Health Information Exchange:
Value, Incentives, and How to get
there.
David C. Kendrick, MD, MPH
Asst. Provost for Strategic Planning, OUHSC
Medical Director for Community Medical Informatics
OU School of Community Medicine
Greater Tulsa Health Access Network
Agenda
• HIE Ongoing benefits: Value aside from ARRA
– Financial
– Clinical
• New, one-time opportunities: ARRA Incentives
in Oklahoma Terms
• How do we get there?
2007 COMMONWEALTH FUND Report
State Scorecard Summary of Health System Performance
OK
2009 State of the State’s Health Summary
Oklahoma is the only state where the death
rate has gotten worse…..
1,050
Some Factors
1,000
1.
950
Age-adjusted
Death Rates
2.
3.
900
Tulsa
US
4.
5.
6.
850
800
1980
1985
1990
1995
Past 25 Years
2000
2005
Economic downturn
healthy people and jobs
left Oklahoma
Poverty remained
Heart Disease –
(Diabetes)
Cancer
Access to Care
Obesity
Current Situation
Hospitals
(inpt)
Rx
ER/UC
Payers
Demographics
Medical claims
Pharmacy claims
Case mgmt records
Patient
Safety Net
Clinics and
community
agencies
Imaging
Doctor offices
EHR
Claims
Rx
Case mgmt
Community
outreach
Other
PCPs
Labs
Manual connection (mail, fax)
Electronic connection
Specialists
Ancillary care
PT/OT/Aud/Diet
Public
Health
What’s the value of HIE?
• 2004: Harvard Center for IT Leadership
published a report on the value of health
information exchange
• $77B in annual savings through Health IT
• Prompted, in part, the creation of the Office of the
National Coordinator for Healthcare IT (ONCHIT),
the Health IT “Czar”
• 2006: GKFF commissioned an OK-specific
evaluation of the value of HIE
Motivation
• Clinicians have incomplete knowledge of their
patients
– Relevant patient data not available in 81% of
ambulatory visits
– 18% of medical errors that lead to ADEs due to
missing patient information.
Tang 1994
Leape JAMA 1995
• Medicare patients see an average of 5.6
different providers each year= 5.6 silos of data
• What is the value of HIE for Oklahoma?
HIE Expert Panelists
•
•
•
•
•
•
•
•
•
David Brailer, MD, PhD
– Santa Barbara County Care Data Exchange, Health Technology Center
William Braithwaite, MD, PhD
– Independent consultant, “Dr HIPAA”
Paul Carpenter, MD
– Associate Professor of Medicine, Endocrinology-Metabolism and Health Informatics
Research, Mayo Clinic
Daniel Friedman, PhD
– Independent public health consultant
Robert Miller, PhD
– Associate Professor of Health Economics, UCSF
Arnold Milstein, MD, MPH
– Pacific Business Group on Health, Mercer Consulting, Leapfrog Group
J Marc Overhage, MD, PhD
– Regenstrief Institute, Associate Professor of Medicine, Indiana University
Scott Young, MD
– Senior Clinical Advisor, Office of Clinical Standards and Quality, CMS
Kepa Zubeldia, MD
– President and CEO, Claredi Corporation
HIE Value Construct
Public Health
Agencies
Payers
Pharmacies
Providers
Hospitals
Clinical
Laboratories
Radiology
Centers
Other Providers
HIE Value Construct
Avoided ADEs, drug
utilization savings,
automated
transaction sets
Public Health
Agencies
Payers
Avoided redundant
tests, Electronic test
ordering and results
delivery
Pharmacies
Providers
Hospitals
Clinical
Laboratories
Electronic referrals,
consultation letter
delivery, chart
requests
Electronic
submission of
reportable
conditions and vital
statistics
Electronic Rx, refills,
interaction checking,
adherence data
Radiology
Centers
Other Providers
Avoided redundant
imaging, Electronic
imaging ordering
and results delivery
Value to Oklahoma
Public Health
Agencies
$1.5
Payers $136
$16 Pharmacies
$1.5
$127
$10
Providers
Provider
Hospitals
$141
$116
Clinical $123
Laboratories
$39
$99
$39
Other Providers
$ Millions
Radiology
Centers
Value by Stakeholder: Oklahoma
Public Health
Agencies
$1.5
Payers $136
$16 Pharmacies
$1.5
$127
$10
Providers
Provider
Hospitals
$141
$116 Per
Adverse Drug Event (ADE) Clinical Results
Physician
$39
Preventable
8.9
Clinical
$123 ADEs Avoided
Laboratorieslife-threatening ADEs Avoided
Preventable
0.59
Avoided ADE-related visits
5.6
$39
Avoided ADE-related hospitalizations
0.82
Other Providers
$ Millions
Oklahoma
25,000
Radiology
$99 Centers
1,700
16,000
2,300
Net value of HIE
Tulsa:
Oklahoma
City:
Oklahoma:
Benefit
Cost
Net Value
Implementation
Years 1-10
$ 1.6 Billion
$ 0.7 Billion*
$ 0.9 Billion
Annual, Steady-State
Starting Year 11
$ 250 Million
$ 42 Million*
$ 210 Million
Benefit
Cost
Net Value
Implementation
Years 1-10
$ 2.0 Billion
$ 1.1 Billion*
$ 0.9 Billion
Annual, Steady-State
Starting Year 11
$ 310 Million
$ 71 Million*
$ 240 Million
Benefit
Cost
Net Value
Implementation
Years 1-10
$ 6.4 Billion
$ 2.7 Billion*
$ 3.7 Billion
Annual, Steady-State
Starting Year 11
$ 990 Million
$ 160 Million*
$ 830 Million
*Software as a service, Cloud computing, and Interoperability
standards have lowered the cost of implementation and
maintenance by an order of magnitude
But wait, there’s more . . .
