Business Case for Adoption: The Federal Perspective 1 Copyright 2009. All Rights Reserved. Quality Improvement Opportunities Using CONNECT A Proof of Concept for Changing the Traditional Methods of Data Exchange Michael Reinhold Acting Deputy Group Director, Information System Group, Office of Clinical Standards and Quality, Centers for Medicare and Medicaid Services Copyright 2009. All Rights Reserved. Quality Improvement • Delivering Care in a safe, effective and efficient manner • Ensuring great communication between health care providers and their patients • Proper and effective stewardship of health care services • Eliminating redundancy of care • Ensuring care is evidence-based and outcome-driven to manage and prevent complications from disease • Educating consumers of health care services • Rewarding health care providers for quality improvement 3 Copyright 2009. All Rights Reserved. CMS Quality Initiatives The Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Program The Medicare Home Health Quality Program • 42 Hospital measures • Clinical Process • Clinical Outcome The Physician Quality Reporting Initiative (PQRI) Program The Medicare Outpatient Prospective Payment System (OPPS) Program • 7 outpatient measures • Clinical Process • Clinical Outcome The Medicare End Stage Renal Disease (ESRD) Program • 153 Physician Office Measures • 26 Clinical Performance Measures (CPM) • Clinical Process • Clinical Process • Clinical Outcome • Clinical Outcome 4 Copyright 2009. All Rights Reserved. The Medicare Electronic Prescribing Program Current Methods of Data Collection for Purposes of Quality Improvement Claims Based Electronic Upload (EU) • Normal CMS Claims Processing • Web interface Custom Registry or Vendor • Web Based Single User Interface – DE • Sending Data to Entity to Submit on Behalf • Extraction Tools for Distribution • Usually Uses One of the Other Identified Methods – EU 5 Copyright 2009. All Rights Reserved. • Batch or shipped media Looks Good to Me Why Change Current Methods of Data Collection? 2 Vendor Claims Method 1 3 4 Billing Software • • • • Various Billing Packages not all uniform and no interoperable standards Cost to update, train, switch and maintain Not developed for purposes of quality reporting - but billing for payment Step for errors to occur in data transaction around quality data Carrier/MAC • • • • Various systems and internal processes Costly to update, train, switch and maintain Not developed for purposes of quality reporting – but billing for payment Step for errors to occur in data transaction Internal Transactional Processes • • • • Various systems and internal processes Costly to update, change and maintain Not intended to ensure quality data is properly captured Step for errors to occur in data transaction around quality data • • • Various systems and internal processes Costly to update, train, switch and maintain Not developed for purposes of quality payment– but transactional payment • • • • Various systems and internal processes Costly to update, change and maintain -must change based on Claims processing systems Performed months after initial data submitted Step for errors to occur in data transaction • • • Various systems and internal processes Costly to update, train, switch and maintain – must change based on Claims processing systems Performed months after the initial data submitted Payment Internal Quality Processes Quality Decisions 5 Data lag for Quality decisions and 4-5 major steps where data errors can occur on Quality Data – Never designed for Quality Purposes 6 Copyright 2009. All Rights Reserved. Looks Good to Me Why Change Current Methods of Data Collection? Electronic Upload Vendor 2 Provider Software Access/System Registration Submit Data • • • • • • • Depending on program variant file specifications must be met • Leaves room for duplication of data and formatting particularly if participation in many programs/efforts • Usually measure driven - not data driven • Step for errors to occur in data transaction 1 Various systems and processes along with file specifications depending on program Burden/duplication on training Feedback submission report issues Usually limited time for submission depending on program and data required Usually measure driven not data driven Step for errors to occur in data transaction around quality data • Various systems and processes along with file specifications depending on program • Burden/duplication on training • Feedback submission report issues • Usually limited time for submission depending on program and data required • Usually measure driven not data driven • Step for errors to occur in data transaction around quality data Data Processes • • • • • • Various systems and internal processes Duplication depending on different specifications Costly to update, switch and maintain