactions.

• Drug-to-drug interaction and allergy alerts. These provide decision support rules at the point of prescribing and combine this information with health insurance formularies and pharmacy benefit plans to assist the prescriber in their drug selection.

• Bi-directional pharmacy communication. This allows the prescribing practitioner to electronically write the prescription and transmit it to the pharmacy. Additionally, the pharmacy may request refills electronically without needing to fax or call the prescriber.

NH’s Progress to Date

~50% of clinicians have an EMR with some level of electronic prescribing; “eRx Lite”; the base is largely in place

79% of our pharmacies are ready to accept fully electronic prescriptions (June 23, 2008 – 179 chain & 47 independent)

Significant payer connectivity to RxHub or SureScripts

Solutions Being Led By Payers – Providers –Employers

Payer Connectivity is at 70+% of NH Residents

RxHubAnthem

SureScriptsNH MedicaidRxhub (majority)National Part D PlansNoneHarvard Pilgrim

RxHubCigna

RxHub Ranking 2007

Source: SureScripts

5957264VT

722729489388RI

1261273123NH

2232224214ME

4505441426571635MA

67762516359CT

Active PrescribersActive PrescribersActive PrescribersActive Prescribers

January 2008200720062005

Prescribers Active on the SureScripts Pharmacy Health Information Exchange, January 2005-January 2008

1MAShare1LightHouse2PracticePartner2NewCropRX3Medinotes4RxNT4EHS4DrFirst5SOAPWare5iScribe6ZixCorp6McKessonPrescriber7NetSmart8eClinicalWorks

13eMD22Emdeon42A4 Allscripts48Allscripts

Count of PrescribersSolution Provider

•183 Prescribers on SureScriptsNetwork as of May 2008

• 57 added since January 2008(46% increase)

1Wolfeboro3Somersworth

1Plaistow3New London

1Pembroke3Amherst

1Northwood4Suncook

1Newington4Colebrook

1Milford5Laconia

1Methuen, MA (Salem practice)5Exeter

1Hampton Falls5Derry

1Enfield6Merrimack

1East Hampstead6Keene

1Chesterfield6Dover

1Center Tuftonboro5Concord

2Wolfeboro7Manchester

2Peterborough7Claremont

2North Hampton10Salem

2Newport13Plymouth

2Littleton14Bedford

2Lebanon15Portsmouth

2Hopkinton16Nashua

2Hampstead18Londonderry

Count of ePrescribersTownCount of ePrescribersTown

Telehealth Usage

Funded by the Endowment for Health and the NH Funded by the Endowment for Health and the NH Charitable FoundationCharitable Foundation

Lou Kazal MD, Director NHTPLou Kazal MD, Director [email protected]@dartmouth.edu

David Price, CoDavid Price, Co--Director NHTPDirector [email protected]@verizon.net

603 444 1626 (Office)603 444 1626 (Office)

107107

"Imagine a world where no matter who you "Imagine a world where no matter who you are or where you are, you can get the are or where you are, you can get the health care you need when you need it."health care you need when you need it."

-- Office of Advancement of Telehealth (HRSA) Office of Advancement of Telehealth (HRSA) websitewebsite

108108

NHCFNH Network of Child Advocacy Centers

Child Abuse Medical Assesments(Telecam)

Labor / HHS9 Non Profit sites

NH Community Health Centers

Labor/HHSManchester 25 Sites

Elliot Hospital/VNARemote Monitoring

$268000 USDA Rural Development Rural Utilities

New London HospitalSoftware Integration to implement a telemedicine program .

Dept of Health and Human Services Rural Health Outreach

RegionalThe Caring Community Network of the Twin Rivers

Chronic disease, telehealth

Hanover, NHNew Hampshire Area Health Education Center Program -Darmouth College

Continuing Education, Professional Devel.

