MASSACHUSETTS eHEALTH COLLABORATIVE
HIT Symposium
July 2006
MASSACHUSETTS COMMUNITY OF E-HEALTH ORGANIZATIONS
1978
1998
“The Convener”
“The Transactor”
“The Grid”
The convener and
educational
organization, the
business incubator
The transactor of
administrative
(HIPAA transaction)
processes
The grid of statewide clinical utilities
Slide title
Massachusetts eHealth Collaborative
2003
2004
“The Last Mile”
The last-mile to
clinician offices
© MAeHC. All rights reserved.
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MAeHC ROOTS ARE IN MOVEMENT TO IMPROVE QUALITY,
SAFETY, EFFICIENCY OF CARE
• Universal adoption of
electronic health records
• MA-SAFE
• Company launched September 2004
– Non-profit registered in the State of
Massachusetts
• CEO on board January 2005
• $50M commitment to heath
information infrastructure
• Backed by broad array of 34 MA health care
stakeholders
• Recognition of “systems”
problem
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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34 ORGANIZATIONS REPRESENTED ON MAeHC BOARD
Hospitals and hospital associations
Health plans and payer organizations
Healthcare professional associations
• Baystate Health System
• Alliance for Health Care Improvement
• American College of Physicians
• Beth Israel Deaconess Medical
Center
• Blue Cross Blue Shield of
Massachusetts
• Massachusetts League of
Community Health Centers
• Boston Medical Center
• Fallon Community Health Plan
• Massachusetts Medical Society
• Caritas Christi
• Harvard Pilgrim Health Care
• Fallon Clinic, Inc.
• Massachusetts Association of Health
Plans
• Massachusetts Nurses
Association
• Lahey Clinic Medical Center
• Massachusetts Hospital
Association
• Massachusetts Council of
Community Hospitals
• Massachusetts Health Quality
Partners
• Tufts Associated Health Maintenance
Organization
• Partners Healthcare
• Tufts-New England Medical
Center
• University of Massachusetts
Memorial Medical Center
Governmental agencies
• Executive Office of Health and
Human Services
Healthcare purchaser organizations
Consumer, public interest, and labor
• Health Care for All
• Massachusetts Coalition for the
Prevention of Medical Errors
• Massachusetts Health Data
Consortium
• Associated Industries of
Massachusetts
• Massachusetts Taxpayers
Foundation
• Massachusetts Business Roundtable
• Massachusetts Technology
Collaborative
• Massachusetts Group Insurance
Commission
• MassPRO, Inc.
• New England Healthcare Institute
Non-voting members
• Center for Medicare & Medicaid
Services
Slide title
Massachusetts eHealth Collaborative
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MAeHC VISION
Tools for better, more
accessible health care…
Improve quality, safety, and
affordability of health care
through:
• Universal adoption of
modern information
technology in clinical
settings
• Access to comprehensive
clinical information in realtime at the point-of-care
Slide title
…incorporated into clinical
practice…
Overcome barriers to promote
widespread use of EHRs and
associated decision support
tools
• Lack of capital
…and sustained over time.
Develop operational and
financing models to foster and
sustain state-wide adoption of
such technologies and
infrastructures
• Misaligned economic
incentives
• Immature technology
standards
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
-4-
MAEHC MISSION: CLINICAL IT ADOPTION THROUGH
COMMUNITY EMPOWERMENT
Slide title
Massachusetts eHealth Collaborative
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PILOT PROJECTS HAVE FOUR MAIN PIECES
ICCC
PSC
PSC
• Quality
• Cost
• Productivity
• Etc.
Intra-community
connectivity
Management &
coordination
PSC
Evaluation
Connectivity
Clinical IT
implementation/
support
Slide title
• Joint oversight and decisionmaking bodies
• Multi-stakeholder governance
Massachusetts eHealth Collaborative
• Quality measurement
• Pilot evaluation
• Clinical access to data
• Data gathering and aggregation
• Communication
•
•
•
•
•
Hardware/software
Implementation/tech support
Systems integration
Workflow redesign
Decision support
© MAeHC. All rights reserved.
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MAeHC PROJECT TIMELINE
Activities
2004
2005
2006
2007
2008
ACP-MA summit
MAeHC launch
Community RFA launch
Pilot communities announced
EHR vendor RFP
EHR vendor finalization
Physician recruitment
Implementation
Evaluation
Formal Pilot completion
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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EVEN $50M CAN’T GET THE LAST 5%
Main sources of attrition:
• Outyear cost
• Close to retirement
• Too much of a hassle
200
180
22
180
9
160
149
140
120
Most didn’t fit MAeHC
definition of community
100
149
=
158
80
94%
participation
60
40
20
0
Initial practices
Slide title
Ineligible
Opted out
Signed contract
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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DIVERSE ARRAY OF SETTINGS
Almost 450 physicians…
Physicians
65
450
Patient population (000)
Offices
200
445
38
400
85
350
48
500
488
37
120
300
184
80
200
150
50
60
175
111
PCPs
Slide title
Small
40
100
20
0
0
Brockton
N. Adams
Newburyport
111
100
Specialists
100
41
140
350
270
Med
160
95
400
295
177
Large
25
180
43
27
250
200
…in almost 200 offices.
