Electronic Health Records and Exchange of Health Information

1. Electronic Health Records and Exchange of Health Information Anthony Rodgers, Director Arizona Health Care Cost Containment System August 28, 2009

2. Definitions- HII, HIE and HIT HII Health Information Infrastructure The wider arena of policies, procedures, technologies and industry standards that facilitate secure and accurate online sharing of electronic medical information between providers, payors and ultimately, patients and their guardians via HIE/HIT. HIE Health Information Exchange “The Network” The electronic movement of health-related information among organizations according to nationally recognized standards. HIT Health Information Technology “The Record” Use of technology to support storage, retrieval, sharing, and use of healthcare information for communication and decision making within healthcare organizations.

3. Definitions- Network Terms HIE Health Information Exchange The electronic movement of health-related information among organizations according to nationally recognized standards. HIO Health Information Organization An organization that oversees and governs the exchange at health-related information among organizations according to nationally recognized standards. RHIO Regional Health Information Organization A health information organization that brings together healthcare stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community. Source: National Alliance for Health Information Technology Report to HHS/ONC

4. Definitions- E-Records Terms EMR Electronic Medical Record An electronic record of health-related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one healthcare organization. EHR Electronic Health Record An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and consulted by authorized clinicians and staff across more than one healthcare organization. PHR Personal Health Record An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared and controlled by the individual. Source: National Alliance for Health Information Technology Report to HHS/ONC

5. State Opportunities for Funding HIT Hospitals Appropriation Program Area Agency Categories of Funds Medicare EHR Incentive Program $23.1 B CMS Medicare $745 M EHR Incentives via Carriers & TPA Doctors EHR Incentive Funds $46.8 Billion Medicaid EHR Incentive Program $21.6 B CMS Medicaid $300 M State Medicaid $1.05B Incentive via State Medicaid Health Centers HITECH FUNDING PROVISIONS ONC Planning Grants HIE Planning & Implementation $300 M Implementation Grants State Designated Entity Loan Funds for States Other Providers Appropriated Grant Funds $2.0 B EHR Adoption Loan Program TBD Health IT Research States Regional Tech Program Regional Tech Centers Universities Medical Informatics HHS NSF Workforce Training Tribes EHR For Med Education GME Training New Technology Research HIT Enterprise Research Research

6. State Readiness Check List • Has an state level environmental scan and gap analysis been completed? • Is there a comprehensive state level strategic HIT plan with specific measurable goals and project accountabilities? • Is the public and private health care leadership engaged and organized? • Do you have key stakeholder involvement in HIT adoption and governance? • Has the State established a supportive regulatory environment for adoption of HIT? • Has the Governor identified the state’s designated entity and state’s agency level coordinator for HIT? • Has the role of the Medicaid agency in EHR adoption been clarified and properly resourced? • Is there and organized HIE governance structure for statewide exchange of health information? • Is there a common technology platform for HIE? • Will you have adequate public and private capital for financial sustainability of the statewide health information system infrastructure and HIE operations? • Has the state identified potential regional centers to provide the technical and user support resources for provider EHR adoption and support to achieve meaningful use?

7. Developing State Specific Strategies States need to plan and implement their specific strategies for achieving wide spread adoption and meaningful use of electronic health records including: • Strategies for building state HIT infrastructure development and governance • Strategies for supporting successful provider EHR adoption • Strategies for financing and sustaining HIT at the state level

8. Federal Grant Program for State HIE Cooperative Agreements Requires states to: • Identify State Designate Entity or State Authority, • Appoint a agency level HIT coordinator • Develop and implement strategic and operational plans for HIE development, • Develop state level directories and enable state wide technology platform for HIEs, • Develop HIE business and operational processes • Be committed to removing barriers to health information exchange and interoperability between electronic health information system. For meeting those requirements states will be eligible to receive $4 to $40 million in federal support over the next four years.

