together for quality making it happen: system fundamentals

1© 2006, Vanderbilt University

Together for QualityMaking It Happen: System Fundamentals

Mark FrisseVanderbilt University

February 7, 2007

This project will result in an automated, inclusive, interoperable, real time HIS and a data driven quality improvement program.

Alabama Medicaid Transformation Grant Application


This presentation

• Is anyone really doing all of this successfully?• What can one learn from other data exchange efforts to

advance the Together for Quality program?• What generic principles can be applied?• Are there examples of “best practices”?• What choices are right for Alabama?• Are there barriers or conflicts associated with each option?

Based on what we know• What is straightforward?• What is challenging?• Where should leadership efforts be focused?


Selected Together for Quality Programs

• Internal integration of HHS systems• Pharmacy management

– Medication history– Prior authorization– Formulary management– Controlled substances

• Clinical programs– High-risk Medicaid patients– Immunizations

• Participants emphasize case managers• Participants include patients, providers….nearly

everyone

Source: Medicaid Transformation Grant Application


Overview

• Statewide electronic health information system

• Links Medicaid, state health agencies, providers, and private payers

• Will provide Medicaid, other HHS agencies, providers, and private payers with secure, real time access to individual health information

– Claims

– immunization records

– prescription data

– laboratory results



Why an interoperable data hub?

• Only a system-wide change can address inadequacies and inconsistencies of patient care

• Establishes a comprehensive quality improvement model for the Alabama Medicaid Program

• Remove duplication• Avoidable emergency room visits• Support creation of a medical home



“Wiring” Healthcare

Hospitals

Primary care physician

Specialty physician

Ambulatory center (e.g.

imaging centers)

Pharmacy

Laboratory

Public health

Current system fragments patient information and creates redundant, inefficient efforts

Future system will consolidate information and provide a foundation for unifying efforts

Hospital

Data Vaults

Health Information Exchange

Network applications

Server

Payers

Labs

Outpatient RX

Physician office

Ambulatory centers Public healthSource: Indiana Health Information Exchange (modified)

Payers


Data Reuse

Data management

Hospital

Data Vaults

Health Information Exchange

Network applications

Server

Payers

Labs

Outpatient RX

Physician office

Ambulatory centers Public health

Data access and use

Hospitals

Physicians

Labs

Publichealth

Payer

• Results delivery• Secure document

transfer• Shared EMR• Credentialing• Eligibility checking

• Results delivery• Secure document

transfer • Shared EMR• CPOE• Credentialing• Eligibility checking

• Results delivery

• Surveillance• Reportable conditions• Results delivery

• Secure document transfer

• De-identified, longitudinal clinical dataResearchers

PayerPayer

Secure Access

Source: Indiana Health Information Exchange


Technical assertions and issues

• A common identifier for Medicaid beneficiaries will be developed

• An overlay that allows agencies to interact at appropriate security levels

• Claims data• Integrated laboratory data from third-party labs• Clinical decision-support tool (pharmacy)• Peer comparisons on patient acuity and outcomes

measures



Sustainability

• A…firm foundation on which to build a permanently funded PDH that will ultimately be supported by primary partners and various funding sources.

• Funding possibilities include both public and private sector funds, membership fees, and access fees from payer groups.

• Identification of additional sources for revenue and the development of a permanent funding plan.



Fundamentals: Patient data hub

Features• Centralized• Medicaid claims

Challenges• Management and oversight• Transparency• Use limitations• Patient involvement• Auditing• Sustainability• Extension – plan and provider “buy-in”

Examples:•Louisiana•TennCare•Indiana•Memphis•New York•Florida


Fundamentals: Reconciliation of HHS Agencies

Features• Efficiency• Multiple uses• Planning• Quality

Issues• Master person index• Access controls• Data mapping• Aggregate data


Fundamentals: Supplemental data

Features• Better immunization records• Controlled substances• Labs – clinical decision support

Issues• Collection of immunization data• Access: controlled substances• Gaining collaboration of clinical labs• Mapping lab results to appropriate patient


Use of data for clinical decision-support

Features• Integration of data for patient care• Profiling• Population care• P4P

Issues• What is covered under HIPAA?• Authorization and authentication• Individual vs. group data• Population data vs. individual use


Interaction with electronic medical records

Features• Practitioners access all data about patient• Data populates hub automatically

Issues• Provider cooperation• Markets – will all “certified” vendors have equal

access?• Vendor integration and cost – who pays?• Data quality and auditing – who is responsible?• Secondary use of data – will it be “sold”?