600
500
300
…who care for ~500K
patients…
All
Brockton
N. Adams
Newburyport
0
All
Massachusetts eHealth Collaborative
Brockton
N. Adams
Newburyport
© MAeHC. All rights reserved.
All
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HIGHLAND PRIMARY CARE KICK-OFF
Docs link up to new record style
By Jennifer Heldt Powell
Tuesday, March 14, 2006
The end of the paper trail
By Ulrika G. Gerth/ ugerth@cnc.com
Friday, March 17, 2006
Setting a new record: Local doctors
pilot electronic patient history system
By Stephanie Chelf
Staff Writer
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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PHYSICIANS “GOING LIVE”, BY COMMUNITY
9
# MDs
7
5
19
21
33
25
24
27
67
121
9
64
1
7
1
441
450
North Adams
(55)
400
350
Newburyport
(81)
300
250
Brockton
(305)
200
150
100
50
0
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
2006
Slide title
Mar
Apr
May
Jun
Total
2007
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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THE GRID AND THE LAST MILE
MA-SHARE
Inter-community
connectivity
Intra-community
connectivity
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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THE NEXT PHASE: CONNECTING PHYSICIANS
Patient permission
Privacy and security
Clinical utility
Health
Information
Exchange
Sustainability
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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NORTH ADAMS HEALTH INFORMATION EXCHANGE
Physician portal
Patient-centric clinical
summary
ehr
ehr
ehr
ehr
eCR
•
•
•
•
•
ehr
Medications
Labs
Allergies
Problems
Other
eReferrals
• Secure-messaging between
care-givers
• Tracks and matches
outbound/inbound referrals,
and outbound/inbound
consult reports
eRef
ePatient
Patient portal
Patient-specific functions
HIS
Slide title
Massachusetts eHealth Collaborative
•
•
•
•
Appointment requests
e-visits
Clinical summary
Other
© MAeHC. All rights reserved.
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DRIVERS OF BUSINESS SUSTAINABILITY
High
Physician adoption
Business sustainability
threshhold
Clinical usefulness
Patient opt-ins
Low
Low
High
Clinical data fields in eHealth Summary
Structured, codified data
Labs
Slide title
Medications
Unstructured, text
Problems
Allergies
Medical/family
history
Massachusetts eHealth Collaborative
Notes
© MAeHC. All rights reserved.
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PRIVACY APPROACH SUMMARY (I)
MAeHC and communities need to decide what patient notification or consent we
will require for data exchange in community pilots
•
Not required for stand-alone EHRs
•
Will be required for data exchange across legal entities
Data exchange already happens today
Slide title
•
Current exchanges happen by fax, phone, mail, email, and remote
access
•
Community network could change the scale but probably not scope of
that exchange (ie, same type of information will be exchanged but more
often)
•
With no “person-in-the-loop”, electronic data access may seem more
risky, whether it is or not
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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PRIVACY APPROACH SUMMARY (II)
Even though we’re just changing the transport vehicle, we can’t rely on existing
notifications and consents to cover exchange over the new network
•
MAeHC commitment to transparency will necessitate some form of
patient notification or consent about new network
•
Furthermore, we can’t assume that current entities have gotten patient
consent that conforms with MA consent laws– very likely that many
have not
Notification about the network is not enough – MA law argues for some form of
affirmative consent BEFORE disclosing data across legal entities
•
HIPAA Notice of Privacy Practices does NOT count for MA consent
•
MA consent requires affirmative consent for disclosure of clinical
information, and a second affirmative consent for disclosure of
sensitive information
Question before us now is how to get patient consent in a way that is ethically
and legally robust and operationally sound
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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ENTITY-BY-ENTITY OPT-IN (REPOSITORY MODEL)
Publish
Name-location index
published for entities who
have gotten consent
Consent
Community Network
Patient chooses
which entity’s
records to make
available to
network
Jane Jones eCommunity Record
June 9, 2006
3
2
Y
Y
Y
1
N
Physician views data prior to
or during patient visit
Visit history
xxx
xxx
Active problem list
xxx
Dr. Jane Brody
Current medications
xxx
Seacoast Cardio
Current allergies
xxx
Dr. Jane Brody
Recent laboratory results
xxx
AJ Hospital
Recent radiology results
xxx
AJ Hospital
Y
4
Retrieve
Jane Jones
Jane Jones
Visit
Other
xxx
XXX
Patient visits clinical entity
for care and is provided
option at first visit to opt-in
all clinical data from EACH
entity
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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EVALUATION PROGRAM WILL SUPPORT THREE KEY PILOT
PROGRAM OBJECTIVES
Adoption
• What are the most significant adoption barriers?
• What are the best ways to overcome them?
Value
• What are the costs (direct and indirect) of adoption of IT?
• What are the benefits?
• How are the costs and benefits distributed across payers, providers,
government, patients, ancillaries, etc?
