Regional Health Information Regional Health Information Organizations (RHIOs)Organizations (RHIOs)

The Primary Vehicle for Achieving the The Primary Vehicle for Achieving the National Health Information Network (NHIN)National Health Information Network (NHIN)

Presented by: Holt AndersonPresented by: Holt Anderson

Executive Director, NCHICAExecutive Director, NCHICA

Presentation OutlinePresentation Outline

• The National FrameworkThe National Framework• The Request for Information (RFI)• Speculative Definitions• Emerging Models for RHIOs

• NCHICA as one possible RHIO modelNCHICA as one possible RHIO model

• Examples of Collaborative Activities and Examples of Collaborative Activities and Challenges IncurredChallenges Incurred

• Q & AQ & A

Obstacles to a Universal EHRObstacles to a Universal EHR

• the multitude of industry standards that have the multitude of industry standards that have yet to be harmonized,yet to be harmonized,

• a lack of clear and unambiguous policies about a lack of clear and unambiguous policies about data control,data control,

• differing security policies among organizations differing security policies among organizations and states,and states,

• the risk that EHR products won't work as the risk that EHR products won't work as promised; and promised; and

• the lack of a business model that creates the lack of a business model that creates incentives for physician investment and incentives for physician investment and adoption. adoption.

David Brailer, ONCHIT, AMIA Conference, April 2005

Framework for Strategic ActionFramework for Strategic Action

• Inform clinical practice with use of EHRsInform clinical practice with use of EHRs

• Interconnect cliniciansInterconnect clinicians

• Personalize care with consumer-based health Personalize care with consumer-based health

records and better information for consumersrecords and better information for consumers

• Improve public health through advanced Improve public health through advanced

biosurveillance methods and streamlined biosurveillance methods and streamlined

collection of data for quality measurement collection of data for quality measurement

and researchand research

Request for InformationRequest for Information

US Dept. of Health & Human ServicesUS Dept. of Health & Human Services

Office of the National Coordinator for Office of the National Coordinator for Health Information TechnologyHealth Information Technology

Issued: November 15, 2004Issued: November 15, 2004

Responses by: January 18, 2005Responses by: January 18, 2005

Framework for Strategic ActionFramework for Strategic Action

• Inform clinical practice with use of EHRsInform clinical practice with use of EHRs

• Interconnect cliniciansInterconnect clinicians

• Personalize care with consumer-based health Personalize care with consumer-based health

records and better information for consumersrecords and better information for consumers

• Improve public health through advanced Improve public health through advanced

biosurveillance methods and streamlined biosurveillance methods and streamlined

collection of data for quality measurement collection of data for quality measurement

and researchand research

The RFIThe RFI

• Addresses goal of Addresses goal of interconnecting interconnecting

cliniciansclinicians by seeking public comment by seeking public comment

and input regarding how widespread and input regarding how widespread

interoperabilityinteroperability of health information of health information

technologies and health information technologies and health information

exchange can be achieved.exchange can be achieved.

Why InteroperabilityWhy Interoperability

• Interoperability is necessary:Interoperability is necessary:• for compiling the complete experience of a

patient’s care

• for maintaining a patient's personal health records, and

• for ensuring that complete health information is accessible to clinicians as the patient moves through various healthcare settings.

• Interoperability is needed for clinicians to Interoperability is needed for clinicians to

make fact-based decisions so medical errors make fact-based decisions so medical errors

and redundant tests can be reduced.and redundant tests can be reduced.

• Interoperability is also critical to cost-Interoperability is also critical to cost-

effective and timely data collection for effective and timely data collection for

biosurveillance, quality measurement and biosurveillance, quality measurement and

clinical research.clinical research.

Why InteroperabilityWhy Interoperability (cont.)(cont.)

