Regional Health Information Exchange .. Laying the Foundation for a New Revolution in Patient Care

1. Regional Health Information Exchange .. Laying the Foundation for a New Revolution in Patient Care Mark D. McCourt Global Solution Sales Leader Interoperability and Clinical Decision Intelligence

3. Several major trends will have a have profound effect on the delivery and financing of healthcare in 2010 Value Based Purchasing and Reimbursement Consumers and payors (employers, health plans, and governments) will increasingly direct their health care purchasing or reimbursement dollar based on value Information Liquidity Advancements in pervasive technologies, interoperability and genomics will increase the availability of meaningful health information. Such information and new decision support approaches will enhance the healthcare ecosystem�s ability to manage and improve the health of populations and individuals across geographies and the continuum of care The Informed Consumer The increasing thirst for healthier lives and preserving youth, increased out-of-pocket costs and the proliferation of the health information will transform many patients into active health care purchasers

4. Change is scary to many people, even the positive outcomes

5. Global Healthcare Challenge: Deliver high quality, service, and access, with a sustainable cost structure Current pressures on the healthcare industry raise the urgency to act Costs Cost of care delivery continues to rise; linked to demand, inefficiency, and errors Government and private industry demanding reform in Healthcare to slow inflation Resources Limited capital for investment Limited pool of resources to meet anticipated demand for service Demographics and Capacity Aging population projections will strain the current infrastructure Public health deficiencies being thrust to the forefront of healthcare agenda Technology The maturation of collaborative technologies and analytical tools Public agencies focus on informatics as tool for governmental reform Investment in Information Technology for improved collaboration has proven to drive cost down in other industries Issue #6: Lack of Capital Investment. The industry under-invested in capital expenditures during the 1990s. In many markets, hospitals are playing catch-up, expanding and building new facilities. Many hospitals lack access to capital, and their investment income, which previously funded capital projects, has been squeezed by poor returns on Wall Street.  A year-long research project, led by the Healthcare Financial Management Association (HFMA) in partnership with GE Healthcare Financial Services and with research led by PricewaterhouseCoopers, has identified a clear trend of hospital capital expenditures lagging historical trends and shows a clear gap between the "haves" and "have nots" in the area of capital access. Furthermore, the Office of Inspector General (OIG) added a review of hospital capital expenditures as one of their work plan items to the 2004 report. Internal Audit risk management warrants efforts to understand your hospital's facilities plan to prepare for the future and understand implications of the OIG work plan matters, if any. Issue #7: Accelerating Costs/Staff Shortages.Healthcare systems and community hospitals are facing a growing dilemma �� rising labor and malpractice costs with an accompanying shortage of nurses and staff. The U.S. Bureau of Labor Statistics last year projected that for the decade 2000-2010, registered nurses would be the third largest growth occupation in numbers of new positions needed; personal/home care aides and medical assistants will be the fastest growing occupation additions. To address these cost pressures, many hospitals have been proactively instituting changes to drive bottom-line growth including increasing utilisation of staff, flattening responsibility throughout the organization, centralization, outsourcing, and benefit and insurance restructuring, to name a few. Internal Audit should ensure such changes to the related control processes do not compromise the hospital's overall financial reporting and control environment. Issue #6: Lack of Capital Investment. The industry under-invested in capital expenditures during the 1990s. In many markets, hospitals are playing catch-up, expanding and building new facilities. Many hospitals lack access to capital, and their investment income, which previously funded capital projects, has been squeezed by poor returns on Wall Street.