• How much money will be required to implement statewide?
Replication
• What is general framework of incentives to implement and sustain
the model?
• What are the most effective management strategies for implementing
and sustaining in communities?
• What are the most effective organization models and tactics for
implementing and sustaining statewide?
Efficacy vs Effectiveness
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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WHAT IS ROI?
Physician Office Example
Easier to measure
Return on
investment =
(ROI)
Harder to measure
• Cost saving
• Quality of care
• Time saving
• Error rate
• Revenue increase
• Patient satisfaction
• Physician/staff
satisfaction
• Liability exposure
Benefits
Costs
Easier to measure
Harder to measure
• Investment cost
• Quality of care
• Investment time
• Error rate
• Ongoing cost
• Patient satisfaction
• Revenue loss
• Liability exposure
• Physician/staff
dissatisfaction
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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MAeHC QUALITY DATA WAREHOUSE
CLINICAL MEASURES FOR PHYSICIAN PERFORMANCE
AQA Recommended Starter Set
1. Breast Cancer Screening
2. Colorectal Cancer Screening
3. Cervical Cancer Screening
4. Tobacco Use #
5. Advising Smokers to Quit
6. Influenza Vaccination
7. Pneumonia Vaccination
8. Drug Therapy for Lowering LDL Cholesterol#
9. Beta-Blocker Treatment after Heart Attack
10. Beta-Blocker Therapy – Post MI
11. ACE Inhibitor /ARB Therapy#
12. LVF Assessment#
13. HbA1C Management
14. HbA1C Management Control
15. Blood Pressure Management#
16. Lipid Measurement
17. LDL Cholesterol Level (<130mg/dL)
18. Eye Exam
19. Use of Appropriate Medications for People w/ Asthma
20. Asthma: Pharmacologic Therapy#
21. Antidepressant Medication Management
22. Antidepressant Medication Management
23. Screening for Human Immunodeficiency Virus#
24. Anti-D Immune Globulin#
25. Appropriate Treatment for Children with Upper
26. Appropriate Testing for Children with Pharyngitis
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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WHY DON’T WE JUST LET THE MARKET TAKE CARE OF THIS?
Current system pays for quantity, not quality
Physicians not trained or compensated to reduce fragmentation of care
Few if any incentives to reduce inefficiency, which rations care away from the
under-served
No obvious place for consumers to voice their concerns about quality, safety, and
protection of privacy
We have a societal interest in how implementation happens
•
Bad systems and/or bad implementations offer little, if any, value
•
Collective action and public goods barriers will prevent effective
interoperability
“In the long run, we’re all dead....”
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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LEVELS OF HEALTH INFORMATION
EXCHANGE
Level
Description
Examples
1
Non-electronic data
Mail,
Nophone
PC/information technology
2
Machine-transportable
data
PC-based and manual fax, secure
Fax/Email
e-mail of scanned documents
3
Machine-organizable
data
4
Machine-interpretable
data
Secure e-mail of free text or
Structured messages,
incompatible/proprietary file
non-standard content/data
formats, HL-7 message
Automated entry of LOINC results
from an
external lab
into a primary
Structured
messages,
care standardized
provider’s electronic
health
content/data
record
26
TECHNICAL STANDARDIZATION IS ONLY THE BEGINNING...
Percent
100
90
80
70
76%
60
•
•
•
•
Technical coordination
Policy coordination
Process coordination
Community coordination
50
40
30
5%
20
10
19%
0
Fax/email
Structured
messages
Standardized
content
Source: Center for Information Technology Leadership, MAeHC calculations
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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EARLY LESSONS LEARNED...
This can get done on a large scale, and it can get done collaboratively
Building the program is more difficult than originally anticipated
•
Fixed cost that we can leverage going forward
The market is shifting – getting attention of vendors somewhat harder than before
Affordability isn’t the only barrier to physician adoption
Starting the conversation creates a community – already seeing synergies
Where are we offering greatest value?
Slide title
•
Funding
•
Practice catalyst – facilitators/navigators
•
Community catalyst – wholesale vs retail
•
Forcing HIE
Massachusetts eHealth Collaborative
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...SUGGEST SOME LESSONS ABOUT HOW TO EXTEND THE
MODEL IN THE FUTURE
Community is an effective level of organization (“wholesale vs retail”)
•
Self-defined, cohesive.
•
Accept accountability for its members, apply peer pressure, and appeal to local
pride
•
Efficient to serve logistically
•
Natural unit for establishing health information exchange
Central coordination and active intervention are key success factors
•
Reduced costs for hardware, software, implementation
•
Dramatic reduction in failure rate
•
Speedier rollout and recovery of physician productivity
•
Application of best practices to realize the systems’ potential
The Golden Rule applies (“whoever has the gold makes the rules”)
Slide title
•
Direct funding increases compliance with best practices, including
standardization, structured data capture
•
Minimizes “paving over the cow-paths”
•
Enables community-wide benefit of HIE
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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www.maehc.org
Micky Tripathi, PhD MPP
President & CEO
mtripathi@maehc.org
781-434-7905
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
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