April 2013 Adel A. Al-Marshad, MD Emergency Medicine UC San Diego Health Sciences

1. April 2013 Adel A. Al-Marshad, MD Emergency Medicine UC San Diego Health Sciences

2. “ Information should follow the patient, and artificial barriers – technical, business-related, bureaucratic – should not get in the way ” • David Blumenthal, MD, Former Director, ONC

3. Technology, Innovations and Emergency Medicine – Where is the Value? • Providers in the ED: Full picture of the patients, including access to previous tests, becomes available real time • Providers in the ambulatory setting: Understanding of when their patients end up in the ED due to an exacerbation – could it have been avoided? • Providers out in the field (EMS): Close alignment with hospital if acute action is required – long term potential to generate hot-spotting data.

4. Overview • Funded by ARRA HITECH Act administered by the Office of the National Coordinator for Health Information Technology • $15 million over three years to use health IT to improve health care delivery in San Diego as model for nation • Transition from a grant-funded initiative to an self-sustaining independent organization providing services to the health care community

5. San Diego No dominant health care entity (Scripps, Sharp, Kaiser, Rady, UCSD) 24% of all 30-day readmissions occurs at a different hospital than the first admission (nearly 30% for Medi-Cal patients) 15% of all ED patients and 69% of “frequent fliers” were seen in multiple hospitals

6. San Diego Beacon Redundant Tests ED/hospital Readmissions Childhood Immunizations Syndromic Surveillance Cardiovascular Disease Build and Strengthen Health IT • Community Health Information Exchange 3 Part Aim Test Innovative Approaches

7. Initiatives Clinics Hospitals SD VA/DOD Kaiser EMS Others County PH

8. Meaningful Use

9. San Diego Beacon Cardiovascular Disease Childhood Immunizations Syndromic Surveillance Redundant Tests ED/hospital Readmissions Improve Quality, Population Health, Costs

10. Improve Cost, Quality, andPopulation Health www.sandiegobeacon.org

11. Health IT

13. Two recent studies indicate significant cost savings, reduction in testing in EDs with access to community HIE

14. HIE: Quality & Cost • Patients seek care at different systems • Lack of timely patient information at point-of-care • Care not coordinated among providers • Medical errors • Risks of unneeded evaluation • Increased Costs • Repeat testing • Redundant evaluations

15. Care Transitions Initiative • Collaboration between San Diego County HHSA and San Diego Beacon Community • Reduce 30 d readmissions for high-risk population by connecting these patients to social services in the community • 460 pts enrolled from 3 sites: UCSD-Hillcrest, Scripps-Mercy, Sharp Memorial

16. ED Visits in San Diego

17. Care Transitions Initiative • Initial Results: 18% baseline 30d readmission rate reduced to 13%

18. Other Initiatives • Real-time reporting for Public Health Meaningful Use • EMS Hub: Transmit & track EMS data • Targeted readmissions reduction efforts • Messaging & notification to providers, health plans, and payers • CRM Device data and other innovation initiatives

19. Test Innovative Approaches • Frequent Fliers / Hot Spots • 1% of SD population generates over 10% of 911 EMS calls • Disproportionately consume acute, emergency, and safety net healthcare resources • Care provided is often mismatched with need creating a recurring cycle

20. San Diego Beacon Community • The EMS hub is an active real-time information exchange between pre-hospital providers and hospitals in San Diego.  The system currently serves the entire San Diego City EMS region (1.7million) and 3 receiving hospitals, with expansion plans to all area hospitals. • Since launching 6 months ago, over 40,000 prehospital records have been sent electronically to hospitals includingfield 12-lead ECGs; reducing false activations of the cardiac catheterization lab, improving resource utilization and reducing costs. • During the first 6 months of the project, total field cardiac catheterization lab activations were reduced for the 3 area hospitals compared to the period before the intervention

21. Test Innovative Approaches • eRAP • Utilize 911/EMS data to identify FF (name), HS (location), or key word • Trigger alerts to EMS case manager • Case manager coordinates with healthcare providers, social services, law enforcement to get the right care for the individual • Senior services, Housing, Treatment, other resources

22. Test Innovative Approaches • Alerts & Actions Specific Neighborhood Hot Spots Specific Patients Project 25

23. ImageTrend MN EMS Hub San Diego San Diego, CA

24. eRAP • eRAP alerts to EMS Case Manager initiated in October 2011 • Decrease in repeat visits to ED and subsequent admissions UCSD Visits by eRAP patients

25. eRAP Alerts & P-25 Program • Project 25 Example • eRAP alerts created for Project 25 clientele • Project 25 – Homeless clients identified by high 911 usage. Clients enrolled in housing and social support program funded by the United Way • eRAP alerts case manager real-time when Project 25 client accesses 911

26. Test Innovative Approaches • Field Electronic Record & NLP Alerts

27. Test Innovative Approaches Elderly patient with frequent falls, 911 access, ED/hospital visits Electronic alert fired on APS text in pre-hospital record Case manager evaluated patient in field, contacted Adult Protective Services and directed patient to appropriate social services support

28. eRAP Alerts & P-25 Program • P-25 Impact at UCSD • Comparison of ED visits by P-25 clients 6 months before and 6 months after enrollment Financial Impact