9. Building State Wide HIT Infrastructure • HIT infrastructure development process • Health information data sources • Establish Health Information Organizations • Build data exchange systems • Identify health information business associates • Identify most commonly used electronic health record systems • Clinical Data Repositories • Organize health information users community • HIT business and operational processes • Security and Privacy • Operations management and accountability • Reliability and State wideness • State designated authority • Governance • Long range HIT planning and development • Policy setting and removing barriers to health information exchange • Standards verification • Project and funding priority setting • Oversight • Financing mechanisms • Public and private contributions • Payers contributions • Providers use fees • Consumers subscriptions fees • Data exchange fees • Provider user support and technical Assistance • Technical Assistance Extension Centers • Medicaid • Others

10. State-wide HIT Strategic Alignment

11. Return on Investment From HIT

12. ROI of EHI at Point of Care: • Improved Patient Safety • Reduced Complications Rates • Reduced Cost per Patient Episode of Care • Enhanced cost & quality performance accountability • Improved Quality Performance Lower Costs Return on Investment: Wide Spread Adoption of Electronic Health Information (EHI) Technologies Can Better Outcomes and Lower Cost Improving Health Care Quality and Cost Performance Better Outcomes

13. Statewide Health Information Exchange

14. Building the State Level HIT Infrastructure EHR1 HIE EHR2 EHR3 EHRn Labs EHR1 EHR2 EHR3 Rxs EHR4 PHR5 Aggregate Database Other PHRn • Highly desirable to couple with HIE

15. Nationwide Health Information Network

16. Adoption and Meaningful Use of Electronic Health Records

17. Regional Centers to Support EHR Adoption and Meaningful Use • Non-profit organizations are eligible to be awarded federal funds to create a regional center(s) for the purpose of providing on-going EHR user support, education, and outreach. • Regional centers • Must serve a minimum of 1,000 priority primary care providers • Disseminate knowledge about best practices, how to select an EHR, how to achieve meaningful use and improve quality. • Participate in a national learning consortium • Partner with local resources such as community colleges. • Provide EHR user support for practice and workflow redesign • Assist provides to connect to HIE • Assist provider with EHR vendor evaluation and selection • Support EHR implementation project management • Assist provider with meeting meaningful use requirements State are eligible to receive $1.0 to $30.0 million dollars in federal funding for Regional Centers

18. Electronic Health Records Incentive Program • Medicare will manage the Medicare EHR incentive program possibility through contract Quality Improvement Organizations (QIO) • The Medicaid will manage the Medicaid EHR incentive program. • The incentive payments can be made to qualifying providers and hospitals starting January 2011.

19. Medicare & Medicaid EHR Incentives for Hospitals • Criteria: • Demonstrates meaningful use of a certified EHR in the hospital setting • Demonstrates that Hospital EHR is connected to a statewide health information exchange infrastructure that support care coordination • Provides specified clinical quality reports and outcome performance

20. MedicareIncentives for Non-Hospitals/Providers • Criteria: • For eligible professionals in a healthcare professional shortage area (HPSA), • the incentive payment amounts will be increased by 10% • Payments are not available to hospital-based professionals, such as • pathologist, emergency room physician, or anesthesiologists) • 3. In 2015 Medicare starts reducing provider Medicare payments for not having EHRs

21. Medicaid EHR Incentives for Non-Hospitals/Providers Criteria: Must demonstrated meaningful use for certified electronic health record Must have at least 30% Medicaid volume (pediatrician must have only 20% workload volume). 3.Ability to produce quality reports and demonstrate improved quality outcomes

22. Managing the Medicaid EHR Incentive Program • Definition of Meaningful Use in Medicaid • Office of National Coordinator’s meaningful use requirements establishes the states minimum standards • A clear set of meaningful use requirements for each category of eligible provider must be approved by the Secretary HHS • Create a process to audit and validate provider EHR meaningful use • Medicaid EHR incentive program administration • Develop state specific policies and procedures for administration of Medicaid EHR incentive program • Develop and implement Medicaid provider education and EHR adoption assistance coordinate with regional extension centers. • Identify providers/hospitals that will be participating in EHR incentive program and track progress • Phase in of meaningful use requirements over three to five years • Establish a specific payout schedule for Medicaid incentives payments • Consider providing other recognitions for physician EHR adoption especially for providers that don’t qualify for Medicaid or Medicare EHR incentive. • Validate return on investment in quality improvement and cost containment

