MASSACHUSETTS eHEALTH COLLABORATIVE
HIT Symposium
July 2006
- 2 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
MASSACHUSETTS COMMUNITY OF E-HEALTH ORGANIZATIONS
1978 1998 2003
The convener and educational organization, the business incubator
The transactor of administrative (HIPAA transaction) processes
The grid of state-wide clinical utilities
The last-mile to clinician offices
“The Convener”
2004
“The Transactor” “The Grid” “The Last Mile”
- 3 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
MAeHC ROOTS ARE IN MOVEMENT TO IMPROVE QUALITY, SAFETY, EFFICIENCY OF CARE
• Universal adoption of electronic health records
• MA-SAFE
• $50M commitment to heath information infrastructure
• Recognition of “systems” problem
• Company launched September 2004
– Non-profit registered in the State of Massachusetts
• CEO on board January 2005
• Backed by broad array of 34 MA health care stakeholders
- 4 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
34 ORGANIZATIONS REPRESENTED ON MAeHC BOARD
Health plans and payer organizations
• Alliance for Health Care Improvement
• Blue Cross Blue Shield of Massachusetts
• Fallon Community Health Plan
• Harvard Pilgrim Health Care
• Massachusetts Association of Health Plans
• Massachusetts Health Quality Partners
• Tufts Associated Health Maintenance Organization
Healthcare purchaser organizations
• Associated Industries of Massachusetts
• Massachusetts Business Roundtable
• Massachusetts Group Insurance Commission
Non-voting members
• Center for Medicare & Medicaid Services
Hospitals and hospital associations
• Baystate Health System
• Beth Israel Deaconess Medical Center
• Boston Medical Center
• Caritas Christi
• Fallon Clinic, Inc.
• Lahey Clinic Medical Center
• Massachusetts Hospital Association
• Massachusetts Council of Community Hospitals
• Partners Healthcare
• Tufts-New England Medical Center
• University of Massachusetts Memorial Medical Center
Governmental agencies
• Executive Office of Health and Human Services
Healthcare professional associations
• American College of Physicians
• Massachusetts League of Community Health Centers
• Massachusetts Medical Society
• Massachusetts Nurses Association
Consumer, public interest, and labor
• Health Care for All
• Massachusetts Coalition for the Prevention of Medical Errors
• Massachusetts Health Data Consortium
• Massachusetts Taxpayers Foundation
• Massachusetts Technology Collaborative
• MassPRO, Inc.
• New England Healthcare Institute
- 5 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
MAeHC VISION
Improve quality, safety, and affordability of health care through:
• Universal adoption of modern information technology in clinical settings
• Access to comprehensive clinical information in real-time at the point-of-care
Tools for better, more accessible health care…
…incorporated into clinical practice…
Overcome barriers to promote widespread use of EHRs and associated decision support tools
• Lack of capital
• Misaligned economic incentives
• Immature technology standards
…and sustained over time.
Develop operational and financing models to foster and sustain state-wide adoption of such technologies and infrastructures
- 6 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
MAEHC MISSION: CLINICAL IT ADOPTION THROUGH COMMUNITY EMPOWERMENT
- 7 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
PILOT PROJECTS HAVE FOUR MAIN PIECES
• Quality• Cost• Productivity• Etc.