$327,100. USDA Rural Development

Keene NHVNA at HCS Inc.Real Time Home Monitoring

Health Services Resources Administration (HRSA)

10 CountiesNorthern New Hampshire AHEC

Distance Learning, telemedicine


Rural Swestern NH

Home Healthcare, Hospice and Community Services Inc.

Telehealth technology for chronic disease management


5Northern Human Services 87 Washington St.Conway,NH

The Northern Tele-psychiatry Initiative

Funding SourceSitesEntityProgram

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$236,898 USDA Rural Dev.

Belknap, Carroll, Coos, Grafton, Merrimack, Rockingham and Sullivan Counties

Dartmouth CollegeContinuing Education and Professional Dev.

$499,996. RUS.Rockingham County

Timberlane Regional School District; Plaistow, NH

Timberlane Regional School District will utilize RUS grant funds to implement adistance learning and telemedicine project

$499,965. USDA Rural devel.

Hillsborough, Sullivan, & Strafford Counties

Southeastern Regional Education Service Center, Inc

Installation of video conference system for raining purposes

$499,330. USDA Rural Development

Carroll, Stafford, Rockingham Counties in New Hampshire; Orleans County in Vermont

Exeter Region Cooperative School District

IP-based video equipment

$10000. Grant from Northway Bank

Franklin Regional Hospital (Genesis Behavioral Health )

Twenty-four-hour emergency psychiatric care

Rural Development fundsCoos, GraftonWeeks Medical CenterObstetrical telemedicine

U.S. Department of Agriculture CogswellBenevolent Trust Agnes Lindsey Foundation

Weeks Medical CenterFetal Monitoring (CALM System)

Funding SourceSitesEntityProgram

Agenda #5

NH Data on HIE (Patrick) – 20 minNorth Country Survey ResultsCare Migrating Out of StateCare Migrating Within State

North Country Survey Result HighlightsFebruary 2008

112

Provider Interviews

n/a1 (NHS)Behavioral Healthn/a1 (DHMC)Tertiary Hospitals

2 (NCHHHA - Littleton, PBHHH - Plymouth)

0Home Health Agencies

1 (TMH - Conway)6 (AVH, CH, LRH, SMH,UCVH, WMH)

CAHs

1 (GCNH - W. Stewartstown)

2 (GCNH, CCNH)County Nursing Homes

1 (WMCHS - Conway)4 (ACHS, CCFHS, ISHC, MSHC)

FQHCs/RHCs

PendingCompleteType

113

Summary – Interviews Not exactly sure what defines the N. Country (ie, Plymouth, Concord, Manchester, Lebanon, Maine Medical have roles too)

Significant amount of health information exchange taking place today (ie, point-to-point and view access as primary mediums)

Recognition that longitudinal health record is the end pointDesire to be more efficientDesire to improve clinical qualityDesire to move beyond point-to-point and view access exchange

114

Summary - View Access

Significant number of organizations providing views access into other systems

DHMC CISCAHs and FQHCs for EMR, PACS, IP Clinical

Typically “one-way”High cost of licensesPrivacy and securityMultiple applications for providers to learn

115

Summary – EMR/EHREMR/EHRs are installed in at least:

100% of the FQHCs1 Nursing Home5 Critical Access Hospitals1 Tertiary Hospital2 Home Health Agencies

116

Summary – IP Clinical Apps.Availability of Clinical Applications across CAHs varies, but includes:

PACSLabSchedulingIP ClinicaleRx

117

LaboratoryRadiologyProblem lists, meds and allergies

Admission, discharge, or transferDemographicQuality improvement

N. Country Exchange Priorities

UniversallyTop 3

UniversallyBottom 3

118

Summary - Technical Architecture

Federated or hybrid model most desiredWill need to be developed further

119

Summary - GovernanceMany options floated:

N. Country goes it alone either as a full region or a sub-regionN. Country partners with DHMCDHMC becomes the exchangeDHHS becomes the exchangeIndependent entity developedPartnership with ME, VT, MAOther……….

