Health Information Exchange: Value, Incentives, and How to get

Health Information Exchange: Value, Incentives, and How to get there. David C. Kendrick, MD, MPH Asst. Provost for Strategic Planning, OUHSC Medical Director for Community Medical Informatics OU School of Community Medicine Greater Tulsa Health Access Network

Agenda HIE Ongoing benefits: Value aside from ARRA – Financial – Clinical New, one-time opportunities: ARRA Incentives in Oklahoma Terms How do we get there?

2007 COMMONWEALTH FUND Report State Scorecard Summary of Health System Performance OK

2009 State of the State’s Health Summary

Oklahoma is the only state where the death rate has gotten worse . 1,050 Some Factors 1,000 1. 950 Age-adjusted Death Rates 2. 3. 900 Tulsa US 4. 5. 6. 850 800 1980 1985 1990 1995 Past 25 Years 2000 2005 Economic downturn healthy people and jobs left Oklahoma Poverty remained Heart Disease – (Diabetes) Cancer Access to Care Obesity

Current Situation Hospitals (inpt) Rx ER/UC Payers Demographics Medical claims Pharmacy claims Case mgmt records Patient Safety Net Clinics and community agencies Imaging Doctor offices EHR Claims Rx Case mgmt Communit y outreach Other PCPs Labs Manual connection (mail, fax) Electronic connection Specialists Ancillary care PT/OT/Aud/Diet Public Health

What’s the value of HIE? 2004: Harvard Center for IT Leadership published a report on the value of health information exchange 77B in annual savings through Health IT Prompted, in part, the creation of the Office of the National Coordinator for Healthcare IT (ONCHIT), the Health IT “Czar” 2006: GKFF commissioned an OK-specific evaluation of the value of HIE

Motivation Clinicians have incomplete knowledge of their patients – Relevant patient data not available in 81% of ambulatory visits – 18% of medical errors that lead to ADEs due to missing patient information. Tang 1994 Leape JAMA 1995 Medicare patients see an average of 5.6 different providers each year 5.6 silos of data What is the value of HIE for Oklahoma?

HIE Expert Panelists David Brailer, MD, PhD – Santa Barbara County Care Data Exchange, Health Technology Center William Braithwaite, MD, PhD – Independent consultant, “Dr HIPAA” Paul Carpenter, MD – Associate Professor of Medicine, Endocrinology-Metabolism and Health Informatics Research, Mayo Clinic Daniel Friedman, PhD – Independent public health consultant Robert Miller, PhD – Associate Professor of Health Economics, UCSF Arnold Milstein, MD, MPH – Pacific Business Group on Health, Mercer Consulting, Leapfrog Group J Marc Overhage, MD, PhD – Regenstrief Institute, Associate Professor of Medicine, Indiana University Scott Young, MD – Senior Clinical Advisor, Office of Clinical Standards and Quality, CMS Kepa Zubeldia, MD – President and CEO, Claredi Corporation

HIE Value Construct Public Health Agencies Payers Pharmacies Providers Hospitals Clinical Laboratories Radiology Centers Other Providers

HIE Value Construct Avoided ADEs, drug utilization savings, automated transaction sets Public Health Agencies Payers Avoided redundant tests, Electronic test ordering and results delivery Pharmacies Providers Hospitals Clinical Laboratories Electronic referrals, consultation letter delivery, chart requests Electronic submission of reportable conditions and vital statistics Electronic Rx, refills, interaction checking, adherence data Radiology Centers Other Providers Avoided redundant imaging, Electronic imaging ordering and results delivery

Value to Oklahoma Public Health Agencies 1.5 Payers 136 16 Pharmacies 1.5 127 10 Providers Provider Hospitals 141 116 Clinical 123 Laboratories 39 99 39 Other Providers Millions Radiology Centers

