Health Alliance Hospital Grand Rounds - Safe Health and Beyond

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Electronic Health InformationExchange in Massachusetts ±

xxxxxxxxxxxx and BeyondHealthAlliance Hospital Grand Rounds

January 4th, 2011

Larry Garber, M.D.

Fallon Clinic Medical Director of Informatics

SAFE Health Principal Investigator



2

Agenda

Health Information Exchanges

Review of SAFE Health project

Review of NEHENThe Massachusetts State HIE



Health Information Exchanges

Rx

Hospital

MD

Other

MD¶s

Patients

VNA

DPH

LTC &

SNF

Rehab

Payers

Imaging

Lab

HIE

Local Health Information

Exchanges (HIEs)

Regional Health Information

Organizations (RHIOs)

National Health Information

Network (NHIN)



Health Information Exchange (HIE)

Each organization

has 1 interface

Only patient

demographicdata stored

centrally

Central hub existsonly to help with

routing of clinical

data

Rx

Hospital

MD

Other MD¶s

Patients

VNA

DPH

LTC &SNF

Rehab

Payers

ImagingLab

HIE



Legislation for HIEs - State

MA Health Care Reform Act of 2008

$15M for community-based HIEs and EHRs

All hospitals and community health centersmust 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 manner

performs clinical quality measures

EHR is connected to other organizations

and the DPH (typically through a

Health Information Exchange)



A Public Utility for

Electronically ExchangingClinical Information in Central

Massachusetts

Secure Architecture For Exchanging

Health Information



Objective of SAFE Health

Build and operate a regional health

information exchange infrastructure to

enable secure, real time transfer of

patients¶ health information between

multiple different organizations with

patient consent in order to improve

patient safety, quality of care, and

efficiency of healthcare delivery.



High Level Design Goals

Integrate seamlessly into physician & staff workflowsClinical data flows from EHR to EHR, and is viewed

by clinicians directly in their EHRs

User authentication and role-based access is

performed by each connected entity through EHRPatients Opt-In once at the connected entity level for

all data content/types for TPO uses only

All authorized entities can access entire patient

recordOne central demographic repository (EMPI)

No central clinical data repository

Leverage existing systems at each organization with

minimal modification



Fallon Clinic

Payers

Other

Mass

Providers

HealthAlliance ER

SAFEHealth Setup� EMPI pre-populated

�

Edge servers pre-populated



Fallon Clinic

Payers

Other

Mass

Providers

HealthAlliance ER

New Patient Registers in ER� ADT to SAFEHealth

�

SAFEHealth assesses consent status

ADT



Fallon Clinic

Payers

Other

Mass

Providers

HealthAlliance ER

No Consent on File� Consent prints next to registrar

�

Patient added to portal workqueue



Fallon Clinic

Payers

Other

Mass

Providers

HealthAlliance ER

Patient Signs Consent� Registrar enters into Consent Portal



Fallon Clinic

Payers

Other

Mass

Providers

HealthAlliance ER

Patient Signs Consent� Registrar enters into Consent Portal

�

Consent status synchronized� Authorized clinical data

synchronization



Fallon Clinic

Payers

Other

Mass

Providers

HealthAlliance ER

ER MD Sees Patient� Reviews SAFEHealth data in ER¶s EHR

�

ER Discharge Note sent to authorizedentities



Fallon Clinic

Payers

Other

Mass

Providers

HealthAlliance ER

Care Continues� Authorized clinical data

synchronization for up to 1 year fromlast visit or until consent revoked



Timeline

2004 ± Awarded $1.5 Million AHRQ HIE Grant

± $4 Million donated by:� Fallon Clinic

� Fallon Community Health Plan

� HealthAlliance Hospital

� UMass Memorial Medical Center

6/2009 ± SAFEHealth go-live



Current Status of SAFEHealth

Local Servers were installed and connected

at Fallon Clinic and Health Alliance Hospital

Leominster Campus

Core Server is hosted by Fallon Clinic

1 Million patients were pre-loaded into EMPI

2 years of clinical data pre-loaded into CDR

HealthAlliance is currently providing ER

notes



Current Status (Continued)

Fallon Clinic is currently providing notes with:

� Medication List

� Allergies

� Problem List

� Immunization History

� Code Status

� Advance Directive Status

� PCP and phone number

� Vital Signs

� Recent Lab/Radiology Results



Statistics after first year:

2,000 patients have signed consents

10 people revoked their consents

50% have consented for all of Massachusetts75% agreed to receiving payer data

22,000 documents have been securely

exchanged



Lessons Learned: Where to file data

1. In a separate portal,

is not as good as«

2. In EHR in a separate area,

which is not as good as...