NCHICA RFI Response ParticipantsNCHICA RFI Response Participants

• Duke Univ Hlth System

• Initiate Systems

• Internet2

• Keane

• LabCorp

• MRNC

• NC DHHS

• NCHIMA

• Physicians EHR

• Robeson Co Med Soc

• RTI International

• Siemens

• Smart & Assoc

• Telumenous

• UNC SPH

• Western NC RHIO

DisclaimerDisclaimer

• The The NHINNHIN and and RHIOsRHIOs are a new but are a new but

important conceptsimportant concepts

• Definitions are not firm at this timeDefinitions are not firm at this time

• Public input is being sought by the Office of Public input is being sought by the Office of

the National Coordinator for Health the National Coordinator for Health

Information Technology (Information Technology (ONCHITONCHIT))

NHINNHIN

• National Health Information Network (NHIN)National Health Information Network (NHIN)

• A supportive, nation-wide, interoperable

system with the capacity to exchange

conveniently and securely healthcare

information culminating in the improvement

of consumer health and the reduction in

healthcare costs.

RHIORHIO

• Regional Healthcare Information Regional Healthcare Information

Organizations (RHIO)Organizations (RHIO)

• A collaborative, consumer-centric organization

focused on facilitating the coordination of

existing and proposed e-health initiatives within

a region, state, or other designated local area.

Types of RHIOsTypes of RHIOs

• FederationsFederations

• Includes large, “self-sufficient” enterprises

• Agreement to network, share, allow

access to information they maintain on

peer to peer basis

• May develop system of indexing and/or

locating data (e.g., state or region-wide

MPI)

Types of RHIOs Types of RHIOs (cont.)(cont.)

• Co-opsCo-ops• Includes mostly smaller enterprises

• Agreement to pool resources and create a combined, common data repository

• May share technology and administrative overhead

Types of RHIOs Types of RHIOs (cont.)(cont.)

• HybridsHybrids• Includes combinations of Federations and

Co-ops

• Agreement to network, share, allow access to information they maintain on peer to peer basis

• Allows aggregation across large areas (statewide or regional

RHIO StructureRHIO Structure

• 501(c)(3) Nonprofit501(c)(3) Nonprofit• Eligible for Federal and State Grants• Contributions may be tax deductible as charitable

• Issues:Issues:• Limit of ~20% on income from “unrelated

business” activities (i.e. not charitable and educational)

• May need to subcontract or otherwise handoff operational aspects of activities

Key Allies for a RHIO Include:Key Allies for a RHIO Include:

• Covered Entities (Providers, Health Plans, Covered Entities (Providers, Health Plans, Clearinghouses)Clearinghouses)

• Medical SocietyMedical Society• Hospital AssociationHospital Association• Nurses AssociationNurses Association• Health Information Management Assn.Health Information Management Assn.• Medical Group Managers AssociationMedical Group Managers Association• Healthcare Financial Management AssociationHealthcare Financial Management Association• Association of Local Health DirectorsAssociation of Local Health Directors• Association of PharmacistsAssociation of Pharmacists• Long-term Care AssociationLong-term Care Association• Association of Health PlansAssociation of Health Plans• QIOsQIOs• VendorsVendors• Etc., Etc.Etc., Etc.

RHIO ManagementRHIO Management

VIDEO CLIP

NCHICA as One Possible NCHICA as One Possible

RHIO ModelRHIO Model

NCHICA BackgroundNCHICA Background

• Established in 1994 by Executive Order of GovernorEstablished in 1994 by Executive Order of Governor

• 501(c)(3) nonprofit - research & education501(c)(3) nonprofit - research & education

• 250 members including:250 members including:• Providers

• Health Plans

• Clearinghouses

• State & Federal Government Agencies

• Professional Associations and Societies

• Research Organizations

• Vendors and Consultants

• MissionMission: : Improve healthcare in NC by accelerating the Improve healthcare in NC by accelerating the

adoption of information technologyadoption of information technology

Terms of MembershipTerms of Membership

A fundamental purpose of NCHICA is to:A fundamental purpose of NCHICA is to:

• facilitate the development of a statewide

healthcare information network incorporating

• open architecture

• interoperable systems, and

• reconfigured information systems.

Applicant agrees to support the following principles: Applicant agrees to support the following principles:

a. to foster interoperability and open-systems architecture

b. to work in good faith to integrate existing healthcare

information systems

c. to provide expert personnel to support the activities of

NCHICA in the spirit of collaboration

d. to support policies adopted by NCHICA to protect intellectual

property

e. to encourage a competitive environment for the development

of the information, telecommunications, and telemedicine

industries in North Carolina consistent with NCHICA's

purposes.