• CMS and Medicaid Incentive payments for
“Meaningful use of an EHR”:
– $44,000 to Medicare providers, $63,000 to Medicaid
– Formula-driven bonus to hospitals: $2-11M per hospital
• What does this mean to OK?
– Assume 9,000 MD’s, DO’s, PA’s, NP’s are eligible
– Assume the following hospital bed distribution:
Less Than 50 =
From 50-199 =
From 200-399 =
400 or more =
146
Facility
80
51
9
6
STATE TOTALS
Admissions
Beds
51,060
2,074
146,885
4,595
223,154
2,555
157,088
3,250
578,187
12,474
CMS wants EMR and HIE adoption . . .
*Assume N=9,000 MDs, DOs, PAs, and NPs focused 30% of the time on Medicare
patients, and 12,474 hospital beds
National: Meaningful Use guidance
• In order to qualify for bonus payments (and
avoid penalties)
– By 2011, the following must be exchanged:
• Doctors: Problem lists, medication lists, allergies, test
results
• Hospitals: Discharge summaries, procedures, problem
lists, medication lists, allergies, and test results
– By 2013, the following must be exchanged:
• Doctors: Share all care transition data across the
community electronically
• Hospitals: Share all care transition data electronically
HIE Progress to date
• Early summer: Small working group met and produced a document:
– Outlined 14 “Items for consideration”
• July 30th: Major stakeholder’s meeting. ~35 people
– Reduced “Items for consideration” from 14 to only 3:
• Meet requirements established by Federal legislation for funding
• Establish planning process, including HIT Policy Committee
• Identify the State Designated Entity
– Agreed that OHCA could be the temporary custodial State Designated
Entity until the planning process is complete or October 16, whichever
comes first.
• August 14: OKHITECH Summit held, wide invitation list, comments and
feedback sought
• August 14-21: Online comment period
• August 20: State HIE Cooperative Agreement Program (SHIECAP) Released
State HIE Cooperative Agreement
Program (SHIECAP)
• Governor must identify State Designated Entity
• Each applicant must have a State Coordinator for
Healthcare IT
• Focus: State Strategic Plan and Operational Plan
• States without plans can spend as much as 6
months on a planning process
• Applicants who fail to submit acceptable plans
will be subsumed into other nearby states
State HIE Cooperative Agreement
Program (SHIECAP)
• Approval: Merit-driven
• Funding: (mostly) Formula-driven
– $4M base for 50 successful applicants
– Additional funding up to $36M per applicant apportioned
thusly:
•
•
•
•
•
applicant region‘s population (5%),
number of PCPs (40%),
Acute Care Hospitals (30%), and
Medically Underserved and Rural Providers (25%).
A final 10% of the total funds will be apportioned based on an
assessment of the relative HIT need of the region, as determined
by evaluation of the Letter of Intent.
– Oklahoma’s likely take: $6-8M
Deadlines and current status
• September 11: Letter of Intent Due
– State Designated Entity- Done, at least temporarily
– Review of existing capabilities statewide
– Report of total expenditures to date in 5 key areas
• October 16: Final application due
– Details of planning process
– Key individuals identified to execute the process
• December 15: Award announcements
• January 15: Work begins
Thanks!
David-Kendrick@ouhsc.edu