3. In EHR integrated with similar types of data

SAFEHealth uses #2 and #3



Value of SAFEHealth(Based on surveys)

� Higher quality, faster, safer care

� Fewer tests/admissions

� Consent process didn¶t interfere withregistration process

� Access to clinical data fits into the workflow

of clinicians



Sustainability of SAFEHealth

Focus has been on reducing operating

expenses

Internally-developed software

Hosting core server in Fallon Clinic¶s data center

No formal third-party organization/RHIO

Just need a Data Use and Reciprocal Support

Agreement (DURSA) in order to establish trustand baseline requirements for HIPAA and

state regulations (e.g. minimal requirements

for authenticating users)



Each organization is responsible for their

own server maintenance/license/replacement

and data mapping costs...

Currently ~$2,000/year/organization!

So the actual cost savings becomes almost

irrelevant

Sustainability of SAFEHealth



New England Healthcare

Exchange Network



The Evolution of NEHEN

1996

HIPAA

2003Standard

Admin Txn&

Trust

2008/2009MA Chapter 305

ARRA/HITECH

2011³Meaningful

Use´ &Standard

Clinical Txn

NEHEN¶s Growth:

Payers 4 8 16

Practices/Facilities 65 81 88

EDI Physicians ~12,000 ~18,000 ~20,000

Portal Physicians ~750 ~1,200

Transactions ~24M/yr ~60M ~100M

NEHEN

established for Administrative

Transactions

NEHEN adds members,

transactions and portal.

MA-SHARE clinicals:MedsInfo-ED, RLS,

NHIN, Rx Gateway

NEHEN/MA-SHARE merge.

CDX Gateway (XDR):

Clinical Summary Push,MAeHC Quality Data Center

integration



Flexible Implementation Options

� Intranet and Hosted Portal versions ± NEHEN Express

± Use when integrated EDI is unavailable in core system ± Supports ad hoc business processes like collections

± Provides means of acquiring early experience with processchange (in parallel with core system integration)

± Extends functionality to outlying practices and businessprocessing areas

� Integrated version ± IDX, Meditech, Eclipsys,

Epic & others ± Preferred method for workflow improvement in

core business processes ± Avoids double-keying / re-keying ± Eases distribution and reduces training

requirements for registration clerks, billing clerks,etc.

� Hybrid Integration version - use a combination of NEHEN-Batch and

core system features ± Cost effective and quicker integration method for Eligibility Verification

� An extract file is built of all scheduled patients from core system and sent to NEHEN-Batch

� NEHEN-Batch, builds the inqui ry transactions and sends it to the payer

� When El igibi l i ty Responses are returned, they are written back into the patient¶s file( in a comment f i eld) within the core system and Responses are made available withinNEHENLite for online viewing or reporting

NEHEN

Express

I nteg rated (Med i tech, IDX,

Epi c, etc.)

Hy br i d (NEHEN Express

& integ rated.)



Hosted Portal / HIE Service

� Hosted by service provider (NEHEN)

� Provides document / data storage, HTTP viewing for subscribers, and

common provider index for dissemination to local gateway participants

Peer-to-Peer Participant

� Local gateway users control integration, etc.

� Can leverage infrastructure for internal integration

� Interfaces can be direct or use interface engine or similar tools

Architecture Overview

Local Provider

Directory

Internet /

Network

Published

Patient DataEMRs and Other

EnterpriseSystems

Secondary

Local

System

E-Mail

Server

CCD Standard

Messages,

e-mail or fax

encapsulation

Interface

Engineor Portal

HIE Application

Server / Gateway

Fax

Server

Web

Server

Service Subscriber

� No infrastructure support requirement ± just Internet connection, fax or

e-mail

Summar

/

¡ ¢ £

ult£

Vi¢

¤

¢

r

Fax

Summar ¥

/

¡ ¢ £ ult £ Vi¢

¤

¢ r E-Mail

Server

Web

Server

Printer

E -mail, fax or

HTTP encapsulation

Published Patient Data

Community Provider Directory

Peer-to-Peer Participant

EMRs and Other

EnterpriseSystems

Secondary

Local

System

E-Mail

Server

Interface

Engineor Portal

Fax

Server

Web

Server

Published

Patient Data

HIE Application

Server / Gateway

Local Provider

Directory

HIE Application

Server / Gateway

CCD Standard Messages,

HTTP encapsulation

Summary /

Results Viewer

External

etwor s



Exchange Partner

Architecture & Workflow

Provider

Directory /

Routing

Internet / Network

Treatment ³events´ (visits,tests, discharges, etc.) trigger

patient data being published or

pushed from one or moresource systems for exchange

Published

Patient

Data

Data is translated to CCD standard

Message is addressed using provider directory

Message is logged and retained for tracking by sender

Source Provider Source EMRs

and Clinical

Systems

Secondary

Local

System

ExchangeInfrastructure

(can be local

to each partner or

centrally hosted)

