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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
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2
Agenda
Health Information Exchanges
Review of SAFE Health project
Review of NEHENThe Massachusetts State HIE
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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)
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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
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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
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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)
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A Public Utility for
Electronically ExchangingClinical Information in Central
Massachusetts
Secure Architecture For Exchanging
Health Information
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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.
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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.
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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
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Fallon Clinic
Payers
Other
Mass
Providers
HealthAlliance ER
SAFEHealth Setup� EMPI pre-populated
�
Edge servers pre-populated
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Fallon Clinic
Payers
Other
Mass
Providers
HealthAlliance ER
New Patient Registers in ER� ADT to SAFEHealth
�
SAFEHealth assesses consent status
ADT
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Fallon Clinic
Payers
Other
Mass
Providers
HealthAlliance ER
No Consent on File� Consent prints next to registrar
�
Patient added to portal workqueue
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Fallon Clinic
Payers
Other
Mass
Providers
HealthAlliance ER
Patient Signs Consent� Registrar enters into Consent Portal
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Fallon Clinic
Payers
Other
Mass
Providers
HealthAlliance ER
Patient Signs Consent� Registrar enters into Consent Portal
�
Consent status synchronized� Authorized clinical data
synchronization
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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New England Healthcare
Exchange Network
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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
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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.)
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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
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
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
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
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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
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
Server
Interface Engine,
Portal or
Direct Interface
Interface Engine,
Portal or
Direct InterfacePrinter
Fax
Server
HIE Boundary
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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
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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
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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
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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
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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
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Statewide HIE for
Massachusetts
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Governance Structure and Elements of
Public/Private Collaboration
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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
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40
Network of
Networks
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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
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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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Financial, Legal and Organizational Approaches to Achieving Electronic Connectivity inHealthcare. Connecting For Health, October 2004.
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Gurwitz JH, Garber LD, Bates DW, et al. Incidence and preventability of adverse drug events
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