NH CHI HIT HIE Work Group Scenarios September 10, 2008 Facilitators s2a John K Evans and Camilla Hull Brown 1
What Has Been Accomplished To Date Affirmed the 08/2007 Vision and Principles document Began creating a common level of understanding of the issues Began defining the current environment of HIT & HIE Started understanding what the providers are doing in this space Created open dialogue and information sharing Learned how others are addressing these issues Have not jumped directly to solutions Determined that HIT and HIE development is largely dependant upon hospital initiatives Decided that a repository HIE model is not appropriate Decided there should be a strong consumer focused strategy Created an outline of the report Realized that more time is necessary to fully develop a comprehensive report (added October meeting) 2
What Remains to be done? Develop and initiate a Statewide assessment of HIT and HIE in place and in use Refine understanding of other information neighborhoods in NH Hear more as to what the integrated delivery systems are doing Document the strategies developed to date regarding HIT, HIE, a convener/coordinating group Document the value proposition for health systems, physicians and consumers Clarify legislative approach to HIT/HIE, including issues of privacy and security Begin to prepare a draft report for review and comment 3
AGENDA Intro by Co-chairs and Facilitators 9:00 Update on process through December October meeting Agenda for today Update on hospital survey (Kathy Bizarro) HIT/HIE at the Community Level Dartmouth Hitchcock Medical Center (Peter Johnson, CIO) 9:15 North Country Initiative (Martha McLeod) 9:40 Workgroup Debrief 10:05 Break 10:15 Development of HIE Scenarios (Facilitators) 10:30 Break-out Group 1: HIE Infrastructure Scenario Health System Centric Overview Stages Role of state-wide entity Break-out Group 2: HIE Infrastructure Scenario Connecting Network Neighborhoods Overview Stages Role of state-wide entity Comparison of pros and cons Working Lunch 12:00 Consensus on recommended scenario Closing comments from group 12:45 Adjourn 1:00 4
Timeline June/July August September October November December Vision & Principles Document validation Problem we re trying to solve Education on HIE at the National and state level Efforts of other States NH issues, challenges and initiatives Specific actions taken in Vermont Stakeholder interviews Introduce Network Neighbors Affirm Network Neighbors Core Strategies for NH Develop specific actions needed to realize Core Strategies Develop specific approaches needed with key stakeholder groups: hospital, physicians and consumers Overview of two options to health information exchange (HIE) Hospital/health system based example: DHMC Community based example: North Country Define two scenarios, develop pros/cons Develop scenario or combination of option (s) as best fit for NH Begin to draft sections of report Match option (s) for NH with recommended actions: -HIT -HIE -State-level convenor - Physicians - Consumer -Hospitals Circulate and review draft report Prepare report; refine process based on feedback in September Review and build consensus around draft document and process Again, revise report and process Fine tuning Submit report to the Governor 5
6 Dartmouth-Hitchcock Electronic Health Record Strategies and Issues A Presentation to the HIT & HIE Strategic Plan Work Group September 10, 2008 Peter A. Johnson Chief Information Officer
Presentation Outline Overview of Dartmouth-Hitchcock Information Systems structure and connectivity History of DH clinical information exchange Purpose, security, standards, policies IT strategies in support of the Dartmouth-Hitchcock Mission, Vision and Strategic objectives Issues & Barriers
D-H H Clinical Information Systems Integrated clinical information system (Inpatient, Outpatient, Ancillaries) in place since 1985 DHMC and DH clinics in over 20 sites DH-Concord and DH-Keene currently use two different clinical information systems connected to local healthcare systems No system-wide access to these EHRs New DH system-wide EHR implementation in process over next 3 years Patient portal (viewing of health record and interaction) in place 4 years 15,000 active users (50,000 signed up)
Map of network connectivity
Sharing of Clinical Information CIS Affiliate Way of providing read-only CIS accounts that allow non-dh providers or their staff to view the DH electronic records of the patients who consent to that access. Individual physicians and providers (AIS) Institutions, like hospitals and nursing homes (IAIS ) Physician offices (PAIS) In place since 1995
Dartmouth- Hitchcock Sites Map of sites
Dartmouth- Hitchcock Sites Hospital/ Institutional Sites
Dartmouth- Hitchcock Sites Hospital/ Institutional Sites Physician Practice Sites
Utilization Patients who have signed consent 280,000 patients Participating Institutions 16 hospitals/nursing homes/vnas Participating Physician Practices 143 practices 190 individual providers
Key Components to Success of CIS Affiliate Patient signs written consent authorizing release Consents requested and signed at Affiliate organization Consent form adheres to parameters of NH law NH legal requirements greater than HIPAA Revocable at any time at request of patient Auditing processes in place
16 Information Systems Connection to Mission Vision Goals
Dartmouth-Hitchcock Mission & Vision Dartmouth-Hitchcock Mission We advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time. Dartmouth-Hitchcock Vision Achieve the healthiest population possible, leading the transformation of health care in our region and setting the standard for our nation.