Provider

Directory /

Routing

Received

Patient

Data

Message or notification of available data is securelyrouted to intended receivers

Message can also be routed as encrypted or secure

e-mail

Fax

Server

Fax

Message can also be routed as facsimile, directly to faxor through fax server at receiver if logging is required

Message is logged and retained for tracking by receiver

Message is inspected for handling and routinginstructions

Acknowledgement is returned to sender based onagreed process and business rules

Message is available for printing (e.g., for paper chart)

Message is available for online viewing from exchangeinfrastructure or in portal

CCD data is translated to proprietary format for use inreceiving system(s)

Exchange infrastructure can also be leveraged for internal / local exchange within the provider organization

CCD Standard Messages

Receiver EMRs

and Other

Systems

Portal or

Dedicated

Viewer

Mail

Server

Interface Engine,

Portal or

Direct Interface

Interface Engine,

Portal or

Direct InterfacePrinter

Fax

Server

HIE Boundary



NEHEN Benefits

Reduction in claim denials� Correcting insufficient or inaccurate eligibility or referral information

� Correcting invalid PCP, DOB

Reduction in write-offs due to eligibility or exceeding

the filing limit Improved collection of Copays

Labor savings� Reduction in ambulatory care staff needed to manage medications

� Reduction in time spent on manual transactions: eligibility, claim

status inquiry� Focusing on the exception processing

Reduction in ³Days in A/R´ & claims rework� Focus on front-end weighted, clinically driven revenue cycle

operations

Reduction in bad-debt



NEHEN Benefits (Continued)

Enhanced communication among providers

Reduction in ambulatory medication errors

Improvement in the Patient Experience

Satisfy ³Meaningful Use´ requirements for:

Clinical Summary Exchange

Medication Reconciliation during transitions of care

Quality Reporting (in conjunction with MAeHC¶s Quality

Data Center)

Public Health Reporting



NEHEN Cost Savings

Brigham & Women's and Mass General Hospital

reduced their ³Total Denial Write Off Rates as a

Percent of Net Revenue´ from 3.78% to 0.88%

and from 4.17% to 1.28% respectively

Brigham & Women's and Mass General Hospital

reduced their ³A/R Days´ from 81 days to 55.6

days and from 99 days to 54 days respectively

Baystate Health System saved over $1.5 Million

in two years by avoiding per-transaction fees



Lessons Learned: Consent

5% of patients get their peace of mind

knowing that they have absolute control

over every piece of their clinical data

95% of patients get their peace of mind

knowing that their clinical data is always

where they need it to be without hassles

Need different mechanisms to accommodate

each



5% who want absolute control:

� NEHEN-style push of specific data with

patient consent on a one-time basis

95% who want it where they need it to be:

� SAFEHealth-style consent and data flow

Lessons Learned: Consent



Statewide HIE for

Massachusetts



Governance Structure and Elements of

Public/Private Collaboration



Massachusetts Statewide HIE Concepts

To meet federal and state requirements (including Chapter 305) ANDsupport health care reform initiatives, the HIE technical architecturemust support:

Privacy and

SecurityPatient control of information on the HIE must be

consistent with state and federal policy

Bi-directional DataExchange

Allow HIE participants (including patients) to contribute data,enabling others to appropriately retrieve data from the HIE

Exchange of

standardized

Clinical Summaries

Adopt the standards needed to exchange summary data,including the CCD, among various clinical settings

Public Health

Reporting

Integrate with a reportable data detection and messaging

solution to drive improved completeness and accuracy for public health reporting

Reporting for

Quality and other

initiatives

Facilitate data routing to reporting tools and support thepossible linkage to registries in the future

Financial

SustainabilityProvide value to participants, such that they are willing to

pay for the services provided



40

Network of

Networks



Summary

NEHEN has a long history of success

focusing on pushing data analogous to the

Fax machine

SAFEHealth¶s success focuses on patient

consent management, automatically moving

data, and low operating expenses

Massachusetts¶ statewide HIE will leverage

existing work and networks through the state



Questions? www.SAFEHealth.org

Larry Garber, MD [email protected]

Rx

Hospital

MD

Other

MD¶s

Patients

VNA

DPH

LTC &

SNF

Rehab

Payers

Imaging

Lab

HIE



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