6. Healthcare: All Signs Point to a need to Increase Quality of Care while Reducing the Cost of Delivery Medical errors, many of which can be prevented, are too common - the Institute of Medicine estimates that 44,000 to 98,000 people die each year from medical errors in the hospital[1] Medication errors are found in 1 of every 5 doses given in the typical hospital and skilled nursing facility, and 7% of those are potentially harmful (more than 40 per day in a typical 300-patient facility)[2] Health insurance costs have risen over 10% in each of the past three years.[3] Better information systems are essential to reducing health care costs One study concludes that 14% of hospital admissions occur because physicians do not have access to complete patient information 17 to 49% of diagnostic laboratory tests are performed needlessly, because medical history and the results of earlier studies are not available when the new tests are ordered.[4],[5] We have no nationwide monitoring system to identify bio-terrorism in a timely manner, to identify potential epidemics at an early stage, to identify patterns of adverse drug reactions, or to integrate a geographically disperse Pt record [1] �To Err Is Human: Building a Safer Health System (2000).� Institute of Medicine (IOM) http://www.nap.edu/openbook/0309068371/html/ [2] Barker KN, Flynn EA, Pepper GA, et al. Medication errors observed in 36 healthcare facilities. Arch Int Med. 2002;162:1897-1903. [3] The 2003 Kaiser Family Foundation and the Health Research and Educational Trust Employer Health Benefits 2003 Annual Survey found that increases in health insurance premiums were 10.9%, 12.9%, and 13.9% for 2001, 2002, and 2003 respectively. See http://www.kff.org/insurance/ehbs2003-1-set.cfm for details. [4] Tierney WM, McDonald CJ, Martin DK, Hui SL, Rogers MP. Computerized display of past test results.: effect on outpatient testing. Ann Intern Med. 1987;107:569�74. [5] HIMSS. �EHR and the Return on Investment.� 2003. http://www.himss.org/content/files/EHR-ROI.pdf The U.S. health care system is challenged by longstanding problems of preventable errors, uneven quality, and rising costs. The root causes of these problems are the limited capability of the human mind for memory and complex problem solving, the separation of necessary patient information and medical knowledge from the decision makers at the point of clinical decision-making, an information recording system that relies heavily on human interpretation (e.g., handwriting, dosages), and the impossibility of human health care providers keeping up with the fast pace of medical knowledge advancement. The solution is greater reliance on IT to present the health care provider with appropriate patient information and medical knowledge at the point of clinical decision-making, to record clinical concepts and events in standard, legible, and computable ways, and double-check for potential errors whenever decisions are made. Currently there is a widespread lack of such a health information technology infrastructure in U.S. hospitals, outpatient settings, and other sites of care.The U.S. health care system is challenged by longstanding problems of preventable errors, uneven quality, and rising costs. The root causes of these problems are the limited capability of the human mind for memory and complex problem solving, the separation of necessary patient information and medical knowledge from the decision makers at the point of clinical decision-making, an information recording system that relies heavily on human interpretation (e.g., handwriting, dosages), and the impossibility of human health care providers keeping up with the fast pace of medical knowledge advancement. The solution is greater reliance on IT to present the health care provider with appropriate patient information and medical knowledge at the point of clinical decision-making, to record clinical concepts and events in standard, legible, and computable ways, and double-check for potential errors whenever decisions are made. Currently there is a widespread lack of such a health information technology infrastructure in U.S. hospitals, outpatient settings, and other sites of care.

8. The traditional institutional approach to systems and data management make it extremely challenging to deliver and interpret information

9. Moving Toward Improving Quality of Care Departmental Automation

10. Health Care in the 21st Century �During the next decade, the practice of medicine will change dramatically, through genetically based diagnostic tests and personalized, targeted pharmacologic treatments that will enable a move beyond prevention to pre-emptive strategies.� -Senate Majority Leader, Bill Frist, MD �Health Care in the 21st Century� New England Journal of Medicine, Jan. 2005

12. IBM endorses the Health and Human Services �Decade of Health� strategic framework which gives the industry a starting point on the road to a national health policy

13. Interoperable healthcare networks can improve the efficiency, cost effectiveness, and safety of healthcare, while delivering the greatest possible health benefits and value to consumers Taconic IPA � MVP � TPA 4 hospitals, 500 physicians, payer getting pulled into the loop. IBM acting as catalyst�have 60k employees in areaTaconic IPA � MVP � TPA 4 hospitals, 500 physicians, payer getting pulled into the loop. IBM acting as catalyst�have 60k employees in area

14. Forrester recently reported the following as a list of active community clinical sharing projects, but we already know that many others are brewing

15. While a common vision is developing, the approaches to clinical information sharing vary widely

16. We view the RHIO focus from the U.S. Federal Government as a catalyst to realize the network effect of information in healthcare Concentric circles of benefits�benefits can be had at different levels..don�t need to do everything at once. Focus and think about a roadmapConcentric circles of benefits�benefits can be had at different levels..don�t need to do everything at once. Focus and think about a roadmap

17. The ability to aggregate information in a format that allows analysis across the community can enable quality measurement and improvement Conceptually simple, special cases make it hard. Still, the most difficult part is setting up the governance and sustainable business model up front. Discuss federated model vs. aggregation model and relative benefits. Real-time information access vs. long-term retrospective analysis / outcomes Identification and normalization once vs. every time you access the data. Not practical for research Many organizations starting simple (federated) with plan to grow to a full repository implementation. Types of RHIOs IDN (Corporate) RHIO IPA (Taconic) Consortium (Santa Barbara � Comprehensive integration of multiple county stakeholders) Functional RHIO (NCI � distributed physical locations, functional relevance � i.e. Leukemia patients) Public Health (Indigent care populations)Conceptually simple, special cases make it hard. Still, the most difficult part is setting up the governance and sustainable business model up front. Discuss federated model vs. aggregation model and relative benefits. Real-time information access vs. long-term retrospective analysis / outcomes Identification and normalization once vs. every time you access the data. Not practical for research Many organizations starting simple (federated) with plan to grow to a full repository implementation. Types of RHIOs IDN (Corporate) RHIO IPA (Taconic) Consortium (Santa Barbara � Comprehensive integration of multiple county stakeholders) Functional RHIO (NCI � distributed physical locations, functional relevance � i.e. Leukemia patients) Public Health (Indigent care populations)