Extremely resource intensive based on submission periods Usually measure driven not data driven Step for errors to occur in data transaction around quality data Internal Quality Processes • • • • • Various systems and internal processes Duplication depending on different specifications Costly to update, switch and maintain Extremely resource intensive based on submission periods Validation is difficult to perform efficiently Quality Decisions 7 • Various Packages not all uniform and no interoperable standards • Cost to update, train, switch and maintain • Often not developed for purposes of quality reporting – retro fitted or manual interaction to meet program data out needs 3 4 • Various systems and internal processes • Costly to update, train, switch and maintain – mostly due to duplication and lack of interoperability standards • Often does not accommodate timely feedback and data resubmission Data lag is far less, however, allows for duplication of data submission, training and systems in conjunction with timely submission & feedback issues. Also generally requires a considerable amount of end user support. Copyright 2009. All Rights Reserved. Looks Good to Me Why Change Current Methods of Data Collection? Registry or Vendor Provider Software • • • • • • Various Packages not all uniform and no interoperable standards Cost to update, train, switch and maintain Often not developed for purposes of quality reporting – retro fitted or manual interaction to meet program data out needs Depending on program variant file specifications must be met Leaves room for duplication of data and formatting particularly if participation in many programs/efforts Step for errors to occur in data transaction Registry or Vendor • • • • • Various Packages not all uniform and no interoperable standards Cost to update, train, switch and maintain Depending on program variant file specifications must be met Quality control issues Usually measure driven - not data driven Access/System Registration Submit Data Data Processes Internal Quality Processes Quality Decisions 8 Usually disconnected from the Registry system 1 2 • Various systems and processes to follow depending on what program participation is in • Burden/duplication on training • Can create confusion depending on reporting periods and programs in in more than one • • • • • • Various systems and processes along with file specifications depending on program Burden/duplication on training Feedback submission report issues Usually limited time for submission depending on program and data required Usually measure driven not data driven Step for errors to occur in data transaction around quality data • • • • • • Various systems and internal processes Duplication depending on different specifications Costly to update, switch and maintain Extremely resource intensive based on submission periods Usually measure driven not data driven Step for errors to occur in data transaction around quality data • • • • • Various systems and internal processes Duplication depending on different specifications Costly to update, switch and maintain Extremely resource intensive based on submission periods Validation is difficult to perform efficiently 3 4 • Various systems and internal processes • Costly to update, train, switch and maintain – mostly due to duplication and lack of interoperability standards • Often does not accommodate timely feedback and data resubmission Data lag is far less, however, allows for duplication of data submission, training and systems in conjunction with timely submission & feedback issues. Also generally requires a considerable amount of end user support. Copyright 2009. All Rights Reserved. Looks Good to Me Why Change Current Methods of Data Collection? Custom Provider Software Access/System Registration Provider Uses System Interface Data Processes Internal Quality Processes Quality Decisions 9 Usually disconnected from • Various Packages not all uniform and no interoperable standards • Usually does not interact with Custom interface for data entry the Custom interface • Cost to update, train, switch and maintain • Leaves room for duplication of data entry – The provider system and the Custom interface • Various Packages not all uniform and no interoperable standards • Usually does not interact with Custom interface for data entry • Cost to update, train, switch and maintain • Leaves room for duplication of data entry – The provider system and the Custom interface • Various systems and processes – may collect duplicate data • Burden/duplication on training • Data entry errors • Performance factors may arise • Usually limited time for submission depending on program and data required –manual burden • Usually measure driven not data driven 1 2 Usually requires increased • Various systems and internal processes • Duplication depending