120

Summary - GovernanceUniversal support for an impartial, 3rd party as the governor of the exchangePartnering with other exchanges was considered favorablyQuestions about DHHS as exchangeConcern over DHMC given market shareConnectivity to statewide effort importantGovernance is linked to sustainability

121

Summary - Financing

IT spending ranked extremely high as overall organization prioritiesThe HIE needs to show some level of ROI, but non-tangible benefits are also understoodDesire for grants or state seed fundingBusiness model for sustainability needs clarityPartnering with other states may make sound fiscal senseMuch benefit accrues to payer; how to involve them

Care Migrating Out of State

123

Commercial Claims Medical Care Expenditures for NH Residents by State All Types

of Service w/ Pharmacy REMOVED CY 2006

NH, 83%

VT, 1%MA, 10%ME, 1%

Other, 4%

124

Commercial Claims Medical Care Expenditures for NH Residents by State

Inpatient Type of Service w/ Pharmacy Removed CY 2006

NH, 73%

VT, 1%MA, 20%

ME, 2%

Other, 4%

125


Outpatient Type of Service w/ Pharmacy Removed CY 2006

NH, 89%

VT, 1%MA, 8%ME, 1%

Other, 1%

126


Professional Type of Service w/ Pharmacy Removed CY 2006

NH, 86%

VT, 1%MA, 7%ME, 1%

Other, 5%

Care Migrating In State

Methodology

2006 commercial insurance claims representing 525,000 covered lives; all commercial lines of business; no Medicaid or Medicare

Medical claims (inpatient and outpatient); no pharmacy claimsHealth Analysis Areas were developed by NH DHHS; 22 total

areasLimitations:

Not all southern NH residents in datasetProvider billing zip code used as location for provider provision of servicesNot broken out by type of service

22 Health Analysis Areas

Source: NH DHHS

847127283 80354 4982253 31139070Rochester

75363119,8847,1684745541161Portsmouth

12,1931662,374862681737,21375020Plymouth

3613,7825206942425,0419275Peterborough

1,913611217461845473247282North Conway

2274,383982,6851,86711,1774,120277516Nashua

1,0945,2643538,7321,82635,61341,8362120461Manchester

15437291430267012713299Littleton

1,1201,536765841152369,444718,6179Lebanon

202929141230645641,205Lancaster

109,1184156,7173571,15947323,208193132Laconia

84126,09576761361771,46651,3304Keene

14,44216118,69612721533618,95716728Franklin

16635017143,50213,40911,2892,883233411Exeter

5171602615,999109,0853741,7331059Dover

159479749,41651698,0492,81421195Derry

8,1922,9753,5282,8633,9253,792379,456671,23455Concord

272371650242644,9690587Colebrook

361,7114561112549528,6970Claremont

164577347149550511227,627Berlin

LaconiaKeeneFranklinExeterDoverDerryConcordColebrookClaremontBerlin

Patient Health Analysis Areaof Residence

Health Analysis Area of Service Encounter Location:

37%18,7866,925Woodsville

41%85,40834,962Wolfeboro

32%164,43652,424Rochester

53%134,96472,020Portsmouth

50%95,26847,621Plymouth

50%110,08955,581Peterborough

68%65,52544,825North Conway

70%588,062409,106Nashua

66%716,863471,444Manchester

63%45,29728,549Littleton

68%259,940176,599Lebanon

52%22,66011,673Lancaster

60%182,116109,118Laconia

71%177,539126,095Keene

29%64,90318,696Franklin

44%323,830143,502Exeter

46%235,453109,085Dover

43%230,56598,049Derry

69%549,777379,456Concord

48%10,2784,969Colebrook

51%56,07328,697Claremont

70%39,28727,627Berlin

% Care Within Resident HAA

Total Encounters Resident HAA

Encounters Within Resident HAA

Member Health Analysis Areaof Residence

Encounters by Health Analysis Area (HAA) For Residents of Four HAAsCY2006 Data With Pharmacy Removed

