INTEGRATING HEALTH CARE
INTEGRATING HEALTH CARE THROUGH INTEGRATED
THROUGH INTEGRATED INFORMATION
K
Kenneth W. Kizer, MD, MPH
th W Ki
MD MPH
California HIE Stakeholder Summit
Sacramento CA
Sacramento, CA
May 8, 2013
Presentation Preview
 Provide an update on California Health e‐Quality (CHeQ) activities
Review ongoing work
Note some new activities about to be launched
 Provide a preview of some ways that we are planning to use HIE to improve population health 2
What is the problem we are trying to fix?
 Modern health care has become one of the most information‐intense and knowledge‐based activities that human beings have ever engaged in
that human beings have ever engaged in
 Health care and health care information has become highly fragmented because of the
highly fragmented because of the
Explosion of biomedical knowledge and technology
Increased medical specialization and sub‐specialization
Increased prevalence of chronic conditions Increased complexity of care
 As a result, the quality of health care is insufficient and costs increases are unsustainable 3
California Health eQuality ACTIVITIES
CHeQ Mission and Strategic Objectives
 Mission
– Promote coordinated and integrated care by catalyzing health i f
information exchange
ti
h
 Strategic Objectives
Strategic Objectives
– Improve integration of care and health outcomes by mobilizing information needed for health‐related decision making – Demonstrate measurable impact within the ARRA funding D
t t
bl i
t ithi th ARRA f di
period while laying a foundation for future growth and sustainability
– Create a trusted environment for clinicians to exchange C t t t d
i
tf
li i i
t
h
information supporting local autonomy
– Integrate HIE with similarly aimed health care reform initiatives
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Trusted Exchange Infrastructure
$1 million
Integrating Clinical Care with Public Health
Increasing Public Health
Public Health Capacity
$1 8 million
$1.8 million
$0.7 million
California
Health eQuality
$16.6 million
Accelerating HIE Accelerating
HIE
Adoption
Federal HIE Funds
Federal HIE Funds
Monitoring HIE Adoption
$4 million
$0.9 million
$0.9 million
Communications and Education
$0.6 million
Personnel $4.1 million
Operations $1 million
Indirects
$2.5 million
CHeQ Activities – National, Statewide & Local
 National activities: promoting standards
Trust environment
P id di t i
Provider directories
HIE Ready
New LOINC mapping  Statewide public health activities
Immunization gateway service
Project INSPIRE
 Regional and local HIE investments
Six programs focusing on infrastructure, interface implementation, Six
programs focusing on infrastructure interface implementation
new data analytics, new coordination in the greater LA area, new rural health initiative, new California Blue Button ® initiative®
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National Activities: Promoting Standards
National Initiative: Create a Trust Environment
Goal: Create an environment that protects health information privacy and promotes f
p
y
p
exchange of health information between and among organizations and across political j i di ti
jurisdictions.
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Trust Environment: The “4 Knows”
2. Know who you are talking to
– Provider Directories
Provider Directories
4. Know you have consent to have the conversation
– Patient consent management
nexxt
steps
3. Know who you are talking about
– Patient matching
current aactivities
1. Know your conversation is secure
– Trust Communities
ONC refers to these concepts as “Scalable Trust”.
10
Creating Trust Communities: Problem
 Community, enterprise HIOs create Community enterprise HIOs create
information stovepipes.
 Thousands of point‐to‐point data sharing agreements between organizations are not practical nor affordable on a statewide or ti l
ff d bl
t t id
national level.
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Trust Communities: Solution
 Create Trust Communities based on
 a common set of polices and practices,
 a multiparty sharing agreement, and
 a simple technical framework.
 W
Western States Consortium created the nation’s first Trust t
St t C
ti
t d th
ti ’ fi t T t
Community; under pilot November 1, 2012
 ONC now promoting Trust Communities as the preferred
method for inter‐organizational trust
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 California participated in creating a consensus national technical standard in March 2013 and that has entered pilot testing
 California adopting model for inter‐HIO exchange in pilot program this summer
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Provider Directories: Problem
 No way to discover exchange methods with y
g
a provider. “What is Dr. Smith’s Direct address?”