ConnectivityConnectivity
Clinical IT implementation/
support
Clinical IT implementation/
support
EvaluationEvaluation• Quality measurement
• Pilot evaluation
• Clinical access to data
• Data gathering and aggregation
• Communication
• Hardware/software
• Implementation/tech support
• Systems integration
• Workflow redesign
• Decision support
Intra-community connectivity
Management & coordination
Management & coordination
• Joint oversight and decision-making bodies
• Multi-stakeholder governance
ICCC
PSC PSC PSC
- 8 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
MAeHC PROJECT TIMELINE
Activities 2004 2005 2006 2007 2008
ACP-MA summit
MAeHC launch
Community RFA launch
Pilot communities announced
EHR vendor RFP
EHR vendor finalization
Physician recruitment
Implementation
Evaluation
Formal Pilot completion
- 9 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
EVEN $50M CAN’T GET THE LAST 5%
0
20
40
60
80
100
120
140
160
180
200
Initial practices Ineligible Opted out Signed contract
180 22
1499
Most didn’t fit MAeHC definition of community
Main sources of attrition:• Outyear cost• Close to retirement• Too much of a hassle
149158
=94%
participation
- 10 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
DIVERSE ARRAY OF SETTINGS
Offices
0
100
200
300
400
500
600
350
Patient population (000)
95
43 488
0
20
40
60
80
100
120
140
160
180
200
111
41
25177
Small
Med
Large
111
37
27
175
184
48
38
270
0
50
100
150
200
250
300
350
400
450
500
295
85
65 445
PCPs
Specialists
Physicians
Almost 450 physicians……who care for ~500K
patients……in almost 200 offices.
BrocktonNewburyport
N. AdamsAll
BrocktonNewburyport
N. AdamsAll
BrocktonNewburyport
N. AdamsAll
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HIGHLAND PRIMARY CARE KICK-OFF
Docs link up to new record styleBy Jennifer Heldt PowellTuesday, March 14, 2006
The end of the paper trailBy Ulrika G. Gerth/ [email protected], March 17, 2006
Setting a new record: Local doctors pilot electronic patient history system By Stephanie Chelf Staff Writer
- 12 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
PHYSICIANS “GOING LIVE”, BY COMMUNITY
0
50
100
150
200
250
300
350
400
450
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Total
# MDs
2006 2007
North Adams(55)
Newburyport(81)
Brockton(305)
9 7 5 19 21 33 25 24 27 67 121 9 64 1 7 1 441
- 13 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
THE GRID AND THE LAST MILE
Inter-community connectivity
MA-SHARE
Intra-community connectivity
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THE NEXT PHASE: CONNECTING PHYSICIANS
Health Information Exchange
Patient permission
Privacy and security
Clinical utility
Sustainability
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NORTH ADAMS HEALTH INFORMATION EXCHANGE
ehr ehr ehr
ehr
ehr
HIS
eCR eRef
ePatient
Patient portal
Patient-specific functions
• Appointment requests• e-visits• Clinical summary• Other
Patient-centric clinical summary
• Medications• Labs• Allergies• Problems• Other
eReferrals• Secure-messaging between care-givers• Tracks and matches outbound/inbound referrals, and outbound/inbound consult reports
Physician portal
- 19 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
DRIVERS OF BUSINESS SUSTAINABILITY
Low
Clinical data fields in eHealth Summary
Structured, codified data Unstructured, text
High
Patient opt-insClinical usefulness
Low High
Physician adoption
Labs Medications Problems Allergies Medical/family history
Notes
Business sustainability threshhold
- 20 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
PRIVACY APPROACH SUMMARY (I)
MAeHC and communities need to decide what patient notification or consent we will require for data exchange in community pilots
• Not required for stand-alone EHRs
• Will be required for data exchange across legal entities
Data exchange already happens today
• Current exchanges happen by fax, phone, mail, email, and remote access
• Community network could change the scale but probably not scope of that exchange (ie, same type of information will be exchanged but more often)
• With no “person-in-the-loop”, electronic data access may seem more risky, whether it is or not
- 21 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
PRIVACY APPROACH SUMMARY (II)
Even though we’re just changing the transport vehicle, we can’t rely on existing notifications and consents to cover exchange over the new network
• MAeHC commitment to transparency will necessitate some form of patient notification or consent about new network
• Furthermore, we can’t assume that current entities have gotten patient consent that conforms with MA consent laws– very likely that many have not
Notification about the network is not enough – MA law argues for some form of affirmative consent BEFORE disclosing data across legal entities