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Berli

n

Cla

rem

ont

Col

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ok

Con

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Der

ry

Dov

er

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Fran

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r

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non

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ay

Pet

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outh

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ip

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MA

Prov

ider

in M

aine

Pro

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VT

Prov

ider

in O

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Sta

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HAA Where Care Received

# of

Enc

ount

ers

Exeter HAAConcord HAAPlymouth HAALebanon HAA

379K(69%)

22K(4%)

51K(9%)

16K(3%)

33K(6%)

133133

NHCHI Discussion on Operational Mission & Vision

For a State-level HIT HIE Initiative

Topic Areas:• The underlying problem• The emergence of network neighborhoods• Operational Mission

134134

The Underlying Problem• Lack of coordinated care exists despite the best

intensions of care providers• Mrs. Jones is 83 and in a county nursing home where she falls

and breaks a hip.• She is transferred to a local acute care hospital for surgery that

uses a paper chart.• She is then transferred to a regional rehabilitation facility in a

different health system that doesn’t communicate electronically outside of its system.

• She is then transferred back to the county nursing home• When she returns to the nursing home, the clinicians have an

incomplete medical record of her treatment including medications and lab and radiology results.

• Coordinated care would dramatically improve if electronic data were exchanged across systems.

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6/28/2008 Event Name 2

Network Neighbors in a Health Information Exchange

136136

Emergence of Network Neighbors

• More network neighborhoods than in the past due to rise of:• Integrated health systems• Physician networks• Clinic networks• Many other provider exchanges

• More network neighbors able to participate as a result of investments in HIT

• Goal• Allow network neighborhoods to thrive; they drive innovation• Enable data to be exchanged across network neighborhoods to

follow patient flow• Make sure all physicians can participate in HIT HIE regardless of

economic resources, not just those in network neighborhoods

137137

How to Listen

• How does this entity distinguish itself from other HIT HIE initiatives?

• In what way does this entity contribute to the growth of other HIT HIE initiatives?

• What are examples of this?• Where is there role confusion with other

entities?

138138

Operational MissionState-level HIT HIE Initiative

• Key healthcare stakeholders in New Hampshire are using the HIT HIE Strategic Planning Process to serve as a primary resource to achieve coordinated care using electronic tools (HIT) and health information exchange (HIE) to significantly improve the quality and value of care for citizens living in New Hampshire and for patients who receive care in New Hampshire

139139

We Do This by:1. Establishing an HIT strategy that ensures that

all providers have access to electronic toolsirrespective of income and geographic location.

2. Establishing an HIE infrastructure that enables providers serving patients to use electronic tool to exchange data across organizations.

3. Serving as a state-level convener and coordinator.

140140

1. Establishing an HIT Strategy…

• Encouraging physician adoption of electronic tools (e.g. EMR, eRX, registries)

• Establishing base level low cost e-tools• Working in collaboration with other HIT

initiatives (e.g. telemedicine)• Identifying and obtaining funding• Facilitating alignment of other major

investments that impact HIT and HIE (e.g. FCC)

141141

2. Establishing an HIE Infrastructure…

• Ensuring that HIE does not compete or replaceexisting network neighborhoods and investments.

• Providing services to support patient-centric care• Achieving critical mass of users/data sources• Meeting standards for interoperability, privacy &

security.• Driving investment in certified EHRs.• Identifying and funding pilot opportunities that

can demonstrate value.

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3. Serving as State-level Convener and Coordinator

• Ensuring activities are consistent with NHCHI HIT HIE Vision and Principles.

• Establishing an over all state-level direction.• Setting state-wide standards – Interop. P&S• Coordinating HIT HIE efforts.• Interacting with other state HIEs for common

solutions and potential opportunities to leverage/share infrastructure.

• Identifying and finding ways to address gaps in services.

• Recommending legislative changes needed.

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