 No way to ensure the identity of an exchange partner. “How do I know this is h
t
“H d I k
thi i
really the right Dr. Smith?”
13
Provider Directories: Solution
 Create a searchable, federated Provider Directory that
 Is maintained by HIOs, clinics, hospitals with provider relationships so data is correct
relationships so data is correct  Establishes provider identity
 Identifies how to exchange data with individuals or organizations
 Western States Consortium (California and Oregon) entered production in April.
 ONC recognized the importance of California
ONC recognized the importance of California’ss approach and approach and
is creating a national standard for Stage 3 certification.
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 California planning pilot program for inter‐HIO exchange this Summer.
 WSC transitioning to National Association for Trusted E h
Exchange (NATE)
(NATE)
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National Initiatives: Promoting Standards
nextt
steps
 LOINC Mapping Assistance
 Logical Observation Identifiers Names and Codes (LOINC) is a
Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations
 Preparing clinical laboratories to meet Stage 2 Meaningful Use requirements
curren
nt activities
 HIE Ready
 Uses existing standards to promote transparency  Reduces the need for creating interfaces
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HIE Ready: Problem
 Stage 1 Meaningful Use doesn
1 Meaningful Use doesn’tt actually actually
promote standards for interoperability. Stage 2 still has gaps.
 Too expensive to custom‐develop interfaces each time.
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HIE Ready: Solution
 Create HIE Ready, a set of interface capabilities
 Based on standards in current products vs. future plans;
 Bundled with a single price so they are easy to buy; and
 Published as side‐by‐side comparison so buyers are informed.
 Published the first Buyers’ Guide in November 2012.
 Currently have 13 participants with many more interested.
 ONC and several states interested in joining or encouraging their vendors to participate.
 Vendors now bidding HIE Ready pricing.
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 All Rural Incentive Program service providers are HIE Ready.
 Planning version 2.0 for Summer 2013 to align with Stage 2 MU
MU.
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HIE Ready Buyers’ Guide
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New National Standards Initiative: LOINC Mapping
Problem – Providers must receive and incorporate lab results using LOINC terminology in Stage 2 MU
– Clinical laboratories are not yet ready and do not Clinical laboratories are not yet ready and do not
receive incentives
Solution – Create the LOINC Mapping Assistance program to
 convert high‐volume, independent and hospital labs to LOINC terminology
gy
 produce materials and tools so they can maintain them
Key – Partnering with California HealthCare Foundation
Advances – Will recruit first labs this Summer
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S
Statewide Public Health Activities
id P bli H l h A i i i
State Initiatives: Expanding Public Health Capacity next
stteps
2. INSPIRE
 Advancing workflow and standards for breast cancer reporting
 Creating a “health information home” for high impact conditions starting with cancer
high‐impact conditions, starting with cancer
 Exploring how the “health information home” can be used by providers for population health management
curre
ent activitties
1. Immunization Gateway Service
 Streamlining the process to register for reporting and test interface capabilities
reporting and test interface capabilities
 Increasing the capacity to receive reports
3. Open Library of HIE Project
 Creating an online ecosystem of ARRA funded work products to be shared and reused
work products to be shared and reused
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Immunization Gateway Service: Problem
 Immunization
Immunization reporting is part of Stage 1 & 2 reporting is part of Stage 1 & 2
Meaningful Use
 California (like most states) lacks the capacity to meet current provider demand for
to meet current provider demand for information. Providers forced to ask for waivers for MU
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Immunization Gateway Service: Solution
 Create Immunization Gateway Services
 automates portions of registration using an online portal
automates portions of registration using an online portal
 streamline testing by validating test messages
 receives ongoing reports and route them to the correct regional registry