on different specifications security requirements • Costly to update, switch and maintain • Extremely resource intensive based on submission requirements • Usually measure driven not data driven • Step for errors to occur in data transaction thus leading to end user frustration and increased inquiry support • Various systems and internal processes • Duplication depending on different specifications • Costly to update, switch and maintain • Extremely resource intensive based on submission periods • Validation is difficult to perform efficiently thus leading to enormous inquiry support efforts • Various systems and internal processes • Costly to update, train, switch and maintain – mostly due to duplication and lack of interoperability standards • Often does not accommodate timely feedback and data resubmission Usually no data lag, however allows for duplication of data submission, training and systems. Also generally requires a considerable amount of end user support to include detailed inquiry support. The biggest con is in most cases the provider still has to enter the data into their system – duplicate data entry Copyright 2009. All Rights Reserved. Summary: Current • Current methods are not wrong. They were the best way of doing business with the resources and technologies available • Until new technologies and/or architectures are created we have to live with them • This means cost increases as quality initiatives and data populations increases How do we move from here to there ? Quality initiatives Improving quality Cost Cost 10 Copyright 2009. All Rights Reserved. ONE Answer is develop an New Architecture and Method for Data Collection Nationwide Health Information Network (NHIN) and CONNECT Architecture Mission To achieve better quality, value, and affordability of health and wellness services by establishing the Nationwide Health Information Network as the common, secure, nationwide, interoperable network for exchanging health information, and provide this infrastructure with low adoption barriers. Provides • Ability to look up, retrieve and securely exchange health information • Ability to apply consumer preferences for sharing information • Ability to apply and use the NHIN for other business capabilities as authorized by the health care consumer • Interoperability Architecture In short provides a single architecture/method for health care data exchange 11 Copyright 2009. All Rights Reserved. Use Test Case/Proof of Concept HIE DEV Instance Test QRDA Documents QRDA NHIN Gateway QRDA NHIN A Perfect Business Use Test Case in Practice NHIN CONNECT or other Gateway CMS NHIN Gateway EHR Application (Data/Structural Validation) The Physician Quality Reporting Initiative (PQRI) program ALS ESB (existing) Currently uses all four current methods of data exchange– EHR Data Application (Data Parsing and Storage) 1.Claims 2.Electronic Upload (EU) Phase out EU and Custom 3.Registry through EU 4.Custom Data Entry App Develop new NHIN method to retrieve data required as needed eliminating or simplifying other methods 12 Copyright 2009. All Rights Reserved. Database QRDA Document Processor Connect Proof of Concept Goals • Embark upon a 4 step proof-of-concept: – Increase/accelerate exposure to NHIN technology and overall business process framework and direction within CMS • Increase business understanding to better influence future design and business process/policy use considerations • Increase functional and technical system design – including security and scalability considerations to reduce possible future implementation risk – Simulation of submission of QRDA data from an EMR, through an HIE, over the NHIN to CMS • Four steps are planned during the POC: – Test gateway-to-gateway communication – Test QRDA exchange – Enhance gateway to integrate and comply with current Quality systems components – Pilot test with other HIEs and possibly other relevant stakeholders 13 Copyright 2009. All Rights Reserved. Important Points • Following NHIN Interoperable standards CMS should be able to integrate and enhance gateway to comply with current Quality systems components and increase overall functionality with other Quality systems/programs • Once integration is complete and data exchange is proven from an HIE CMS can : – Pilot test with other HIEs and possibly other relevant stakeholders – Provide feedback on any NHIN improvement areas – Expand testing to other Quality Programs – Obtain and provide feedback on quality data sooner – Lessen the burden on external stakeholders that belong to HIE’s or are an HIE that have adopted the NHIN architecture standards – Reduce redundancy in systems and data request – Expand quality measurement data specifications to EHR vendors – Continue to work with standards organizations such as HL7 to expand or modify CDA templates 14 Copyright 2009. All Rights Reserved. In Summary “Technology does not drive change – it enables change” Following NHIN Interoperable standards and architecture around new technology areas, CMS believes that current methods of Quality Data collection could be simplified to achieve better quality, value, and affordability. As CMS and other organizations adopt the NHIN architecture it will help lessen the burden of data exchange to all stakeholders and help increase quality improvement. CMS is working on enabling change through its various Quality, Medicare, and Medicaid programs! 