18. For stakeholders to maximize benefits in the new ecosystem additional value must be obvious at the end-user application level

19. There are many entry points to begin realizing the benefits of Interoperability

20. For interoperability to succeed you must conceptualize the road map that ultimately will deliver you to a sustainable operational model in which stakeholders find clear benefits for participation

21. The WebSphere Healthcare Collaborative Network was developed to support the needs for information sharing in healthcare and served as the technical foundation for our demonstration project among leading US Health organizations Key Features The IBM WebSphere Healthcare Collaborative Network revolutionizes fast and secure data collaboration across multiple stakeholders and applications. IBM WebSphere Healthcare Collaborative Network integrates key clinical data from disparate applications allowing open standards-based exchange, simplifying and automating adverse event detection, and enabling faster and easier aggregation and analysis of information for quality of care management. Message Oriented Integration Architecture - Secure �publish and subscribe� Using standards based technologies and messaging (HL7, MAGE-ML, etc.); connects to existing clinical information systems applications, Lab, Pharmacy, and Admission/Discharge systems Infrastructure for electronic data aggregation and correlation (for Datamarts) Hub and spoke messaging solution clinical data interchange Built on WebSphere Business Integration (WBI) technologies Uses publish and subscribe model for data exchange A Secure WebSphere Application Allows data owners to specify what data should be shared and with whom Allows data consumers to select topics of information they wish to receive Secure WebSphere MQ Messaging Data transport, middleware solution Assumes existence of clinical applications to create HL7 messages Assumes existence of data analysis applications or processes at the subscriber to extract knowledge HCN Gateway - WBI Server Express based Allows for selective movement of data from target to source; not all data is necessarily moved; selective extract One source can feed many targets and vice-versa (large fan-in or large fan-out of data) Supports dynamic selection of data to be published or consumed Data is transformed into a standardized format after extract Related messages can be aggregated at source Provides configurable de-identification of data to support HIPPA regulations Secure, reliable message transfer between HCN gateways Hub and spoke messaging solution clinical data interchange Built on WebSphere Business Integration (WBI) technologies Uses publish and subscribe model for data exchange A Secure WebSphere Application Allows data owners to specify what data should be shared and with whom Allows data consumers to select topics of information they wish to receive Secure WebSphere MQ Messaging Data transport, middleware solution Assumes existence of clinical applications to create HL7 messages Assumes existence of data analysis applications or processes at the subscriber to extract knowledge HCN Gateway - WBI Server Express based Allows for selective movement of data from target to source; not all data is necessarily moved; selective extract One source can feed many targets and vice-versa (large fan-in or large fan-out of data) Supports dynamic selection of data to be published or consumed Data is transformed into a standardized format after extract Related messages can be aggregated at source Provides configurable de-identification of data to support HIPPA regulations Secure, reliable message transfer between HCN gateways

22. Healthcare leaders backed the HCN demonstration, to enable rapid sharing of health data and improved bio-surveillance, which included federal agencies and nationally recognized institutions

23. HCN Architecture

24. Specific examples of HCN in practice give a picture of how organizations can benefit Clinical Data Repository Population (EHR) Aggregate electronic health records from multiple sources for patient care For intelligent data warehouse population Quality of Care Analysis Prompt identification/notification of patients for whom care departs from established care paths Development of best practice guidelines for specific patient populations facilitated through easier aggregation and analysis of outcomes across disparate systems Evaluation of the practices pattern for specific patient population to support outcomes assessments Detection of Adverse Drug Events Evaluation of drug effects relative to outcome indicators like lab values Patient with prescription for Coumadin exhibiting International Normalized Ratio (INR)/ Prothrombin Time lab result greater than 8 Monitoring across larger populations for lower frequency adverse events Public Health Alerts Rapid notification of sentinel events related to direct diagnosis of public health concerns Rapid notification of syndromic indicators which could warrant deeper epidemiologic investigation as precursors of outbreaks

25. Across the healthcare ecosystems HCN supports the needs of many stakeholder relationships Hospitals - Internal collaboration for: Research/ Outcomes Analysis/ Quality Improvement Studies Adverse Event Detections Hospitals and Payers Improved coordination for case management Improved identification of disease management candidates Support for quality incentive programs Hospitals and Pharmaceutical Researchers Identification of candidates for clinical trials Post market population analysis Compliance observation for outcomes analysis States (and Local) - Public Health Reporting Bio-surveillance/ Situational awareness Health/disease management program candidate evaluation, outcomes analysis and resource planning Population monitoring

