Health Information Exchange and the National AgendaHealth Information Exchange and the National Agenda

May 2008May 2008

Kelly CroninKelly CroninDirector, Programs and CoordinationDirector, Programs and CoordinationOffice of the National Coordinator for Office of the National Coordinator for Health Information Technology (ONC)Health Information Technology (ONC)

2May 2008

HIE and the National HIT Agenda

• Where are we?• Challenges • Overcoming the barriers• Moving toward a connected network of networks – the

NHIN– Trial implementations– Accreditation and certification

– Develop the business case • Where do we go from here?

3May 2008

Key Health IT Components to Enable Transformation

• Electronic Health Records (EHR)

• Personal Health Records (PHR)

• Population Health Information (Public Health, Quality Improvement, Research)

A Robust, Interoperable, Health IT Environment that brings together:

• Standards (Data, Technical and Security)

• Interoperable Health Information Exchange Network (Nationwide Health Information Network - NHIN)

Governance

Pieces of the Puzzle Necessary for Transformation of Health and Care through HIT

Privacy & Security Policies

Standards in HITProducts

Nationwide Health Information

Network

Adoption of Interoperable

Health IT

5May 2008

Status of HIE – Findings from eHI Survey

• 125 initiatives reported on stage of development in the 2007 survey– 20 are just getting started (stage 1 or 2)– 68 are in the process of implementation (stage 3 or 4)– 32 are operational (stage 5, 6 or 7)– 5 are no longer moving forward

• 15% fewer participating than in 2006• 32 HIEs exchanging data (Stages 5-7)• 25% dependent on grants (or don’t know)• 75% rely on results delivery (but other sources important as

well)

6May 2008

Funding Sources for RHIOs in 2007

Funding Source Overall Advanced

Hospitals 24% 58%

Public Payors 21% 38%

Physician Practices 16% 46%

Laboratories 13% 33%

Private Payors 10% 46%

Philanthropic 9% 29%

7May 2008

Services Offered in 2007

Service Overall Advanced

Results Delivery 30% 75%

Clinical Documentation 27% 63%

Enrollment or Eligibility Checking 26% 54%

Consultation/Referral 21% 54%

Alerts to Providers 19% 48%

Disease or Chronic Care Management 18% 32%

Disease Registries 14%

QI Reporting for Clinicians 12%

Reminders 12% 33%

8May 2008

32 Operational Initiatives: Sources of Revenues

Funding Source 2007 2006

Hospitals 58% 54%

Payers – Private 46% 19%

Physician Practices 46% 33%

Payers – Public 38% 18%

Laboratories 33% 42%

Federal Government 29% 17%

Philanthropic Organizations 29% 21%

State or Local Government 21% 26%

Purchasers/Employers 17% 0%

Pharmacies 13% 11%

Pharmaceutical Companies 4% 6%

9May 2008

State Level HIE - An Evolving Landscape

4. Operating

3. Early Implementation

2. Foundational

1. Early Planning

(RI)

(DE)

(CT)

State/Regional Contracts (6)

Medicaid Transformation Grants – HIE/EHR focus (15)

NHIN Trial Implementation (9)

10May 2008

Major Challenges for All HIE Initiatives

Challenge 2006 2007

Developing Sustainable Business Model 88% 91%

Securing Funding 88% 80%

Defining Value for Users of the HIE 89% 81%

Privacy 79% 85%

Engaging Clinicians 80% 82%

11May 2008

Challenges: Sustainability of HIE

• No silver bullet to get to viable business model

• Need to be market savvy and develop HIE services that meet a customer need and deliver value

• No obvious demand for HIE with current reimbursement system

– But an increasing number of RHIOs are in the red

– Successful RHIOs are inducing demand by providing services that demonstrate value

– Know your customer – don’t build it and expect they will come

– Need business acumen and good market research to develop a viable, marketable services

• Social capital is essential for effective governance and sustainability

12May 2008

Challenges: Value Proposition

• Needs to be defined according to type of service and from each stakeholders perspective– i.e., results reporting for hospitals

• Are the costs and benefits of each function/service for each stakeholder different at a regional and state level?– Some providers, employers or plans might only have a

regional interest

• Data suggests that hospitals are deriving value more often than other stakeholders

• Employers seem least likely to be engaged

13May 2008

Value from a higher level perspective

Health information exchange can:–Produce cost savings from decreased redundancy

• In duplicated care

• In the costs of data sharing

–Enable quality improvement and Medicare payment reform by making clinical (not just claims) data available for performance measurement and reporting

–Support public health and emergency preparedness including situational awareness and response management

14May 2008

What is the problem we are trying to solve?