15 Copyright 2009. All Rights Reserved. “Believe you can and you're halfway there” “Far and away the best prize that life has to offer is the chance to work hard at work worth doing” Quotes by Theodore Roosevelt Q: WHAT CAN THE SYSTEM DO? A: WHAT DO YOU WANT IT TO DO? Enhanced Care Delivery by CONNECTing to the NHIN: Improving Disaster Medical Care Robert Bencic, DDS, MBA CAPT USPHS Director, QA National Disaster Medical System Copyright 2009. All Rights Reserved. Problems Caused by Disconnected Systems Patients are removed from their typical medical providers and care plan Inability to acquire patient care information from other Federal partners (DoD, VA, SSA, IHS, CMS) Inability to share information among various response locations in a federally declared disaster Inability to quickly send data to other healthcare providers 17 Copyright 2009. All Rights Reserved. Expected Benefits from CONNECTing to the NHIN • Access to medical data from other deployment locations • Enable the acquisition of patient information from other federal departments (VA, CMS) • Lay groundwork for future information sharing with non-federal government entities (hospitals, pharmacies, urgent care centers, and state programs) • Enhance the usability of NDMS Disaster Medical Information System (DMIS) 18 Copyright 2009. All Rights Reserved. DMIS Continuum of Care 19 Copyright 2009. All Rights Reserved. What This Means for the Rest of the Healthcare Industry • NDMS can leverage ONC’s standards and achieve its goal of having a standard framework for retrieving and sending patient data to other healthcare providers • CONNECT software will minimize the in-house development time and costs • Leveraging standard CONNECT software enhances patient care while minimizing limited implementation resources 20 Copyright 2009. All Rights Reserved. CONNECTing the Indian Health System James Garvie, CAPT, USPHS Deputy Director, Division of Information Resources Indian Health Service Copyright 2009. All Rights Reserved. IHS as a Provider of Health Services American Indian and Alaska Native Healthcare CHALLENGES • Information tends to be facility-based and is generally not available to staff at other IHS, Tribal or Urban Indian facilities. • There is no central registry of Indian health system patients, providers and other resources. • Secure messaging is not available among Indian health system facilities. 22 Copyright 2009. All Rights Reserved. SECURE EXCHANGE OF INTEROPERABLE HEALTH INFORMATION Patients Providers Population Health CONNECT Solution EXPECTED OUTCOMES • Information at the point of care from all Indian health system sources. • Immediate access to patient, provider and essential health resource information. • Secure messaging throughout the Indian health system. IHS as a Payor for Health Services American Indian and Alaska Native Healthcare CHALLENGES • IHS and Tribal programs purchase health services that are not available within the Indian health system. • Information regarding purchased care conforms to financial formats and is often clinically incomplete. • Purchased care providers generally do not have electronic health record systems. 23 Copyright 2009. All Rights Reserved. SECURE EXCHANGE OF INTEROPERABLE HEALTH INFORMATION Patients Providers Population Health CONNECT Solution EXPECTED OUTCOMES • Information at the point of care from all health system sources. • Complete, clinically relevant information. • Seamless sharing of health information by all healthcare providers. IHS and Population Health American Indian and Alaska Native Healthcare CHALLENGES • Notifiable disease reporting capabilities vary considerably among states. • Immunization and disease registry functionality is inconsistent among collecting organizations. • Reporting is usually paperbased, sometimes via web portal and rarely from an electronic health record system. 