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 Prepares for CAIR 2.0
 Established a strong collaboration between state CDPH, g
,
regional CAIR registries, CHHS, CHeQ and STC (vendor)
 Completing extensive testing in CDPH’s IT environment in
Mayy
 Starting pilot submissions in mid‐May
 Enabling submissions for all providers in June
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Immunization Gateway Service
7 CAIR Regions
Legacy
Registration
R i t ti
Portal
Provider
Gateway
G
Service
Validation
lid i
Service
EHR in
T ti
Testing
Community
HIO
Enterprise
HIO
EHR
Hosted ERH
or EHR Hub
EHR H b
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Project INSPIRE
Integrating Clinical Care with Public Health
Integrating Clinical Care with Public Health
Project INSPIRE
INSPIRE – INteroperability
p
y to Support Practice pp
Improvement, Disease REgistries, and Care Coordination
Improve the acquisition and exchange of patient d t f hi h i
data for high impact conditions in order to t
diti
i
d t
support care coordination, practice improvement and longitudinal disease registries
longitudinal disease registries
INSPIRE’s Two Initiatives
1. Next Generation Registries
2. The “Health Information Home”
Next Generation Disease Registries:
Transforming Disease Registries With EHRs and HIE
Problem
 Registry reporting utilizes manual abstraction from charts –
expensive and slow
 Registry knowledge of a new cancer takes 24‐36 months, which significantly impacts data usability
i ifi
l i
d
bili
 Data needed by registries are also needed to provide good care
Structured data capture from EHRs and transfer through EHRs and transfer through
Opportunity  Structured data capture HIEs can dramatically improve registry case ascertainment while also improving care coordination for cancer patients
Solution
 Implement EHR‐based capture of structured
f
breast cancer case data at point‐of‐care from clinicians in the Athena Breast Health Network
 D
Demonstrate use of new HL‐7/ASCO “clinical oncology data t t
f
HL 7/ASCO “ li i l
l
d t
exchange standards”  Demonstrate the benefits of making the same case data available for both registries and clinical care
available for both registries and clinical care
The “Health Information Home” ‐
Improving Care with an HIE Document Repository
Problem
 Patients with high impact conditions receive care from multiple providers across time and space
 No provider has a complete view of the patient record
 This leads to poor care coordination, duplicative testing, errors This leads to poor care coordination duplicative testing errors
of omission, and missed opportunities for health improvement
Opportunity  A “health information home” will facilitate accountable care by providing a shared common view of the patient for all b
d
h d
f h
f
ll
providers
 Data going to disease registries has clinical care value
Solution
 Implement a “health information home” using HIE technology
 Make the health information home accessible to providers as an HIE ‘node’ for population health management
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 Work with providers to have registry‐bound data sent to the health information home
 Use standards‐based data transfer
New Open Library of HIE Project (OLHIE)
The Problem
 ARRA funded assets are generally lost or impossible to find
Our Solution
 OLHIE is developing an online ecosystem
 “Authors” of HIE‐related contracts, best practices, and software have a place to share their work
 “Readers” with real‐world resources can use to inform their work
Key K
 Promotes reuse, cooperation, and learning to reduce P
t
ti
dl
i t
d
Advances
the cost of building and operating HIE
 Prevents the loss of ARRA funded assets
 Enables peer review and co‐authorship of assets
 Streamlines workflow for authors to publish, version, p
,
make private, and remove assets
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Regional and Community HIE Investments
HIE Acceleration Award Program: Problem
 Eligible providers need access to information g
Meaningful g
exchange services in order to achieve
Use
p
 EHR’s are not interoperable and the costs of interface development for connectivity between unaffiliated providers is expensive, sometimes cost‐
prohibitive
 Medical care occurs locally
 California’s size and diversity precludes it from effectively implementing a “one‐size‐fits‐all” state HIE
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HIE Acceleration Award Program: Solution
 Design targeted award programs aimed at accelerating the development of local/regional HIE accelerating the development
of local/regional HIE
infrastructure, connectivity and capacity to increase the flow of private and secure health information between unaffiliated health professionals and
