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A Public Utility for Electronically Exchanging Clinical Information in Central
MassachusettsHealthAlliance Hospital Grand Rounds
March 3rd, 2009
Larry Garber, M.D.
Fallon Clinic Medical Director of Informatics
SAFE Health Principal Investigator
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Agenda
Health Information ExchangesWhat are they?Why do we need them?
Review of SAFE Health project
HealthAlliance Hospital’s role in SAFE Health
Current status of SAFE Health project
The future of SAFE Health
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EMRs are great, however…
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Hospitals don’t easily interface to office EMRs
ERs don’t know your outpatient information30% of ER visits lack important medical
information, half of which are “critical”15% of ER admissions could be avoided if
the ER had outpatient information150,000 preventable ADEs ($8 Billion
nationwide wasted) each year occur at the time of admission due to inadequate knowledge of outpatient medication history
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Hospitals don’t easily interface to office EMRs
Your EMR won’t have ER notes or discharge summaries unless you scan them inOnly 6% of small practice EHR’s are
interfaced to hospital information systems2 million adverse events each year are
due to inadequate communication at time of discharge
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Most offices don’t have lab and imaging interfaces
Costly to interface to lab and radiology systemsOnly 50% of small practice EHR’s are interfaced to lab systems5-20% of lab and x-rays are ordered redundantly because original results can’t be found40% of Prostate Cancer malpractice cases in MA (2002-2007) were due to failure to transmit/receive test results
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Most offices don’t have all of the patient’s physicians in their practice
Visits are split 50/50 between PCP’s and specialistsAverage Medicare patient sees 6.4 different MDs per year25% of prescriptions are not known by the treating physicianPatient data missing 80% of time in one study25% of PCPs lack consult note 4 weeks after outpatient consultation20% of medical errors are due to inadequate availability of patient information
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EMRs are great, however…
Without interfaces to the other parts of the healthcare system,
EMRs will fall short of their goal to improve the quality and
safety of healthcare while reducing costs
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EMRs are great, however…
Each interface costs $5,000 - $20,000 in hardware, software, and consultant time
A small office EMR should have at least:LabImagingHospitalPharmacyOther physician practices?
Interfaces can double the cost of EMRs
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The Solution:
Health Information Exchanges (HIEs)
Rx
Hospital
MD
OtherMD’s
Patients
VNA
DPH
LTC &SNF
Rehab
Payers
Imaging
Lab
HIE
Local Health Information Exchanges
Regional Health Information Organizations (RHIOs)
National Health Information Network (NHIN)
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Health Information Exchange (HIE)
Each organization has 1 interface
Central hub onlyroutes clinical data
Only patient demographic data stored centrally
Rx
Hospital
MD
OtherMD’s
PatientsVNA
DPH
LTC &SNF
Rehab
Payers
ImagingLab
HIE
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Community Portals and Health Record Banks vs. True HIEs
Clinical data stored centrally and viewed through website (portal)
Often can use CCOW to synchronize user and patient context between EMR and portal
Clinicians have to learn to use two systems
Can’t directly use portal data in EMR (e.g. allergies, medication list, immunization history, etc…)
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Personal Health Records (PHRs) vs. HIEs
Clinical data stored centrally
Larger focus on patient access to data (for now)
Less focus on downloads into EMRs or Provider/Ancillary/Payer healthcare transactions (for now)
Over time, the distinctions will blur as HIEs emphasize patient portals, and PHRs/PHPs interface more Providers/Ancillaries/Payers
Patient enrollment is a bottleneck to data flow
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The Benefits of HIEs:
All achieved with MDs using their own EHRImproved coordination of carePCP SpecialistInpatient Outpatient
Improved patient safetyImproved quality of careReduced redundant testingFewer hospital daysFewer adverse events (3% reduction)Better medical history on patients in ER (2%
reduction)
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“I ran out of one of my pills. Not sure which one. I lost my wife’s note… ”
We can know our patients better than they know themselves
Excellent Patient Service
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Other Benefits of HIEs:
Automated public health reporting
Automated bio-surveillance
Quality Measurements/Benchmarks
Facilitates research
Reduces the cost of interfaces
Reduces barriers to adopting EMRs
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Value of National HIE Network
$337 Billion savings during 10-year implementation period
$78 Billion savings each year thereafter:$34 Billion to providers/facilities$22 Billion to payers$13 Billion to reference laboratories $8 Billion to imaging centers $1 Billion to pharmacies $0.1 Billion to Public Health agencies
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Legislation for HIEs - State
MA Health Care Reform Act of 2008$15M for community-based HIEs and EHRsAll hospitals and community health centers
must 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 mannersubmits clinical quality measures
EHR is connected to a Health Information Exchange
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A Public Utility for Electronically Exchanging
Clinical Information in Central Massachusetts
Secure Architecture For Exchanging
Health Information
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Funding for SAFE Health
$1.5 Million Agency for Healthcare Research and Quality (AHRQ) Grant #1 UC1 HS015220 (10/2004 9/2009)
$4.2 Million donated by:Fallon ClinicFallon Community Health PlanHealthAlliance HospitalUMass Memorial Medical Center
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Objective of SAFE Health
Build and operate a health information exchange infrastructure for Central Massachusetts to securely enable real time aggregation and presentation of patients’ health information from multiple different organizations in order to improve patient safety, quality of care, and efficiency of healthcare delivery.