24 Copyright 2009. All Rights Reserved. SECURE EXCHANGE OF INTEROPERABLE HEALTH INFORMATION Patients Providers Population Health CONNECT Solution EXPECTED OUTCOMES • Increased standardization among states for notifiable disease reporting. • Increased standardization among registry oganizations. • Direct, bidirectional exchange of information between EHRs and reporting, registry organizations. CONNECTing the Indian Health System Facilities MPI Integration Engine IHS Adapter/ Gateway Facilities MPI Integration Engine Tribal Adapter/ Gateway Internet 25 Copyright 2009. All Rights Reserved. Facilities MPI Integration Engine Urban Adapter/ Gateway A Snapshot of Success: CONNECT’s Demonstrated Achievements Dr. Taha Kass-Hout, MD, MS BioSense Program Manager US Centers for Disease Control and Prevention Copyright 2009. All Rights Reserved. Web Search Volume Screenshot 27 Copyright 2009. All Rights Reserved. Source: GI4S Web Search Volume Screenshot 28 Copyright 2009. All Rights Reserved. Source: GI4S Web Search Volume Screenshot 29 Copyright 2009. All Rights Reserved. Source: GI4S iPhone App Store Analogy Photos Credits: Raven Zachary and Scott Janousek 30 Copyright 2009. All Rights Reserved. Enhanced Care Delivery: Problems Caused by Disconnected Systems • Critical data needed for surveillance is not captured in many instances • Acquired information is not received in a timely manner • Public health interventions are delayed • Ability to communicate critical messages to the medical community is impaired • Community health programs are not designed and monitored effectively 31 Copyright 2009. All Rights Reserved. Enhanced Care Delivery: Expected PH Benefits from CONNECTing to the NHIN • Enhanced surveillance capabilities to support situational awareness and notifiable disease scenarios in a timely manner • Integration of relevant public health information into decision support processes effective response • Improved community health intervention and evaluation processes Reduce Morbidity and Mortality and Improve Outcomes 32 Copyright 2009. All Rights Reserved. BioSense Strategy Overview Next Generation: Present Strategy: • Situational awareness • Syndromic monitoring and electronic laboratory reporting pilots • Centralized model with CDC stewardship of data • State systems, national sources, & individual hospitals • Sharing of aggregated (summary) data across jurisdictions • Social networking model Trust • Federated model with joint state & CDC stewardship Feasibility • Service Oriented Infrastructure • Supports many surveillance needs (e.g. ELR) • State systems, national data sources, NHIN 33 Copyright 2009. All Rights Reserved. Biosurveillance using Summary Data Geocoded Interoperable Population Summary Exchange (GIPSE) Services Value of Aggregate Data – Public Health surveillance/quality monitoring – Response to natural/manmade disaster – Cross-jurisdictional situational awareness GIPSE Format – Provides access to data by leveraging service oriented architecture or grid methods to expose summaries of data within state and local systems – Each service returns a set of aggregate counts that map to a common geographic data structure – Supports aggregation – Supports computation and testing using spatio-temporal anomaly (e.g., SatScan) methods – Developed as CDC-hosted open source project 34 Copyright 2009. All Rights Reserved. Biosurveillance using Summary Data Geocoded Interoperable Population Summary Exchange (GIPSE) Services • CDC uses NHIN Gateway to subscribe to summarized Biosurveillance data from State Health Departments (SHD) • SHD’s publish summarized biosurveillance data via NHIN Gateway • CDC aggregates and visualizes summarized data using Quicksilver or other summary data viewers 3. Quicksilver Viewer CONNECT Gateway CONNECT Gateway CONNECT Gateway 35 Copyright 2009. All Rights Reserved. GIPSE A set of matrices Aggregates (e.g.; counts, rates, or alerts) Zip codes Date range 1,2,3,5,0,6,… 2,1,4,7,0,3,… …. …. …. ILI 36 Copyright 2009. All Rights Reserved. Abdominal Rash GIPSE + adds cross tabulation on age category and gender Date range + ILI 37 Copyright 2009. All Rights Reserved. Zip codes Zip codes Date range National Biosurveillance Model: Summary Perspective Systems Partners DISTRIBUTE State Health Departments RODS State Health Departments ESSENSE BIOSENSE CDC NEDSS National Poison Control Center Regional HIE Local Health Departments Hospitals, Clinics, etc. NHIN Gateway 38 Copyright 2009. All Rights Reserved. POISON DATA Summary Data Source Summary Data Source Clinical Data Source Summary Data Bus State Health Departments GIPSE SERVICES REGISTRY CLIENT VIEWER Authenticated Cardea Cardea is a platform and a set of services that build a general purpose interface to support message transformation and workflow intelligence between a healthcare system/laboratory/health information exchange and public health BioSense Integrator Pilot in GA, 2009 39 Copyright 2009. All Rights Reserved. What This Means for the Rest of the Healthcare Industry? • Enhanced surveillance capabilities are an important component in improving the overall health of the population, serving to reduce health care costs • Quality of care can be positively impacted when clinicians have easy access to important public health