23. Developing a Performance Outcomes for HIT Performance Outcomes Strategic HIT Focus Areas HIT Strategic Performance Metrics Reduced Unnecessary Cost/Utilization = Reduced PMPM & Lower % Admin Cost Meaningful Use of EHR to reduce Duplication, Errors and improve Admin Efficiency Cost Containment Quality Improvement Meaningful Use of EHR to better coordinate care and Quality Performance Improved Quality Against HEDIS and Other Benchmarks Strategic Planning Logic Map Higher Provider Satisfaction & Reduction in Admin. Cost Administrative Efficiency Meaningful use of EHR to Reduce Admin. Process Cycle Times Public Health & Research Meaningful Use of EHR to build Population Health Mgmt. & Research Public Health Responsiveness Reduction in Health Disparities Meaningful USE Barrier PERFORMANCE Management Barrier

24. Strategies to Support Provider EHR Adoption and Meaningful Use • Regional Centers for EHR technical support and • Medicaid program EHR support of provider adoption • Graduate medical education training programs EHR adoption • Federal outreach and education • Other state agencies • Hospitals and major group practices

25. State Level HIT Financing Strategies • Federal EHR incentive funds for Medicare and Medicaid • Pool EHR provider financing support • Payers • Hospitals • Others • Transaction or user fees to support HIE sustainability • Health plan tax or fee for HIE support • 90/10 federal Medicaid funding • Regional Center Grants • Research fund assessment

26. Gartner Consulting EHR Findings Key Findings • Physicians in small practices need help — financial and logistical — to implement EHRs. • Organizations that help physicians implement EHRs often overlook the need to select and implement products in a way that enhances the physician's day-to-day effectiveness. • Used properly, an EHR subsidy or implementation support can assist hospital organizations in physician bonding.

27. Gartner Consulting Recommendations Those setting the approach to assisting physicians in choosing or implementing EHRs should follow these recommendations. • Establish partnerships with EHR vendors that place the overall responsibility for implementation on the subsidizing and assisting organization. • Don't rely on vendors to determine the readiness of practices for EHR implementation. • Maintain a continued, central role in advising physicians, monitoring progress, and sustaining the ongoing relationship between the practice and the vendor. • Choose products that integrate practice management and EHR capabilities. • Strongly encourage practices to replace practice management systems with an integrated product. • Evaluate and advocate products that facilitate reliability, networking options, and remotely hosted EHRs that do not require a thick client.

28. Logical Phases of State Level HIT Development2010 thru 2015 Phase 1 HIT infrastructure planning and development phase Phase 2 EHR initial implementation and initial meaningful use: • Practice workflow redesign • Training and EHR user technical and system support Phase 3: EHR managed performance phase • Improved coordination of care and care integration • Process improvement outcomes Phase 4: EHR meaningful use optimization • Improved quality and cost effectiveness outcome • Maximized return on investment

29. Structural Development Phase2010 thru 2012 • Acquisitions and Installation of a certified EHR • E-prescribing • Computerize order entry results reporting • Quality reporting capabilities • Clinical Decision Support capability • Building the exchange health information infrastructure, interfaces and operational processes • Development of clinical data repositories and disease registries • Providing ongoing User support for provider practices, and hospitals and process reengineering

30. EHR “Initial Use” Phase2011 thru 2013 • Building EHR Meaningful Use Competency (EHR System Burn In) • On-going technical assistance and support for provider practice EHR adoption • Focus shifts to process and practice productivity improvement • Data conversion assistance and support • Implement EHR system failure “risk reduction” strategies • Continue to build health information exchange interfaces with various external healthcare data sources

31. EHR Managed Performance Phase2012 thru 2014 • Develop quality networks for comparable performance analysis and improvement • Enhance specific EHR configuration to achieve effective use of clinical decision support • Build web based health-e learning programs and personal health records for patients and to improve self management (electronic reminders, instant messaging, and telehealth) • Enhance use of telemedicine • Electronic performance reporting • Enhance disease registries

32. EHR “Optimized Use” Phase2014 and Beyond • System configuration for optimization of integrated patient management • Optimization of system configuration for episode of care management • Patient center care • Best practice • Improved patient and provider engagement and connectivity • Advanced messaging and alerts • Integration of Web 2.0 functionality for patient support and care management • Integration of remote monitoring tools, telemedicine, telehealth and health e-learning functionality and tools • Integration of health plan care management systems • Translational research and enhanced quality network infrastructure

33. The Connected Healthcare System Hospital Care Coordination Diagnostics Specialist Referral Primary Care Medical Home Provider Order Entry Lab Result Reporting EHR/HIE Research E-Prescribing Remote Patient Self Monitoring MCO Medical Medical Mgmt.

34. Discussion or Questions