between unaffiliated health professionals and entities throughout the state
 Invest in building HIE infrastructure and expanding HIE services at the local/regional level to better serve patients integrate/coordinate care and
serve patients, integrate/coordinate care and decrease cost 33
HIE Acceleration Award Program: Key Advances
Funding Progress
– Nearly $6,000,000 awarded to date
– Half ($2.8M) awarded since HIE programs transitioned to CHeQ
Half ($2 8M) awarded since HIE programs transitioned to CHeQ in Fall 2012 in Fall 2012
– CHeQ currently administering 17 awards to 13 different HIE organizations participating in 5 distinct HIE Acceleration programs (not including Rural Incentive Program)
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HIE Progress
– More than 270 HIE connections established by awardees to transmit health More than 270 HIE connections established by awardees to transmit health
information electronically (not necessarily all through CHeQ funding)
– More than 15 million lives potentially covered by HIE through awardees (nearly 40% of CA population) – Patient lives covered by HIE up 6.5 million lives or 80% from estimates given in 2012 (8M lives to 14.5M lives – mainly attributed to IEHIE & OCPRHIO) 34
New Rural HIE Incentive Program: Problem
– Many obstacles to coordinated care in rural California
– Patients travel long distances to receive care. Scarcity and distance i
increase likelihood providers don’t have access to all of a patient’s lik lih d
id d ’ h
ll f
i ’
health information resulting in fragmented and inefficient care
– Implementation of Affordable Care Act (more patients) combined p
(
p
)
with declining number of rural physicians poised to exacerbate situation
– HIE supports care integration strategies to address these challenges, HIE supports care integration strategies to address these challenges
however, very limited uptake of HIE in rural California
– Need for additional resources and transparency in funding for rural areas; need for standardized HIE implementations
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d d d
l
– Sizeable or under‐serviced areas (“white space”) in many rural parts of the state
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New Rural HIE Incentive Program: Solution
Launch Rural HIE Incentive Program


Promote HIE in rural areas by subsidizing the implementation services p
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for rural hospitals, clinics, and individual providers
Enable rural providers to adopt high‐priority, standards‐based HIE services from qualified service providers at manageable prices
Program Structure
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
Selected five Designated Rural HIE Service Providers that offer:  1)Direct services 2) Results delivery using traditional HL7 messaging
 2) Results delivery using traditional HL7 messaging
 3) Community longitudinal patient record through a repository and portal or 
federated repository 

Allows new rural participants to choose services that best meet their Allows
new rural participants to choose services that best meet their
needs
$1M fund available to subsidize 65% of the cost of qualifying service implementations through November 2013
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New Rural HIE Incentive Program: Designated Rural HIE Service Providers
Directed Exchange Services
Informatics Corporation of America (ICA)
Informatics Corporation of America (ICA)
Redwood Mednet
Directed Exchange and Longitudinal Community Record Services
Di
t dE h
dL
it di l C
it R
dS i
Axesson
Inland Empire Health Information Exchange
Orange County Partnership Regional Health Information
Organization (OCPRHIO)
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New Patient Access Initiative: Blue Button for Medi‐Cal
Opportunity Medi‐Cal is moving most beneficiaries into managed care plans
Medi‐Cal
Cal Managed Care offers an important source of Managed Care offers an important source of
 Medi
health information for patients to access
Solution
 Create the California
Create the California Blue Button Initiative to
Blue Button Initiative to
 Partner with one or two Medi‐Cal managed care plans
 Fund implementations of Blue Button functionality for patient access to health information
 Share as a replicable solution for Medi‐Cal managed care
Advances
 Coordinating with Department of Health Care Services
Coordinating with Department of Health Care Services
 Assessment of readiness among plans
 Will select partner health plans this summer
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Q
QUESTIONS ???