information • Health disparities can be recognized, assessed and evaluated more effectively with more robust surveillance capabilities Enhanced Care Delivery 40 Copyright 2009. All Rights Reserved. Thank You! Taha Kass-Hout, MD, MS BioSense Program Manager Centers for Disease Control and Prevention Les Lenert, MD, MS, FACMI Director, National Center for Public Health Informatics Centers for Disease Control and Prevention Barry Rhodes, PhD Division of Emergency Preparedness and Response (DEPR) Director (Acting) Centers for Disease Control and Prevention 41 Copyright 2009. All Rights Reserved. Business Case for Adoption: National Cancer Institute/caBIG George A. Komatsoulis, Ph.D. Deputy Director NCI Center for Biomedical Informatics and Information Technology (CBIIT) Copyright 2009. All Rights Reserved. Individualized, Targeted Cancer Care 43 Copyright 2009. All Rights Reserved. NCI Cancer Research Enterprise The cancer Biomedical Informatics Grid (caBIG) was initiated in 2004 to connect the disparate parts of the cancer community via a semantically Interoperable Service Oriented Architecture (SOA) 44 Copyright 2009. All Rights Reserved. = NCI-Designated Cancer Centers = CCOPs = NCI Community Cancer Centers caBIG® Enables All Major Functions Needed to Link Research to Care Clinical Research Molecular Biology 45 Copyright 2009. All Rights Reserved. Imaging Pathology caBIG® Enables All Major Functions Needed to Link Research to Care • Track clinical trial registrations • Utilize the National Cancer Imaging Archive repository for medical images including CAT scans and MRIs • Facilitate automatic capture of clinical laboratory data • Visualize images using DICOM-compliant tools • Manage reports describing adverse events during clinical trials Clinical Research Imaging • Annotated Images with distributed tools • Combine proteomics, gene expression, and other basic research data • Access a library of well characterized, clinically annotated biospecimens • Submit and annotate microarray data • Use tools to keep an inventory of a user’s own samples • Integrate microarray data from multiple manufacturers and permit analysis and visualization of data 46 Copyright 2009. All Rights Reserved. Molecular Biology Pathology • Track the storage, distribution, and quality assurance of specimens NCI caGrid Portal Screenshot 47 Copyright 2009. All Rights Reserved. December caBIG/NHIN Demonstration: Partnership that Promotes Child Care Demonstration illustrated: • Methods for physicians conducting clinical trials to obtain health history and treatment information • Methods for sharing details about care received during trial • Ways to share care information with future healthcare providers • How continuity of care can be achieved through partnerships between federal and private care providers 48 Copyright 2009. All Rights Reserved. Integrating with the NHIN NHIN Services (WSDL) caBIG® Services (WSRF and WSDL) Subject Discovery Subject Discovery Document Query Document Query Document Retrieval Document Retrieval INTRODUCE Generated caGrid Service Wrappers 49 Copyright 2009. All Rights Reserved. NHIN and caBIG® Moving Forward • A caBIG® compatible NHIN solution is simply a matter of capturing the semantics of the service – Provides both a Grid Service and a conventional Web Service • A “caBIG® compatible” NHIN gateway could be deployed at caBIG® participating institutions (that have significant expertise in deploying caBIG® technology) • Similarly, caBIG® could become “NHIN compatible” by supplying caBIG® compatible versions of NHIN services 50 Copyright 2009. All Rights Reserved. Leveraging the NHIN to Improve the Disability Determination Process Authorized Release of Information Justine Piereman Senior Advisor to the Office of the Deputy Commissioner for Systems Social Security Administration Copyright 2009. All Rights Reserved. An American First: The Telegraph Human-to-Human Transmission of Text Over Wire • Innovation supported by the Congress • First test - Baltimore to Washington – 38 miles • Standardized language (Morse Code) • Rapid expansion by private sector • Benefits to citizens 52 Copyright 2009. All Rights Reserved. – Expansion of commerce – Immediate access to news Another American First: Live patient transfer across the NHIN NHIN Patient Information Patient Information This one-way electronic transfer of patient data between MedVirginia, a regional health group, and the Social Security Administration will enable SSA, with the patient’s authorization, to obtain medical records for the disability review process in minutes instead of the current weeks and months. 