Market forces have not realized the potential of electronic health information exchange

– Fee for service payment system provides no incentives to share data

– Cost savings don’t accrue to those who need to invest

– Proprietary, one to one, relationships are easier to create technically and legally

– Public health does not get the data it needs – it’s viewed as a government, not a private sector responsibility

– The tipping point for participating in data exchange has not been achieved

15May 2008

Different models for exchanging health information

Network Type

ExamplesExample Benefits

Biggest Challenge

Organizational

Integrated delivery systems, hospital chains

Effort of exchanging data

internally is aligned with

business outcomes

Extra-organizational exchange is needed for care provided in other organizations

GeographicRHIOs,

jurisdictional HIEs

Non-proprietary exchange

Struggle to achieve sustainable business

models

Personally Controlled

Health data banks:

Microsoft, Google, Intel

Consumer access to, and

control of, health information

Based on point to point connections, have challenges in

supporting provider data access

16May 2008

Collaborative Governance Needed Across Jurisdictions

• With varying approaches to HIE, multi-stakeholder governance is needed at the regional, state and national level

• There is currently no coordination of HIE governance across jurisdictions to eventually reach interoperability on a technical and policy level

– Some state level governance entities coordinate with RHIOs but not all– No explicit coordination exists between national and state level governance– National governance has been informal through AHIC and Secretary

Leavitt’s leadership

• No oversight mechanisms exist to ensure accountability of HIE – State governments are increasingly interested in accountability and

mechanisms to protect consumers– Accreditation and model data sharing agreements could support trust among

stakeholder involved with HIE and protect consumer interests

17May 2008

Some Solutions to Challenges

• Improve business case at regional, state and national level– Stakeholder specific value propositions

– State and federal policy changes • Advance governance of HIE

– Establish national level governance– Promote effective governance models at state level– Consider oversight mechanisms such as accreditation to

support interoperability of policies/data sharing agreements

• Identify and adopt common standards and specifications for health information exchange

18May 2008

Where are we going?

• What projects and efforts are advancing HIE?

19May 2008

State-level Health Information Exchange Consensus Project

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

• State-level HIE governance entity is a public-private partnership entity

• Sits between state government and the health sector and industry• Involves state government, but independent of state government• Addresses public and private sector interests, blends investments• Mechanism for coordination of HIE policies and practices

• 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

20May 2008

State-level HIE Leadership Forum

• In 2008, a forum will be established for all states to share information among peers who are responsible for leading state level efforts to advance HIE

• Enable peers to learn from each other and share progress, challenges, and creative ways to advance statewide agendas

• The forum will foster better understanding and coordination of many related but separate projects to advance HIE including HISPC, HITSP, NHIN, CCHIT, and AHIC 2.0

21May 2008

State Alliance for e-Health

• Examination of Financing, Accountability and Oversight Models to Sustain Health Information Exchange

– To inform Governors and State Legislators about the various models for financing and ensuring accountability

– A key financial consideration: appropriate role for states in providing oversight and support

– Final report to the Alliance in August 2008

22May 2008

The AHIC Successor – Why Change?

• Continuity of leadership is needed to sustain the momentum gained over the past 24 months– Government transition occurs every four years– Uncertainty under new leadership places momentum at risk

• Sustainable business model is needed to support perpetual operation– Congressional appropriations are a cyclical model

• Decisive action is needed keep pace with large scale innovation and transformation– Government is necessarily a deliberate process

23May 2008

AHIC 2.0 – What It Will Do…

• Provide continuity -- accelerate and coordinate current AHIC interoperability initiatives

• Provide strong leadership in– determining priorities– harmonizing interoperability standards– certifying products and systems to those standards

– overseeing and facilitating the NHIN– establishing criteria for assuring interoperability, privacy and

security

• Construct and champion a balanced view – that takes into account the needs of all stakeholder groups

24May 2008

NHIN Trial Implementations

• Awards to 9 state & regional Health Information Exchanges (HIEs) and another 6 grants to other entities

• Forming the NHIN Cooperative to implement, test, and demonstrate core services by September 2008– Support of consumer access controls

– Lookup and retrieval of clinical information

– Exchange of patient summary records

• Test implementations of the first 7 priority scenarios– Lab result reporting ; medication history exchange; quality and

public health, etc.

• Expanding to include other types of HIEs, such as – Multi-community Integrated Delivery Systems

– Health plans

– Health data banks

25May 2008

NHIN Business Model

• Contract awarded to nine HIEs for trial implementations of inter-HIE connectivity

• Contract requirement to develop business model• Emphasis on HIE-to-HIE sustainability. Considerations

may include:– What are the business drivers for inter-HIE connectivity?– Sourcing of core services (in-house, outsource, some services

being provided by a state-level HIE, etc.)– Costs to obtain core services – Source of funds for start-up costs and ongoing funding options– What is the value proposition for each participant in the

transaction?– How does cost and benefit distribution work for a transaction that

has participants residing in more than one HIE?

26May 2008

Other Federal Activities Addressing Sustainability

• Six state HIE initiatives with State and Regional Demonstration Project contracts from AHRQ are informing business model development using the eHI Value and Sustainability Model

• AHRQ sponsored case studies of stakeholder engagement in HIEs and the impact on sustainability

• Thirteen state Medicaid agencies are using their Centers for Medicare and Medicaid Services Medicaid Transformation Grant awards to advance HIE efforts within their states.

• State-level HIE Consensus project will address the Value Proposition for each Stakeholder participating in a state-level HIE

27May 2008

Important Next Steps to Advance Sustainable HIE

• Coordinated research agenda– NGA, eHI, AHIMA, HHS, and other partners work together to

answer key questions• State and federal policy development to support sustainability

– Commonwealth report called for mandates for providers to participate in interoperable networks

• AHIC 2.0 established - national governance• State Forum established to facilitate state level approached to

HIE governance

28May 2008

Health IT is a key enabler for us ALL to get:

The Ultimate Reason for Health IT

The quality of health we want and deserve

The quality and value of health care services we demand

29May 2008

For More Information:For More Information:

www.hhs.gov/healthitwww.hhs.gov/healthit