Dartmouth-Hitchcock Goals Provide Patient and Family Centered Care: Unwavering commitment to provide care that is coordinated, effective, efficient, compassionate and safe. Advance Scholarship: Vigorously promote the creation, dissemination and application of new knowledge in support of our Vision. Close the Quality Gap: Lead the way in discovering and closing the gap between the best that can be and where we are today. Attract and Engage Others: Build essential partnerships and convene group and community resources at the local, regional and national levels to achieve our vision. Create Systems that Work: Establish a population based health care system supported by technology and processes that improve health outcomes, efficiency, access and continuity. Build an Empowering Culture: Enable people to attain ever-increasing levels of excellence by establishing environments of continuous learning and accountability. Practice Careful Stewardship: Steadfast dedication to create the highest value given the resources available.
Issues and Barriers Data definitions Standards Resources ($$, people) NH is highly fragmented NH state law higher standard than HIPAA Comprehensive automation is not prevalent across healthcare continuum Reimbursement policies don t incent HIE
20 Dartmouth-Hitchcock Electronic Health Record Strategies and Issues A Presentation to the HIT & HIE Strategic Plan Work Group September 10, 2008 Peter A. Johnson Chief Information Officer
North Country Project: Update Report September 10, 2008 21
Project History April 2007 initial call with NCHC May-Jun 2007 HRSA bid opportunity July 2007 initial survey; low response rate May-Sep 2007 Statewide group developed to focus on HIT/HIE vision and principles Fall 2007 N. Country provider interviews begun; NCHC Board presentation February 2008 Working group presentation 22
Survey Area Ammonoosuc Community Health Services Androscoggin Valley Hospital Coos County Family Health Services Coos County Nursing Home Berlin Cottage Hospital Dartmouth Hitchcock Medical Center (Lebanon) Grafton County Nursing Home Indian Stream Health Center Littleton Regional Hospital Mid-State Health Center North Country Home Health and Hospice Agency Northern Human Services Speare Memorial Hospital Upper Connecticut Valley Hospital Weeks Medical Center Hospital = Primary Site (n=15) 23
120% 100% 80% 60% 40% 20% 0% Exchange Timeframe by Type of Data Exchange Timeframe by Type of Data Not Needed > 2 years 6 to 18 months Within 6 months Already Complete 24 Quality improvement & P4P Regulatory reporting Demographic Data Clinical Chemistry Microbiology, Pathology, Cytology Radiology Results Images Ambulatory Data Problem List Medications Allergies Alerts Immunization Records Admission, Discharge or Transfer
120% 100% 80% 60% 40% 20% 0% Need for Data Exchange by Type of Data Expressed Need for Data Exhange by Type Not Needed Low Medium High Regulatory reporting Demographic Data Clinical Chemistry Microbiology, Pathology, Cytology Radiology Results Images Ambulatory Data Problem List Medications Allergies Alerts Immunization Records 25 Quality improvement & P4P Admission, Discharge or Transfer
Summary EMR/EHR EMR/EHRs are installed in at least: 100% of the FQHCs 1 Nursing Home 5 Critical Access Hospitals 1 Tertiary Hospital 2 Home Health Agencies 26
Summary IP Clinical Apps. Availability of Clinical Applications across CAHs varies, but includes: PACS Lab Scheduling IP Clinical erx Key finding: not all applications within CAHs integrated currently in all facilities 27
Summary Interviews Not exactly sure what defines the N. Country (ie, Plymouth, Concord, Manchester, Lebanon, Maine Medical have roles too) Significant amount of health information exchange taking place today (ie, point-to-point and view access as primary mediums) Desire to move beyond point-to-point and view access exchange Significant number of organizations providing views access into other systems DHMC CIS CAHs and FQHCs for EMR, PACS, IP Clinical Typically one-way High cost of licenses could help pay for HIE 28
Summary - Interviews Recognition that longitudinal health record is the end point Desire to be more efficient Desire to improve clinical quality Privacy and security Multiple applications for providers to learn Federated architecture model most appealing 29
N. Country Exchange Priorities Laboratory Radiology Problem lists, meds and allergies Universally Top 3 Admission, discharge, or transfer Demographic Quality improvement Universally Bottom 3 30
Governance Universal support for an impartial, 3 rd party as the governor of the exchange Partnering with other exchanges was considered favorably Questions about DHHS as exchange Concern over DHMC given market share Connectivity to statewide effort important Governance is linked to sustainability 31
Governance Many options floated: N. Country goes it alone either as a full region or a sub-region N. Country partners with DHMC DHMC becomes the exchange DHHS becomes the exchange Independent entity developed Partnership with ME, VT, MA Other. 32
Financing IT spending ranked extremely high as overall organization priorities The HIE needs to show some level of ROI, but non-tangible benefits are also understood Expected that clinical messaging would be largest savings Desire for grants or state seed funding Business model for sustainability needs clarity Partnering with other states may make sound fiscal sense Much benefit accrues to payer; how to involve them 33