53 Copyright 2009. All Rights Reserved. The Face of Disability 54 Copyright 2009. All Rights Reserved. Nationwide Health Information Network State Agency Phone, Web, In-Person Med Records Labs Background DETERMINATION RECOMMENDATION St. Francis Medical Center St. Mary’s Hospital NHIN SSA Field Office Demographic Information DECISION MADE 55 Copyright 2009. All Rights Reserved. SSA National Computer System Med Records Labs Background Claimant Electronic Folder Memorial Regional Medical Center + CONNECT Auth. To Release Medical Records Richmond Community Hospital Information Available About Claimant Additional Providers brought to the NHIN through ARRA and other mechanisms in FY2009 and beyond Enhanced Care Delivery by CONNECTING to the NHIN Dr. Steve Steffensen Chief Medical Information Officer Telemedicine & Advanced Technology Research Center Copyright 2009. All Rights Reserved. Department of Defense Commitment to Care Military Beneficiaries: 9.3 million Military Bases in US: 202 Military hospitals 63 Medical/Dental Clinics Encounters/month 9 million Average outpatient visits/year/patient 826 4 1:4 military families move in a given year <50% of network consults make it back to the PCM CONUS Military Bases 74% 57 Copyright 2009. All Rights Reserved. 70% 59% 56% Federal and Private Partnership Dr. Tim Cromwell Director, Standards and Interoperability Office of Health Information Veterans Health Administration Jamie Ferguson Executive Director of Health IT Strategy and Policy Kaiser Permanente Copyright 2009. All Rights Reserved. Introduction • The US Department of Veterans Affairs (VA) and Kaiser Permanente (KP) have collaborated on clinical standards development and other interoperability issues prior to NHIN • Our limited production implementation sharing standardized health information for patient care will go live late in 2009 • Our teams have been meeting regularly, working to resolve a myriad of issues in three main areas: – Technical capability – Operational preparedness – Policy • We think we have a story to tell about what we have done so far – Lessons learned – Challenges remaining 59 Copyright 2009. All Rights Reserved. Outline Introduction Business Case VA | KP Challenges Technical | Operational Conclusion 60 Copyright 2009. All Rights Reserved. | Policy Business Cases Veterans Affairs Kaiser Permanente • 3 out of 4 Veterans receive care in the private sector • Many thousands of KP members receive care from VA • More and more private sector providers will use EHRs • Improved information can help clinical decision-making • Complete set of data will lead to better quality of care • Complete set of data will lead to better quality of care • Veteran satisfaction with overall care will be higher • Opportunity to avoid duplicate or conflicting clinical orders • Executive Order 13410 mandates use of recognized standards for Agencies • Additional cost reduction from automation of manual processes • Executive Order 13410 mandates use of recognized standards for FEHB carriers 61 Copyright 2009. All Rights Reserved. Technical: Physical Environments VA • KP • Lab environment in 2008 Trial Implementation • Test environment remains from 2008 NHIN Trial Implementation • Internal development environment • Internal development environment • CONNECT Gateway received from FHA • Adapter developed internally • Test • Test databases, test systems, test patients • Production environment • TBD 62 Copyright 2009. All Rights Reserved. • Internally-developed NHIN Gateway (not using FHA CONNECT software) • Shared environments with EHR systems and other internal systems • Production environment • TBD Technical: Interfaces to Existing Systems VA • KP • Viewer: VistAWeb • Web services interface to EHR • Data sources: 128 VistA instances • Terminology translation services • Translation to HITSP specified terminology • CPP for consumer permissions & enterprise policies • Will enforce authorization, auditing, authentication 63 Copyright 2009. All Rights Reserved. • Patient demographics • Clinical data • Separate interface for document storage subsystem • Separate interfaces for enterprise services, e.g. audit logs, system monitoring Technical: Content Payload VA and KP HITSP C32 patient health summary • Version 2.1 - Minimum data set • Personal information • Contacts • Allergies • Medications • Problems • Source of information All required data elements in the specified HITSP terminologies to the extent possible, others optional (pending NHIN certification criteria) 64 Copyright 2009. All Rights Reserved. Policy: DURSA VA and KP • 2008 test patient data DURSA signed • 2009 live patient DURSA finalized/ in clearance, and under review by VA and KP management • DURSA overview (plain English) available 65 Copyright 2009. All Rights Reserved. Policy: Shared Patient Population in the San Diego Area VA and KP • Oversight by our legal and privacy officers • Analysis indicates approximately 1400 patients • seen within last year at VA • a standing appointment for next year • With a secondary insurance indicating KP • No sensitive