Terms of Membership Terms of Membership (cont.)(cont.)

Successes and Challenges Successes and Challenges

Raised in NCHICA ProjectsRaised in NCHICA Projects

Characteristics of ProjectsCharacteristics of Projects

• All have evolved from earlier effortsAll have evolved from earlier efforts

• All are statewide effortsAll are statewide efforts

• All involve public and private sectorAll involve public and private sector

• All build toward a North Carolina “Local Health All build toward a North Carolina “Local Health

Information Infrastructure” and are positioned to Information Infrastructure” and are positioned to

connect into national PHIN and NHIN effortsconnect into national PHIN and NHIN efforts

• Expectation is for continued evolution and Expectation is for continued evolution and

refinementrefinement

Statewide Master Person IndexStatewide Master Person Index

• 1994 Goal: 1994 Goal: • Develop Voluntary Patient Information Locator (VPIL) so that

records could be accessed for care

• Business / Policy: Business / Policy: • Shared “customer lists”

• Legal: Legal: • Privacy & Liability• No State or Federal Laws covering electronic health info

• Consumer: Consumer: • Privacy

• Technical:Technical:• Availability of standardized MPIs from all providers and sectors• Synchronizing databases• Standards for data

• Lessons Learned: Lessons Learned:

• Technology is the easy part

• Business and Policy Considerations are much

harder and “Show Stoppers”

• Develop clinical leadership for project with

technologists in support role

Statewide Master Person IndexStatewide Master Person Index

HIPAA EffortsHIPAA Efforts

• 1995-1999 Privacy & Confidentiality Focus 1995-1999 Privacy & Confidentiality Focus GroupGroup• Model Privacy Legislation

• 1998-2003 HIPAA Implementation Planning 1998-2003 HIPAA Implementation Planning Task ForceTask Force

• 1998-Present1998-Present• Privacy Work Group• Security Work Group• Transactions, Code Sets and Identifiers Work Group• Privacy & Security Officials Work Group

• DeliverablesDeliverables: Compliance tools, model : Compliance tools, model documents, education and training programsdocuments, education and training programs• and, method of building community consensus

Statewide Immunization RegistryStatewide Immunization Registry

• 1998 Goal:1998 Goal:• Combined registry of public and private children’s immunization

records from multiple sources available via secure Internet

• Business / Policy:Business / Policy:• Internet access to public health database

• Legal:Legal:• Privacy and Security• Non-stigmatizing data

• Consumer:Consumer:• Well understood need

• Technical:Technical:• Data quality and matching entries from different sources• Move from mainframe to server with SSL Web technology and

authentication

Statewide Immunization RegistryStatewide Immunization Registry

Statewide Immunization Registry StatusStatewide Immunization Registry Status

• Combined DatabaseCombined Database• Public Health

• BCBSNC

• Kaiser Permanente (historical)

• ~ 2M Children~ 2M Children

• ~ 20M doses~ 20M doses

• 425 sites; 2250 authenticated users425 sites; 2250 authenticated users• 90 Local Public Health Departments

• 335 Private Providers, Schools, State of TN

New Statewide Immunization RegistryNew Statewide Immunization Registry

• Lessons Learned: Lessons Learned:

• Choose project with clear benefits

• Find clinical champions

• Enlist CEO-level champions

• Share the load

• Celebrate success

• PKI is not like falling off a log

• Proof is in the utility of the project and user

demand for sustaining it past pilot stage

Statewide Immunization RegistryStatewide Immunization Registry

Statewide Emergency Dept. DatabaseStatewide Emergency Dept. Database

• 1999 Goal:1999 Goal:• Standardize and electronically collect clinical data from emergency

departments for:• Best Practice Development & Community Assessments• Public Health Surveillance (2001)

• Business / Policy:Business / Policy:• Participation Agreement covering access and use of data

• Legal:Legal:• Privacy and Security

• No state mandate for collection of certain data elements with identifiers (Limited Data Set and Data Use Agreement)