• HIPAA Notice of Privacy Practices does NOT count for MA consent
• MA consent requires affirmative consent for disclosure of clinical information, and a second affirmative consent for disclosure of sensitive information
Question before us now is how to get patient consent in a way that is ethically and legally robust and operationally sound
- 22 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
ENTITY-BY-ENTITY OPT-IN (REPOSITORY MODEL)
Jane Jones
Patient visits clinical entity for care and is provided option at first visit to opt-in all clinical data from EACH entity
Patient visits clinical entity for care and is provided option at first visit to opt-in all clinical data from EACH entity
1
Visit
YY Y YN
2
Patient chooses which entity’s records to make available to network
Patient chooses which entity’s records to make available to network
Consent
Jane Jones
3
Name-location index published for entities who have gotten consent
Name-location index published for entities who have gotten consent
Publish
Physician views data prior to or during patient visit
Physician views data prior to or during patient visit
4 Retrieve
Community Network
Jane Jones eCommunity RecordJune 9, 2006
Visit historyxxxxxx
Active problem listxxx Dr. Jane Brody
Current medicationsxxx Seacoast Cardio
Current allergiesxxx Dr. Jane Brody
Recent laboratory resultsxxx AJ Hospital
Recent radiology resultsxxx AJ Hospital
Otherxxx XXX
- 23 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
Adoption
EVALUATION PROGRAM WILL SUPPORT THREE KEY PILOT PROGRAM OBJECTIVES
• What are the most significant adoption barriers?
• What are the best ways to overcome them?
• What are the costs (direct and indirect) of adoption of IT?
• What are the benefits?
• How are the costs and benefits distributed across payers, providers, government, patients, ancillaries, etc?
• How much money will be required to implement statewide?
• What is general framework of incentives to implement and sustain the model?
• What are the most effective management strategies for implementing and sustaining in communities?
• What are the most effective organization models and tactics for implementing and sustaining statewide?
Value
Replication
Efficacy vs EffectivenessEfficacy vs Effectiveness
- 24 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
WHAT IS ROI?Physician Office Example
Return on investment
(ROI)=
Benefits
Costs
• Quality of care
• Error rate
• Patient satisfaction
• Liability exposure
• Investment cost
• Investment time
• Ongoing cost
• Revenue loss
• Physician/staff dissatisfaction
Easier to measure Harder to measure
• Cost saving
• Time saving
• Revenue increase
• Physician/staff satisfaction
Easier to measure Harder to measure
• Quality of care
• Error rate
• Patient satisfaction
• Liability exposure
- 25 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
MAeHC QUALITY DATA WAREHOUSE
1. Breast Cancer Screening 2. Colorectal Cancer Screening 3. Cervical Cancer Screening 4. Tobacco Use # 5. Advising Smokers to Quit 6. Influenza Vaccination 7. Pneumonia Vaccination 8. Drug Therapy for Lowering LDL Cholesterol# 9. Beta-Blocker Treatment after Heart Attack 10. Beta-Blocker Therapy – Post MI 11. ACE Inhibitor /ARB Therapy# 12. LVF Assessment# 13. HbA1C Management 14. HbA1C Management Control 15. Blood Pressure Management# 16. Lipid Measurement 17. LDL Cholesterol Level (<130mg/dL) 18. Eye Exam 19. Use of Appropriate Medications for People w/ Asthma 20. Asthma: Pharmacologic Therapy# 21. Antidepressant Medication Management 22. Antidepressant Medication Management 23. Screening for Human Immunodeficiency Virus# 24. Anti-D Immune Globulin# 25. Appropriate Treatment for Children with Upper 26. Appropriate Testing for Children with Pharyngitis
1. Breast Cancer Screening 2. Colorectal Cancer Screening 3. Cervical Cancer Screening 4. Tobacco Use # 5. Advising Smokers to Quit 6. Influenza Vaccination 7. Pneumonia Vaccination 8. Drug Therapy for Lowering LDL Cholesterol# 9. Beta-Blocker Treatment after Heart Attack 10. Beta-Blocker Therapy – Post MI 11. ACE Inhibitor /ARB Therapy# 12. LVF Assessment# 13. HbA1C Management 14. HbA1C Management Control 15. Blood Pressure Management# 16. Lipid Measurement 17. LDL Cholesterol Level (<130mg/dL) 18. Eye Exam 19. Use of Appropriate Medications for People w/ Asthma 20. Asthma: Pharmacologic Therapy# 21. Antidepressant Medication Management 22. Antidepressant Medication Management 23. Screening for Human Immunodeficiency Virus# 24. Anti-D Immune Globulin# 25. Appropriate Treatment for Children with Upper 26. Appropriate Testing for Children with Pharyngitis
CLINICAL MEASURES FOR PHYSICIAN PERFORMANCEAQA Recommended Starter Set
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WHY DON’T WE JUST LET THE MARKET TAKE CARE OF THIS?