diagnoses • Confirmation of the list of potential shared patients among our two organizations is working its way through permissions to share 66 Copyright 2009. All Rights Reserved. Operational: Patient Consent VA and KP • Emulating existing manual/paper workflow • • • • 1 letter 2 authorizations 1 return envelope 1 help desk 67 Copyright 2009. All Rights Reserved. • Processing of return envelopes at local San Diego VAMC • Final workflows subject to approval Operational: Authority To Operate • VA • KP • VA has formal process for certification and accreditation • KP not subject to internal federal agency requirements • 600 Enterprise Requirements reviewed to assess which ones apply to VA NHIN solution • KP process addresses similar points somewhat differently • Document compliance traceability • Design reviews • Project reviews • Requirements analyses and documentation • Solutions analyses and documentation 68 Copyright 2009. All Rights Reserved. Operation: VA-KP Schedule Item Title KP date VA date Agreed date - 6/12 6/12 1 VA and KP validate initial shared patients under active care 2 Forms and letter defined 6/19 6/19 6/19 3 Patient authorization processing process defined 6/26 6/26 6/26 5 VA and KP validate final shared patients under active care 7/03 - 7/03 7 Gateway 2.1 certification by NHINC (connection to FHA) soap 1.2 - 7/17 7/17 8 Regression test of KP/VA CCD exchange across NHIN soap 1.2 complete 7/15 7/20 7/20 9 Forms and letters ready for mailing 7/24 7/24 7/24 11 KP/VA doc exchange across NHIN Kaiser C32s generated on demand 6/30 7/29 7/29 12 Patient authorizations mailed 7/31 7/31 7/31 13 KP/VA subject discovery inter-gateway integration test complete (using test patients from forum) 8/14 8/14 8/14 14 San Diego face-to-face demos with KP and VA local clinical staff 8/24 8/24 8/24 15 End-to-end integration test complete (using test patients) 8/28 8/28 8/28 19 Patient authorization returns processing complete TBD TBD TBD 21 Pre-prod verification of both KP and VA environments (setup for UAT) TBD TBD TBD 22 Deployment to production TBD TBD TBD 23 KP/VA UAT begins (end-to-end using shared patients that opted-in*) 9/28 TBD TBD 24 KP/VA GO LIVE (Full Deployment) TBD TBD TBD 69 Copyright 2009. All Rights Reserved. Operational: Local Sites Involvement • VA • KP • San Diego VA Medical Center & Clinics • San Diego KP Medical Center & Clinics • Support from Chief of Staff and Director of informatics • Assist with patient consent • Assist with clinicians training (little training required as same GUI is used to access remote VA sites or NHIN ‘sites’) 70 Copyright 2009. All Rights Reserved. • Support from Assistant Medical Director, Chief Medical Information Officer and Regional Director KP HealthConnect, local physician lead • Clinician involvement in screen design • Assist with patient consent • Assist with clinicians training Operational: Measures of Success VA KP • Pilot in San Diego must help refine national rollout plan • NHIN membership • Usage metrics will be incorporated in software • Patients count • Pilot in San Diego will inform national rollout plan • Measures under development • Care Quality • Clinical Workflows • C32s content stats • Financial • Impact on workflow • Other • Clinicians count • C32s exchanged count • Impact on quality • Cost of system 71 Copyright 2009. All Rights Reserved. Operational: NHIN/FHA Support VA and KP • NHIN participation • Varying roles: • HITSP, IHE, SDOs; • NHIN (spec factory/testing criteria); • NIST (tools); • CCHIT • NHIN Cooperative workgroups • DURSA, Specification Factory, Testing, … • NHIN/ONC/FHA staff support • Vanessa/Virginia, Craig/Dave, Mariann/Jeff, etc. 72 Copyright 2009. All Rights Reserved. Operational: Stakeholders Buy In VA KP • Presentations and demonstrations • Senior leadership support • VSO, IDMC, CPRS WG, etc. • Regular stakeholders status report • Business, clinical, and technical staff kept informed from national office and local San Diego VAMC • CIO, CEO, SVP’s • Physician leaders • Presentations to Regional Operations staff & managers • Governance groups • IT • Business • Clinical 73 Copyright 2009. All Rights Reserved. Next Steps: VA and KP TESTING & CERTIFICATION Limited Production Roll Out in San Diego Training and Communication Measurements Lessons learned SECOND, THIRD, … ADDITIONAL SITES SCALABILITY PLAN – TOWARD NATIONAL RELEASE 74 Copyright 2009. All Rights Reserved. Contact Information VA contact KP contact Tim Cromwell, RN, PhD Jamie Ferguson Director, Standards & Interoperability Executive Director, HIT Strategy & Policy Office of Health Information Jamie.Ferguson@kp.org Tim.Cromwell@va.gov 510-271-5639 801-588-5022 75 Copyright 2009. All Rights Reserved. CONNECT Seminar Presentations are Available for Download Online at http://www.connectopensource.org 76 Copyright 2009. All Rights Reserved.