29. Ambulance ECG Transmission • Reduced false-positive catheterization activations at San Diego hospitals with significant cost savings • UCSD, Rady, Navy, Sharp live on EMS Hub

30. Public Health Reporting • Over 700,000 lives covered to meet Meaningful Use Stage 1 reporting requirements for Immunization Reporting (participants include UCSD, Rady, Sharp, Council of Community Clinics) • SDB to have SDIR mirror server to meet MU Stage 2 requirements • Testing for Syndromic Surveillance reporting

31. Bangor Beacon Community • The value of exchange: Medical records are shared through our statewide health information exchange – HealthInfoNet. Right now, 22 hospitals and several ambulatory practices across the state are participating. • Early results for “high risk/high cost patients” who are actively being case managed (note: interventions include more than access to HIE, n = 721, comparing baseline to 6 months): • Patients with at least one ED visit: 26.5% down to 17.7% • Patients with at least one non-urgent care visit: 19.9% down to 12.8% • Patients with at least one hospitalization: 25.7% down to 14.2%

32. Greater Cincinnati Beacon Collaboration • The value of ED alert systems to patients, families and providers: 69 Beacon physician practices are currently receiving alerts, 18 to go. Participating hospitals include Mercy Health, TriHealth, UC Health, Cincinnati Children’s, St Elizabeth Health Center, The Christ Hospital • The practice transformation has begun when the team is learning how to best respond to the alert and “pulling the patient in for care” rather than expecting the patients to call after an ED visit of hospitalization. • Around 60% of the time, the patient had X-ray done while at the ED. Practice outreach to that family has made them aware of open access scheduling in the practice and helped coach the family on how to handle episodes in the future. 

33. CCTP • Community-based Care Transitions Program • $15m grant over 3 years • Partnership between the HHSA/AIS, Palomar Health, Scripps, Sharp and UCSD -11 hospitals with 13 campuses • Targets 21,000 Medicare SD lives for case management and care coordination • Goal to reduce 30day readmissions rate

34. Community HIE • Patients seek care at different system - Lack of timely information • Lower Quality - care not coordinated among providers • Increased Costs – repeat testing, evaluations • Providers access patient information during treatment encounter • Summary information (meds, allergies, problem lists) • Documents (DC summaries, notes, procedures) • Images (radiology, ECGs, etc)

35. Long-term Vision • Clinical benefit and improved care • Patients, providers, organizations • ROI for all participants • Patients see personal health value • Care delivery efficiency gains, lower costs • Support new care models (case management, coordination, ACOs) • Federal funding for providers connecting to other organizations electronically

36. Devices - Geneva Healthcare EMR/HIE

37. Heart Failure Monitor At-a-glance Dashboard Latest Episode Info Summarized History EMR Integration In-ER Interrogation Upload

38. IDCO Profile Data Expandable EP Window Embedded EKG

39. DELPHI • Develop a platform to enable integrated access to, analysis and use of all data relevant to health – medical record, genomic, behavioral, environment (built/natural) • Overall vision is to develop and pilot a local “ecosystem” with low barriers of entry to mobile device and app developers of all kinds • Partners: Qualcomm, SD Beacon Community, SD County, SANDAG, CONNECT PI: K. Patrick; Co-PI’s: C. Baru, T. Chan, S. Dasgupta, B. Griswold, J. Huang, L. Ohno-Machado, Y. Papakonstantinau NSF 1237174, Information & Intelligent Systems – Project Dates: 2012-2016

40. DELPHI

41. Multiple sources of health data • Webified hospitalmedical record systems • Personal health data(weigh-ins, run info on apps, meals…) • Genomic data(mutations, …) • “Environmental” data(pollution, food deserts…) • Online research troves(journals, some data) SANDAG

42. Messaging/Notification • System can utilize ADT moment or patient index list to generate message/notification and recipient • Secure direct email addresses available • Limited clinical data to reduce risks • Consent vs HIPAA requirements • Utility for providers, plans, payors, others • In development with CHG, Molina • Interest from UHG, P25, others

43. Messaging/Notification • Real-time patient event notifications • ED visit, hospital admission/discharge • Secure delivery of event information to interested parties (secure email or website posting)

44. Relevant components of ADT Registration Message MSH|DATETIME|REGISTRATION EVENT PID|MRN^LOCATION|LNAME^FNAME^MNAME|DOB|SEX|ADDRESS|PHONE NUMBER| PV1|INTERNAL PROVIDER ID^PROVIDER NAME^PROVIDER LOCATION^PROVIDER TYPE DG1|DIAGNOSIS|

45. Community Governance • Independent entity established • Initial board slate with representation from major healthcare providers in San Diego

46. PHI Security • Each participating organization maintains its own consent policy around sharing health information • No clinical data are stored centrally • Data storage and transmission protocols adhere to the most recent security guidelines

47. Long-term Vision • Clinical benefit and improved care • Patients, providers, organizations • ROI for all participants • Care delivery efficiency gains, lower costs • Support new care models (case management, coordination, ACOs) • Federal funding for providers connecting to other organizations electronically

48. Questions? Adel A. Al-Marshad, MD aalmarshad@ucsd.edu