Value by Stakeholder: Oklahoma Public Health Agencies 1.5 Payers 136 16 Pharmacies 1.5 127 10 Providers Provider Hospitals 141 116 Per Adverse Drug Event (ADE) Clinical Results Physician 39 Clinical Preventable 8.9 123 ADEs Avoided Laboratories Preventable life-threatening ADEs 0.59 Avoided 39 Avoided ADE-related visits 5.6 Other Providers 0.82 Avoided ADE-related hospitalizations Millions Oklahoma Radiology 25,000 99 Centers 1,700 16,000 2,300

Net value of HIE Tulsa: Oklahoma City: Oklahoma: Benefit Cost Net Value Implementation Years 1-10 1.6 Billion 0.7 Billion* 0.9 Billion Annual, Steady-State Starting Year 11 250 Million 42 Million* 210 Million Benefit Cost Net Value Implementation Years 1-10 2.0 Billion 1.1 Billion* 0.9 Billion Annual, Steady-State Starting Year 11 310 Million 71 Million* 240 Million Benefit Cost Net Value Implementation Years 1-10 6.4 Billion 2.7 Billion* 3.7 Billion Annual, Steady-State Starting Year 11 990 Million 160 Million* 830 Million *Software as a service, Cloud computing, and Interoperability standards have lowered the cost of implementation and maintenance by an order of magnitude

But wait, there’s more . . . CMS and Medicaid Incentive payments for “Meaningful use of an EHR”: – 44,000 to Medicare providers, 63,000 to Medicaid – Formula-driven bonus to hospitals: 2-11M per hospital What does this mean to OK? – Assume 9,000 MD’s, DO’s, PA’s, NP’s are eligible – Assume the following hospital bed distribution: Less Than 50 From 50-199 From 200-399 400 or more 146 Facility 80 51 9 6 STATE TOTALS Admissions Beds 51,060 2,074 146,885 4,595 223,154 2,555 157,088 3,250 578,187 12,474

CMS wants EMR and HIE adoption . . . *Assume N 9,000 MDs, DOs, PAs, and NPs focused 30% of the time on Medicare patients, and 12,474 hospital beds

National: Meaningful Use guidance In order to qualify for bonus payments (and avoid penalties) – By 2011, the following must be exchanged: Doctors: Problem lists, medication lists, allergies, test results Hospitals: Discharge summaries, procedures, problem lists, medication lists, allergies, and test results – By 2013, the following must be exchanged: Doctors: Share all care transition data across the community electronically Hospitals: Share all care transition data electronically

HIE Progress to date Early summer: Small working group met and produced a document: – Outlined 14 “Items for consideration” July 30th: Major stakeholder’s meeting. 35 people – Reduced “Items for consideration” from 14 to only 3: Meet requirements established by Federal legislation for funding Establish planning process, including HIT Policy Committee Identify the State Designated Entity – Agreed that OHCA could be the temporary custodial State Designated Entity until the planning process is complete or October 16, whichever comes first. August 14: OKHITECH Summit held, wide invitation list, comments and feedback sought August 14-21: Online comment period August 20: State HIE Cooperative Agreement Program (SHIECAP) Released

State HIE Cooperative Agreement Program (SHIECAP) Governor must identify State Designated Entity Each applicant must have a State Coordinator for Healthcare IT Focus: State Strategic Plan and Operational Plan States without plans can spend as much as 6 months on a planning process Applicants who fail to submit acceptable plans will be subsumed into other nearby states

State HIE Cooperative Agreement Program (SHIECAP) Approval: Merit-driven Funding: (mostly) Formula-driven – 4M base for 50 successful applicants – Additional funding up to 36M per applicant apportioned thusly: applicant region‘s population (5%), number of PCPs (40%), Acute Care Hospitals (30%), and Medically Underserved and Rural Providers (25%). A final 10% of the total funds will be apportioned based on an assessment of the relative HIT need of the region, as determined by evaluation of the Letter of Intent. – Oklahoma’s likely take: 6-8M

Deadlines and current status September 11: Letter of Intent Due – State Designated Entity- Done, at least temporarily – Review of existing capabilities statewide – Report of total expenditures to date in 5 key areas October 16: Final application due – Details of planning process – Key individuals identified to execute the process December 15: Award announcements January 15: Work begins

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