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SAFE Health Architecture
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High Level Design GoalsNo central clinical data repositoryOne central demographic repository (EMPI)Preservation of data and transaction ownershipMinimize duplicate data from multiple sourcesSecure and auditable; Protect patient privacyScalable and high performanceInteroperable with other local health information exchanges and the NHINNo rip and replace – leveraging existing systemsIntegrate seamlessly into varied physician workflowsMinimize cost
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Levels of Participation – current & planned
Portal access – web browser access to display patient informationPractice management system integration – medical summary prints out automatically when patients arrive triggered by ADTEHR integration – One or two-way integration with existing information systems to display patient information while in those systems and supply data to the SAFE Health network. Clinical information supplier– Ancillary systems that receive orders and provide results, or health insurance carriers that only feed patient data to SAFE Health network.
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Privacy and SecurityUser Authentication – performed by each entity
Patient Authorization Opt-in consent for “Pulls”Ordering/Referring/Authoring/CCd provider for “Pushes”Privacy Notice covers “Pushes” as well as release of
demographics to Core Server
Encryption - HTTPS
Audit trails – maintained within each Local SAFE Health server as well as the Core Server
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Patient Opt-in Consent AutomationWhen patient who has been at more than one participating entity, arrives at a participating entity and a consent form hasn’t authorized all of the entities that the patient is registered at yet, a consent form automatically prints on the registration clerk’s local printer.
Consent is to authorize a participating entity to both disclose as well as view patient information
Patients can authorize any or all of the current entities participating in SAFE Health, or they can authorize all current and future healthcare providers in the state of Massachusetts
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Patient Opt-in Consent AutomationPatients can authorize their medical insurance carrier(s) to provide information to SAFEHealth, but these payers can not view information.
Consent only needs to be signed once at one organization to authorized any or all entities
Consent can be revoked from any or all entities for future disclosures and viewing, but past disclosures cannot be revoked.
Patients cannot refuse to participate in the “Push” of results to ordering/referring/ authoring/CCd MD
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Patient Opt-in Consent AutomationAfter the consent form is signed, a clerk clicks on patient’s name in the worklist to acknowledge that form was or was not signed and which entities were authorized, triggering clinical data to be exchanged between these authorized entities and imported into the local EHRs
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Current Status of SAFE Health
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Current Status of SAFE Health
SAFEHealth went live on June 24th, 2009!
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Current Status (continued)
For any patient that presents to the HealthAlliance Hospital Leominster Campus ER or Fallon Clinic Leominster or Fitchburg sites that chooses to participate, regardless of PCP site or health insuranceHealthAlliance Hospital Leominster Campus ER provides Fallon Clinic with ER Summaries
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Current Status (Continued)Fallon Clinic provides visit notes with:Medication ListAllergiesProblem ListImmunization HistoryCode Status and Advance Directive StatusPCP and phone numberVital SignsRecent Lab and Radiology Results
No confidential notes
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What do ER Doctors Want to See?
34 Shapiro JS, Kuperman G, et al. J Am Med Inform Assoc. 2007;14:700–705.
Phase 1
Phase 2
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Future Plans for SAFE HealthIntegration with any hospital, physician practice/group, or other provider in the region that wishes to participateIntegration with any imaging center, reference lab, or other ancillary service in the region that wishes to participateIntegration with any health insurance carrier that is willing to provide patient information to the SAFE Health network
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Potential Physician Concerns
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Potential Physician ConcernsWill I be overwhelmed with too much data?
If the same data comes from 2 sources, will I see duplicates?
Will the data be incorporated into my EHR so I can use it to defend my decisions in court if necessary?
Will the incorporated data be in a discrete data format that matches my EMR so I can do decision support with it?
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Potential Physician ConcernsWill my staff and I be overwhelmed getting consent to use the HIE from each patient?
Will it be too easy for patients to transfer their care to competing practices?
Will it be easier for lawyers to access my records? Can they case-find through the HIE?
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Summary
Clinical data sharing has great potential to help us and our patients with:QualitySafetyEfficiencyServiceImplementation of an EMR
SAFE Health is a low-cost, secure Health Information Exchange for our region
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Questions? www.SAFEHealth.org
Larry Garber, MD [email protected]
Rx
Hospital
MD
OtherMD’s
Patients
VNA
DPH
LTC &SNF
Rehab
Payers
Imaging
Lab
HIE
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BibliographyBates DW, Teich JM, et al. A randomized trial of a computerbased intervention to reduce utilization of redundant laboratory tests. American Journal of Medicine 106(2), 144-50. 1999.Brailer DJ. Connection tops collection. Peer-to-peer technology lets caregivers access necessary data, upon request, without using a repository. Health Management Technology. 22[8], 28-29. 2001.Financial, Legal and Organizational Approaches to Achieving Electronic Connectivity in Healthcare. Connecting For Health, October 2004.Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Annals of Internal Medicine 138: 161-167. 2003. Gurwitz JH, Garber LD, Bates DW, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289:1107-1116. 2003.Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform. 2007 Dec;40(6 Suppl):S40-5. Epub 2007 Sep 7.Overhage JM, McDonald CJ, et al. A randomized, controlled trial of clinical information shared from another institution. Annals of Emergency Medicine 39[1], 14-23. 2002.Overhage JM, Suico J, McDonald CJ. Electronic laboratory reporting: barriers, solutions and findings. Journal of Public Health Management & Practice 7[6], 60-66. 2001.Poon EG, Bates DW, et al. Dissatisfaction With Test Result Management Systems in Primary Care. Arch Intern Med. 164:2223-2228. 2004.Stiell A, Forster AJ, Stiell IG, van Walraven C. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003 Nov 11;169(10):1023-8.The Value of Computerized Provider Order Entry in Ambulatory Settings, Center for Information Technology Leadership (C!TL), April 2003.Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The Value of Healthcare Information Exchange and Interoperability. Hlth Aff (Millwood) 2005 Jan-Jun;Suppl Web Exclusives:W5-10-W5-18.