Solution: Stakeholder Council

Oversight• “Architects and engineers”• Critical examination – now – of major aims and concerns• Development of a roadmap consistent with the aims of

state government and its citizens• Clearly-defined tasks for work groups with time lines• Realistic expectations: focus on Medicaid but address

whether or not the same system – alone or as a central hub – will meet the care needs of everyone in Alabama

• You may need sustained and consistent leadership from senior state officials – not just Medicaid



Solution: Work Groups

Policy • Responsible for the very difficult work of reconciling various interests with the

Together for Quality Agenda. Health care is more than Medicaid

Privacy• Its more than HIPAA; it is about public trust (patients, providers)

Clinical• Must focus on a realistic view of care for individuals and populations

Technical• Must focus on technical limitations, realities. Must help State deal with

“Vendor frenzy syndrome.”• You don’t have to build it all or “own” it – e.g., Medication history

Finance• Must view the Hub as a part of the overall care delivery infrastructure and not

only as a separate entity



Today’s decisions influence tomorrow’s markets

• What will be the role of a non-profit organization fostering exchange?

• How do your decisions influence market choice? Do they lead to innovation or monolithic bureaucracy?

• What is the best way to align state, federal, employer incentives

• What is the ideal infrastructure in terms of technology and intermediaries (plans, PBMs)

• What is the measurable “end game”?• What “portfolio of initiatives” should be developed to

focus on the best solutions for your state?


A regional effort in Memphis

Three-county region that includes Memphis TN; Approximately 1 million residentsSerious community health problemsMajor public hospitalMultiple competing providersThis is not a state-wide Medicaid initiative


A regional effort in Memphis

• Based on real patient data, not claims• Governance through a 501(c)(3) corporation• Participation of major hospitals and clinics• Participation of state and local government• Involvement of the business community• University participation

– Tennessee Tech– University of Memphis (pending)– University of Tennessee– Vanderbilt University

• National collaborators• Cost: $12 million over 5 years


Goal: To understand what the market should be

• Legal / policy framework• Public Health (Robert Wood Johnson grant)• E-prescribing (AHRQ contract expansion)• Quality (AHRQ contract expansion)• Community Action (Robert Wood Johnson; Healthy Memphis

Common Table)• Understanding of emergency department use• Extension to safety-net clinics to strengthen “medical home”

concepts• Technology – Vanderbilt technologies, Tennessee Tech• Retail pharmacy (coming soon)• Commercial vendors (coming soon)


The real opportunity: find alternatives to ED care

This individual had over 40 ED visits to multiple emergency departments within a 7-month periods. Options:- more effective treatment in ED- more effective care outside of ED


What we have not resolved

We believe much more work is required:• Public trust• Provider trust• Appropriate use• Transparency• Auditing and reporting• Identity management• Cost-effective integration with all certified clinical

information vendors• Medicaid vs. future medical markets• Population data use vs. individual care


Links:http://www.volunteer-ehealth.orghttp://www.connectingforhealth.org/http://www.mc.vanderbilt.edu/vcbh/ds/0606_privacy/http://www.volunteer-ehealth.org/frisse/http://www.volunteer-ehealth.org/frisse/frisse-policy-confidentiality/http://www.volunteer-ehealth.org/news/info/2006/09/midsouth-ehealth-alliance-data-sharing.php


Additional slides

Screen shots of current systemData are from a fabricated test data set


We can locate records and allow “opt out


We can show encounter data


Our user interface is based on user feedback


We can now display data across institutions


(Million)

Net Financial Benefit ($ Million)

Net Present Value

Assumptions

Includes only hospital ED benefits

No adverse drug event benefits modeled

No population health or practitioner productivity modeled

Based on data obtained on the core healthcare entities

Deployment schedule is limited initially to EDs and Labor & Delivery; years four and five will extend to all healthcare providers

Inflation and volumes remain constant

The costs to move and support the RHIO data center are not included in the five-year forecasts

The RHIO support desk infrastructure is not established

The average cost for a core healthcare entity for implementation and operation activities is $30,000 per year.

The State of Tennessee and the Core Healthcare Entities realize a higher financial gain when you consider the

different stakeholder contributions.

State of Tennessee

Payback Period = 1.7

Return on Investment = 1.95

Core Healthcare Entities

Payback Period = 0.5

Return on Investment = 17.5

Payback Period (years) = 3.3

-$2.2

$4.6$1.9

-$0.3

$3.9

-$2.2

-$2.2

$4.2

$1.8

$3.5

-$3

-$2

-$1

$0

$1

$2

$3

$4

$5

Yr 1 Yr 2 Yr 3 Yr 4 Yr 5

Project Return on Investment = .56

NPV (based only on urban ED) is $4.2 Million

together for quality making it happen: system fundamentals

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