• Consumer:Consumer:• Collected and transmitted to aggregation point as deidentified data

• TechnicalTechnical• Standards for data elements (CDC’s DEEDS Standard)

• Mapping of systems so extracts could be transformed into DEEDS

• No standards for coding of Chief Complaint and First Report of Injury

Status as of 1-31-2005:Status as of 1-31-2005:

• Data from 24+ hospitalsData from 24+ hospitals

• 4000+ visit records per day on average

• Total Number of Visits: 1.6M +

• Total Number of Patients: 875K +

• Total Number of Final Diagnosis Codes: 4.2M +

• Total Number of Cause of Injury Codes: 478K +

• NCHA now involved to accelerate collection from all NCHA now involved to accelerate collection from all

124 hospitals with EDs across NC124 hospitals with EDs across NC

Statewide Emergency Dept. DatabaseStatewide Emergency Dept. Database

• Lessons Learned: Lessons Learned: • Provide neutral table for collaboration

• Make it easy for IT Departments to provide data

• Keep it simple and cheap

• Expect new opportunities for data use

• Professional associations are better at policy issues than technology implementation

• While HIPAA is permissive, providing information voluntarily (e.g. without safe harbor) makes legal counsel very uncomfortable

Statewide Emergency Dept. DatabaseStatewide Emergency Dept. Database

• NCNC--PHINPHIN• North CarolinaNorth Carolina Public Health Public Health

Information NetworkInformation Network

• NCNC--HANHAN• North CarolinaNorth Carolina Health Alert NetworkHealth Alert Network

NC Public Health InitiativesNC Public Health Initiatives

Vision: Framework for the FutureVision: Framework for the Future

• Automated electronic reporting of data Automated electronic reporting of data

• Secure Internet pipeline for reporting information Secure Internet pipeline for reporting information

• Consistent user interfaces Consistent user interfaces

• Common data definitionsCommon data definitions

• Reusable software componentsReusable software components

• Shared analysis and dissemination methods, e.g., Shared analysis and dissemination methods, e.g., outbreak detection algorithmsoutbreak detection algorithms

• Secure, HIPAA-compliant data warehouseSecure, HIPAA-compliant data warehouse

• Established set of technical standards acceptable Established set of technical standards acceptable and adopted by preparedness partnersand adopted by preparedness partners

NCNC--PHINPHIN

NCNC--PHIN PHIN ComponentsComponents

Health Alert Network Health Alert Network NCNC--HANHAN Epi-X Epi-X (secure interactive (secure interactive

communications with CDC communications with CDC and other states)and other states)

Enhanced Public Health Enhanced Public Health SurveillanceSurveillance

Electronic Disease Reporting

Hospital Data (ICD-9, UB92 Admin. Data)

Syndromic Surveillance Hospital Clinical Data

Poison Control Center PreMIS Aberrancy Detection

Medical Examiner Data

Program Area ModulesProgram Area Modules TB Hepatitis Meningitis HIV/STD Vaccine Preventable

Diseases Immunization RegistryImmunization Registry Multi-Hazard Threat DatabaseMulti-Hazard Threat Database

GIS Electronic Laboratory Results Electronic Laboratory Results

(LRN)(LRN) Vital Records AutomationVital Records Automation

Public Health InitiativesPublic Health Initiatives

• Lessons Learned: Lessons Learned:

• HAN starts us on the path to connectivity

• Connectivity drives additional opportunities

• Use immunization registries to drive public-private

connections

• EHRs have potential of improving surveillance

capabilities and improving population and public

health

North Carolina Healthcare Quality North Carolina Healthcare Quality InitiativeInitiative

Improving Healthcare in North Carolina by Accelerating the Improving Healthcare in North Carolina by Accelerating the Adoption of Information TechnologyAdoption of Information Technology

NC Healthcare Quality InitiativeNC Healthcare Quality Initiative

• GoalGoal::• Phase I - Provide list of medications at point of encounter to save

time, improve accuracy of treatment and avoid medication errors• Include ability to automate refills, e-Rx, and access to formularies• Phase II – Electronic handling of Lab and Radiology data

• Business / PolicyBusiness / Policy::• Access to data from health plans, PBMs, pharmacies and other

providers• Cost of operation; Sustainability

• LegalLegal::• Privacy and Security (limit use to Treatment)• Rights to data; Liability

• ConsumerConsumer::• Who has been looking for and at my information?• Drugs for behavioral health, communicable diseases, etc.

• TechnicalTechnical• Accessing records from multiple sources and linking same patient

data

Medications ManagementMedications Management

• Key attributes:Key attributes:

• Saves clinician’s time (10%-40% of encounter)

• Improves patient safety

• Leads to automating medication refills

• Leads to e-Prescribing

• Example: Medicare PopulationExample: Medicare Population

• 20% have 5 or more chronic conditions

• Those 20% see on average 13.5 different physicians per year

• Potential for prescribing errors, duplication of orders, tests, etc.

• Chronic Care accounts for 70%-80% of expenditures

• Important data in emergent casesImportant data in emergent cases• Frequently not available• Identifies current medical conditions• Avoids inappropriate drug-drug interactions

• Currently kept by different repositoriesCurrently kept by different repositories• Pharmacy claims• Health Plans• Patients

• Requires policy and technology solutionsRequires policy and technology solutions• Privacy and Security considerations• Business and collaboration considerations• Technology issues:

• Data Quality• Networked databases• Data repository vs. Portal technology

Medications Management InitiativeMedications Management Initiative

Presentation

Data Integration

Identity Hub/Repository Administration

INQUIRY HISTORY DATABASEIDENTITY HUB

EAI

Inquiry History

Database

Web portalWeb portal eRxeRx EHREHR

TransactionServices RxHUBRxHUB SureScriptsSureScripts DirectDirect

Electronic Prescriptions& Refills

Community Medication History PortaCommunity Medication History Portal

Patient Data Sources

PBMs PharmaciesHealth Plans, including

NC Medicaid

RegionalHospital

s

RegionalClinics

CommunityDatabase

Medicare

Medications Management InitiativeMedications Management Initiative

NC HC Quality Initiative - Project ManagementNC HC Quality Initiative - Project Management

Proposal Development TeamsProposal Development Teams

• TechnologyTechnology• Technical approach, diagrams

• Clinical IntegrationClinical Integration• Clinician role and adoption and consumers role,

adoption, satisfaction

• Business / FinanceBusiness / Finance• Business Model, budgets and justification

• PolicyPolicy• Role of patients, agreements

• MetricsMetrics• Assess value of project

• CoordinationCoordination• Executive Summary, letters of commitment, etc.

Values for the TransitionValues for the Transition

• Keep the health and safety of the individual Keep the health and safety of the individual

as the core objective.as the core objective.

• Use RHIOs as an opportunity and vehicle to Use RHIOs as an opportunity and vehicle to

transform healthcare into a more effective and transform healthcare into a more effective and

efficient system.efficient system.

• Promote clinical and business benefits of Promote clinical and business benefits of

information technology and secure information technology and secure

communications .communications .

Generating RHIO Proposals for FundingGenerating RHIO Proposals for Funding

• Lessons Learned:Lessons Learned:• Understand the requirements from the funder e.g.:

• Contract or Grant• WMOB Subcontracting• Principal Investigator• Cognizant Auditing Agency

• Time commitment of team to develop proposal:• Limited capabilities of volunteers with primary responsibilities

elsewhere• Technical & Clinical Expertise• Policy and Business Requirements

• Privacy & Security• Shared information among competitors

• Commitments from top executives (private and government)• Educate and Obtain Commitment

The Race Goes to the SwiftThe Race Goes to the Swift

VIDEO CLIP

Holt Anderson, Executive DirectorHolt Anderson, Executive Director

Holt@nchica.orgHolt@nchica.org (919) 558-9258 ext. 27 (919) 558-9258 ext. 27

North Carolina Healthcare Information and Communications Alliance, Inc. North Carolina Healthcare Information and Communications Alliance, Inc.

www.nchica.orgwww.nchica.org

Thank YouThank You

Questions ?Questions ?