2007 Health Information Exchange Activities Northern New Hampshire Hospitals and Clinics Current data exchange Current data inquiry Upcoming data exchange Desired data exchange Fax or paper From To Ammon. Community Health FQHC Androscoggi n Ammon. Community Health FQHC Centricity CPM 2004 Androsco ggin Meditech Magic no EMR COOS FQHC Centricit y v5.6 EMR Immun COOS Nursing Home None Cottage Hospital HMS, MedHost, PACS PACS Lab Transcpt ED data Grafton Nursing Home American Healthcare Indian Stream FQHC Elect. Health. Systems Littleton Regional Hospital eclinical Works, CPSI for schedule, McKesson or Meditech for IP PACS Transcpt The Memorial Hospital Northern Human Services Upper CT Valley Hospital Weeks Medical Center None CPSI eclinical Works and McKesson Paragon, upcoming PACS White Mt FQHC COOS FQHC Lab EMR for their pts PACS 34
Upper CT Valley Hospital Laboratory Androscoggin Valley Hospital Laboratory DHMC CIS Indian Stream FQHC Coos County Health Center Other: Grafton County Nursing Home Weeks Medical Center Laboratory Cottage Hospital Laboratory Pemi-Baker Home Health Care Littleton Hospital Laboratory North Country Home Health and Hospice Coos County Nursing Home Laboratory Speare Memorial Hospital Ammonoosuc FQHC MidState Health Center Commercial Laboratory SureScripts / RxHub EDI Planned/Desired View Access Planned/Desired 35 Southern Hospitals
North Country Project: Update Report September 10, 2008 36
Transition Slide to Break Out Group Session 37
The Challenge HIE Infrastructure Assumption: General consensus around need for HIT support; not agreement on HIE infrastructure approach. Challenge: How do you grow the HIE infrastructure given: There are three levels of HIE infrastructure Health system Community-wide Cross-community Many health systems are heavily invested in data exchange within their own systems? Several regions, providers and systems are outside this flurry of activity? 38
Transition to HIEs Slide by IHIE Point to Point Interfaces Health Information Exchange Model Laboratory Pharmacy Payors Hospit als Public health Primary care physician Ambulatory center (e.g. imaging centers) Specialty physician Laboratory Pharmacy Payors Hospitals Health Information Exchange Public health Primary care physician Specialty physician Ambulatory center (e.g. imaging centers) 39
Levels of Data Exchange in an HIE Health system level Data exchange within an affiliated system Community level Data exchange across systems and other providers within a community (connecting network neighbors) Cross-community level Data exchange between providers in different communities 40
Health System HIE Infrastructure Granite Physician Owned Practices Granite Surgi-center Granite Clinic Granite Nursing Home GRANITE HEALTH SYSTEM Granite Hospital North Granite Hospital South Granite Imaging Center 41
Network Neighbors in a Health Information Exchange 6/28/2008 Event Name 2 42
CROSS-COMMUNITY HIE INFRASTRUCTURE NATIONAL HEALTH INFORMATION NETWORK - CONCEPT NH Other HIE HIE NH HIE Other State or regional HIEs 43
Two Scenarios HIE Infrastructure Health System Centric Model Focus on health system data exchange before moving on to community-wide and then cross-community data exchange Focus on formal affiliations Infrastructure EMR adoption IT infrastructure end result eventually data exchange within a system, within a community, and across communities Consistent with state-level role of convener and coordinator Organic Growth Model Focus on where the need is greatest (e.g. North Country) and provide what is needed irrespective of whether it is health system, community or cross-community level Focus area driven by results of gap analysis and areas of commonality within communities Same as other model EMR adoption End result IT infrastructure State-level role 44
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Scenario Comparisons Approach to Growth Local Health System Centric Build on heavy investment by health systems IT investment driven by health system specific needs Focus on going deep with EMRs in early years within health system affiliations Build state-level infrastructure in later years after health systems and community data exchange are on their way Organic growth Focus on areas where there is the greatest community-wide need IT investment and starting point for HIE driven by community-wide needs Need to come to consensus on the IT infrastructure early Focus on low cost, high state-wide user access to electronic tools (e.g. clinical messaging and inquiry) 46
State-level HIE Infrastructure Both Scenarios Standards for data exchange Investments driven by gap analysis outcomes Higher initial investment in HIT than HIE Higher initial investment in HIE than HIT Priorities established for data to be exchanged Statewide provider e-inbox, one Master Person Index (MPI) and Record Locator Service (RLS) High provider input to specifications/vendor selection Address connectivity with non-nh based HIEs Health System Centric YES YES YES NO By health system Developed in later phases YES By health system Organic Growth YES YES NO YES By state-wide entity Developed in early phase YES By state-wide entity 47
Role of State-level Entity Same for both Scenarios Establish standards for data exchange and privacy & security Engage consumer Provide resource center for HIT adoption Provide incentives for HIT adoption Mobilize communities to focus on population health, quality improvement Provide legislative mandates for participation in HIE 48
Group Break-out Focus What are the pros and cons of the scenarios? Politically Economically (investments/costs) Access within a community and across communities Adoption Competitiveness Interoperability Timing of developing regional data exchange services Governance Sustainability Privacy and security Population health/clinical care Other Is there a hybrid solution? 49