Current system pays for quantity, not quality
Physicians not trained or compensated to reduce fragmentation of care
Few if any incentives to reduce inefficiency, which rations care away from the under-served
No obvious place for consumers to voice their concerns about quality, safety, and protection of privacy
We have a societal interest in how implementation happens
• Bad systems and/or bad implementations offer little, if any, value
• Collective action and public goods barriers will prevent effective interoperability
“In the long run, we’re all dead....”
27
LEVELS OF HEALTH INFORMATION EXCHANGE
Level Description Examples
1 Non-electronic data Mail, phone
2Machine-transportable data
PC-based and manual fax, secure e-mail of scanned documents
3Machine-organizable data
Secure e-mail of free text or incompatible/proprietary file formats, HL-7 message
4Machine-interpretable data
Automated entry of LOINC results from an external lab into a primary care provider’s electronic health record
No PC/information technology
Fax/Email
Structured messages, non-standard content/data
Structured messages, standardized content/data
- 28 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
TECHNICAL STANDARDIZATION IS ONLY THE BEGINNING...
Percent
0
10
20
30
40
50
60
70
80
90
100
Source: Center for Information Technology Leadership, MAeHC calculations
19%
Fax/email
5%
Structured messages
76%
Standardized content
• Technical coordination• Policy coordination• Process coordination• Community coordination
• Technical coordination• Policy coordination• Process coordination• Community coordination
- 29 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
EARLY LESSONS LEARNED...
This can get done on a large scale, and it can get done collaboratively
Building the program is more difficult than originally anticipated
• Fixed cost that we can leverage going forward
The market is shifting – getting attention of vendors somewhat harder than before
Affordability isn’t the only barrier to physician adoption
Starting the conversation creates a community – already seeing synergies
Where are we offering greatest value?
• Funding
• Practice catalyst – facilitators/navigators
• Community catalyst – wholesale vs retail
• Forcing HIE
- 30 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
...SUGGEST SOME LESSONS ABOUT HOW TO EXTEND THE MODEL IN THE FUTURE
Community is an effective level of organization (“wholesale vs retail”)
• Self-defined, cohesive.
• Accept accountability for its members, apply peer pressure, and appeal to local pride
• Efficient to serve logistically
• Natural unit for establishing health information exchange
Central coordination and active intervention are key success factors
• Reduced costs for hardware, software, implementation
• Dramatic reduction in failure rate
• Speedier rollout and recovery of physician productivity
• Application of best practices to realize the systems’ potential
The Golden Rule applies (“whoever has the gold makes the rules”)
• Direct funding increases compliance with best practices, including standardization, structured data capture
• Minimizes “paving over the cow-paths”
• Enables community-wide benefit of HIE
- 31 -Massachusetts eHealth CollaborativeSlide title © MAeHC. All rights reserved.
www.maehc.org
Micky Tripathi, PhD MPPPresident & CEO
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