26. HCN is ready today to enhance the capabilities for collaboration among various stakeholders in support of improved quality and reduced medical errors Summary of HCN solution benefits: Enables monitoring groups (e.g. Local health jurisdictions, FDA, CMS, CDC) to improve detection and response time for bio-surveillance, adverse drug reactions, quality of care, and disease outbreaks Enables rapid ability to aggregate and share data Enhances ability to judge quality of care Facilitates and improves efficiency of mandatory reporting and collaboration with business partners Provides a secure environment for clinical data transmission using SSL and the highest level of encryption Leverages existing applications minimizing barriers to implementation

28. The Enterprise Healthcare Service Bus can offer stakeholders basic as well as enhanced functions, both clinical and technical Business Services Authentication and Access Control Patient Index and Cross Reference Location Services Decision Support Engine Risk Modeling Engines Repository � Consumer or Provider Workflow and Context Management MED � Medical Entities Dictionary NLP � Natural Language Processing Business Partner Connections Lab Pharmacy Eligibility Audit Logging Monitoring, Reporting, and Alerting Technology Foundation Integration Engine Industry Specific Connectors and Data Handlers HL7, CDA, CCR DICOM XML ebXML EDI Connectors JDBC FTP, SMTP ODBC Text, etc. CIT System application adapters Mapping, Transformation, De-Identification - Pub/Sub Applications supporting services (e.g. EMR, Clinical Messaging, eRX, Decision Support)

29. IBM is extending this model through the development of the Integrated Healthcare Infrastructure (IHII)

31. IBM has made much progress helping our clients achieve interoperability through various stages Sick Kids, eCHN � 58 hospitals connecting longitudinal data in the province of Ontario, full MPI, Clinical Chart, MED ST Justine, Montreal, Arc-en Ciel � 88 node MPI clinical and encounter information WNC � connecting 15 hospitals throgh portal technology NYP roadmap to connect 5 hospitals, 1 clinic and one phy practice with goal to extend to all 60 affiliated NYP hosp Canada Health Info Way � IT architecture across all provinces, working with Ontario, Quebec and other provinces HHS � Brailer HHS, eHealth, Markle Foundation, HCN demonstration project SES � Extramadura region of Spain, pr0vide health svc to 1M population, EMR implementation w/SAP connecting to 2900 GPs in primary care, 5600 professionals in acute care and more than 500 people in support areas: logistics, finance, human resources 8 Hospitals (2.799 beds) and two more to be built in the near future 104 Primary Care Centers, 394 Local clinics, 22 dentistry units, 15 mental health units, 13 drug addicts help units, 25 family help units and 35 rehabilitation units More than 12.500 users connected to the new Healthcare Information System Denmark � integrated HER throughout the country, including patient access WNY � financial model, architecture and roadmap CHW � allow exchange of info across 42 hosp, including CCOW access using business partner CareFx Trillium � integration within the network UPMC � SIMS � strategtic incident mgmt architeture and natl guard China CDC � IT strategy and arch CRTI � Winnepeg Real-time biosurveillance and response readiness using Sick Kids, eCHN � 58 hospitals connecting longitudinal data in the province of Ontario, full MPI, Clinical Chart, MED ST Justine, Montreal, Arc-en Ciel � 88 node MPI clinical and encounter information WNC � connecting 15 hospitals throgh portal technology NYP roadmap to connect 5 hospitals, 1 clinic and one phy practice with goal to extend to all 60 affiliated NYP hosp Canada Health Info Way � IT architecture across all provinces, working with Ontario, Quebec and other provinces HHS � Brailer HHS, eHealth, Markle Foundation, HCN demonstration project SES � Extramadura region of Spain, pr0vide health svc to 1M population, EMR implementation w/SAP connecting to 2900 GPs in primary care, 5600 professionals in acute care and more than 500 people in support areas: logistics, finance, human resources 8 Hospitals (2.799 beds) and two more to be built in the near future 104 Primary Care Centers, 394 Local clinics, 22 dentistry units, 15 mental health units, 13 drug addicts help units, 25 family help units and 35 rehabilitation units More than 12.500 users connected to the new Healthcare Information System Denmark � integrated HER throughout the country, including patient access WNY � financial model, architecture and roadmap CHW � allow exchange of info across 42 hosp, including CCOW access using business partner CareFx Trillium � integration within the network UPMC � SIMS � strategtic incident mgmt architeture and natl guard China CDC � IT strategy and arch CRTI � Winnepeg Real-time biosurveillance and response readiness using

32. Conclusion: