What does the future hold and taking HIEs to the next level: Transforming Care Delivery

1. Can HIEs Really Achieve Financial Sustainability:
A Case Study and Discussion on Transformational
Approaches and Unique Partnerships
© 2012 PAeHI 1
Making Magic with Medicine, Technology, and
Innovation Conference
New Jersey and Delaware Valley HIMSS Chapters
Atlantic City, NJ
October 4-5, 2012

2. Presented by
Dr. Chris Cavanaugh, Executive Director, Pennsylvania eHealth
Initiative (PAeHI)
William “Buddy” Gillespie, PAeHI Chair HIE Committee,
Director of HealthCare Solutions for Distributed Systems
Services (DSS)
Camilla Hull Brown, MBA, Principal & Founder, Strategies for
Tomorrow Inc
© 2012 PAeHI
www.dsscorp.com
www.paehi.org

3. Agenda
Learning Objectives
1
• Discuss the Pennsylvania eHealth Initiative
2
• Explore trends and models from across the state and from a
national perspective
3
• Examine critical lessons learned based on a case study of key
stakeholder from the Commonwealth of Pennsylvania
4
• Highlight some best practices and care transformational
approaches
HealthCare Transformation Track October 4, 2012

4. Overview
The Pennsylvania eHealth Initiative (PAeHI) was
created in 2005 as a voluntary, public, private,
non-profit coalition to bring together
Pennsylvania’s healthcare and business
stakeholders to develop a vision and a plan for
the future of health information technology and
the secure exchange of health information in
Pennsylvania.
Governed by a representative board of
directors, PAeHI offers a neutral forum for the
health IT community to work together for a
common mission—to improve patient care
through the effective use of health
information technology.
Mission
To enable the use of information technology to
improve healthcare quality and efficiency and
ensure patient safety for all Pennsylvanians.
To ensure secure, confidential access to health
information to enable individuals and
communities to make the best possible health
decisions.
Purpose
Working collaboratively under the
direction of a Board of Directors, PAeHI
endeavors to achieve greater HIT adoption
throughout the Commonwealth.
Helping healthcare providers achieve
meaningful use for HIT ultimately benefits
the patient; through our efforts, we hope to
assist providers in improving quality,
improving patient safety and lowering costs.
The Pennsylvania eHealth Initiative

5. Key Foundational Roles
5
Identify opportunities for
Pennsylvanians to use HIT
and HIE to improve
healthcare.
Educate the public
providers and policy
makers regarding the
benefits and challenges of
HIT and HIE.
Coordinate the efforts of
all Pennsylvania HIT and
stakeholders.
Identify opportunities to
coordinate with and
benefit from federal
initiatives.
Develop statewide
consensus on established
and emerging standards
(e.g., data, communication
and reporting).
Work with providers,
payers, policy makers to
define business cases for
HIT and HIE.

6. PAeHI Research Studies and White Papers
Establishing
widespread
adoption of
electronic health
records and
electronic
prescribing in
Pennsylvania
(2008)
Ensuring privacy
and security of
Health Information
Exchange in
Pennsylvania
(2009)
Building a
Sustainable Model
for Health
Information
Exchange in
Pennsylvania
(2009)
Financing Research
and Framework
Development for a
Health Information
Exchange (2010)
6

7. Financing Research and Framework Development
for a Health Information Exchange
2010 Study Conducted by PAeHI
1.
• Trends and demographics
2.
• Approaches for “thinking about sustainability”
3.
• Prior planning efforts by PA’s Health Information Exchange and PAeHI
4.
• Interview findings from 11 leading national HIE’s on models and experiences
5.
• Findings from 26 individuals representing 13 Pennsylvania stakeholder groups
6.
• Current Pennsylvania HIT/HIE initiatives
7.
• Assessment of opportunities
8.
• Go-forward strategy
Summer 2011 JHIM Article

8. Case Study
Impact of Pennsylvania Demographics
• Large populations to leverage economies of scale
• Many medium-to-large size health systems with some already achieving electronic
adoption
• Multiple private health insurers/Medicaid covers 78% of population
• Medicaid representing 16% of this population
• Numerous small hospitals with 84% of total hospital having less than 300 beds and 47%
having less than 100 beds
• Estimated 3,000 physicians in small, 1-2 physician-independent practices with
approximately 2,300 in rural areas
• Majority of private insured covered lives are self-insured large corporations
(national/international); Fully insured plans have interest in local, community or regional
HIEs

9. Case Study
Historical Pennsylvania HIE Activities
• Comprehensive Roadmap -- Prescription for Pennsylvania (2007)
• ONC has provided $17.1M in funds for a state-level HIE
• HIE initiatives across Pennsylvania
• 12 Hospital based, community, regional HIE’s in operation/planning stages
• Public Health Initiatives
• 9 current or emerging
• Medicaid is developing plans to engage the state health care providers and patients
• Broadband deployment goals by 2015
• 6 initiatives totaling $130.2M in grants to expand broadband and telemedicine
• Includes $99.7M to establish 1,700-mile fiber network to provide affordable services
across the Commonwealth

10. Case Study
Basics of HIE Financial Sustainability
Typical Participant in HIE
•Data exchange between key
providers utilizing common
data to treat shared patients
•HIE also include providers
along the continuum of care
who can join as standalone
institutions or network.
•ACO member to support Care
Coordination and the Patient
Experience.
Typical Core Function
•Core services include
•Secure clinical messaging
(the exchange of data)
•Inquiry (the ability to look up
key clinical and
administrative data)
•Web-based EHR and
ePrescribing (for those
without other solutions)
•Public health connectivity
(reportable conditions and
alerts)
•Direct data feeds through
the HIE to EHRs, databases,
and registries.
Typical HIE Technical
Infrastructure
•Distributed Media Model such
as when a patient is given a
CD by the physician to update
a personal health record.
•Peer-to-Peer Model is
commonly used with a
hospital portal providing the
hospital’s patient data to
physicians at remote locations
such as their practice sites.
•Federated/Record Locator
Service Model
•Centralized Warehouse Model
•Hybrid Model that enable data
exchange and data access
across multiple organizations.

11. Case Study
Simple Framework
Comparing HIEs & Impact on Financial Sustainability
Integrated delivery
networks (IDNs)
•Organized by one Institution
•Hospital to connect its
physicians & provider partners
& ensures that hospitals and
physicians can participate in
Meaningful Use Incentive
•Costs are absorbed by
Institution & Hospital vendors
set up networks
•Examples: Pinnacle Health
System and Doylestown
Hospital
Community/Regional HIE
•Organized around one or more
medical referral regions with a
multi-stakeholder governing
body
•Fees are paid by the
stakeholders based on benefits
received & startup funding
coming from key stakeholders
or outside funding sources
(grants)
•Examples: Geisinger’s KeyHIE
and UPMC’s HIE are blended
IDN/Regional HIEs.
State-level HIE
• State geographic boundaries
• Responsible for addressing
barriers to HIE adoption
around privacy and security,
standards, and legal issues
with bordering states
• Funded by federal
government to include state
agencies such as Medicaid
and Public Health
• Example: Designation of a
state-level HIE in
Pennsylvania

12. Case Study
PAeHI “Go Forward” Strategy
HIE
Sustainability
Model for
Three Levels
of HIE
1. Articulate a high-level
model that shows how IDNs,
community/regional-level
HIEs, and a state-level HIE
can flourish across the state.
Consider the unique issues
in each medical referral
region and statewide.
2. Collect market research by
medical referral region and
statewide in areas that need
more exploration.
3. Engage stakeholders in a
discussion about the model.
4. Come to general
consensus on an HIE
Sustainability Model for the
state and next steps.
© 2012 PAeHI 12

13. Case Study– Pennsylvania's Next Steps
Phase 1- ONC 2012
(Push)
• Leverage DIRECT
specifications
• PA eHealth
Collaborative
• HISPs
• Allied HIE
• Geisinger Clinic
(KeyHIE)
• MaxMD
• Secured
Exchange
Solutions (SES)
• RFP for Community
Shared Services
• DIRECT Grants
• Establishing
Authority (SB8)
Phase 2 – ONC 2013
(Push & Pull)
• PA eHealth
Partnership
Authority Board
• Sustainability
• Aligning HIPPA
with PA
• Expand
capabilities as
defined by the
stakeholder
community
• MU Stage 1 & 2
Environmental Scan
(Internal )
• Listing of all PA HIE
Stakeholders
• Current
• Newly formed
• Planning phase
• Identify potential
stakeholders not
active and/or in
under-served areas
(urban, rural, CAH)
• Develop DB and
map of HIE
Stakeholders
Environmental Scan
(External)
• PA shares borders
with 5 states
• What are current
cross-border data
exchange use
cases?
• Where do border
HIEs currently
exist?
• Can they be
leveraged by PA
stakeholders or
visa versa?
• Identify issues and
complexities of
cross-border data
exchange
Models
•Questions on Models
•Sustainability
Whitepaper identifies
three models; are there
others?
•How do we categorize
hybrid approaches?
•How do we categorize
Direct Project
participants?
•What are the models
identified by other
leading HIE authorities
(e.g. ONC, eHI)?
•How do we make it
easier for stakeholders
to identify a model
which is right for them?
•How do ACO’s fit into
these models?
© 2012 PAeHI 13

14. National Perspective
Key Points
• Federal funding and prominence for HIE
• 250 HIE’s nationally with 18 financially self-sustaining
• Initiatives to drive Meaningful Use of EHRs and HIEs
• Health Reform Legislations 2010 is pushing coordinated
care through ACO’s and patient centered medical home

15. Health Information Exchange
Services Provided
Majority Provide
• Clinical messaging
and Inquiry (CCD)
• PH Dept. reportable
conditions or
Immunization
Registry
Most Provide
• Had or planning
eRX, orders,
physician workflow
tools
• Six of 11 had or
planning low-cost,
Web-based certified
EHRS that meets
Meaningful Use
Unique Services
• INHS (WA) offers
shared IT services to
38 hospitals plus
majority of
physicians; others
use Virtual Private
Network
• MiHIN Resource
Services plans to
implement 7 sub-
state HIEs over 18
months.

16. Seven Success Strategies
1 • Innovative stakeholder negotiations
2 • Building the right relations hospitals & payers
3 • Physician adoption as driver of sustainability
4 • Innovation to bring payers/providers together
5 • Innovative sources for fee income
6 • State leaders drive healthcare transformation
7 • Longer-term HIEs look to the future

17. 1- Innovative Stakeholder Negotiations
That made getting 1/3 funding much easier.
Showed HIEs that were funded 100% by physicians, 100%
by hospitals, and 100% by payers.
Started with a highly successful claims exchange in the
1990s – easier to implement, faster ROI.
UTAH (UHIN)
How did they get each stakeholder group (physicians,
hospitals, and payers) to pay 1/3 of the fees each to fund
sustainable operations for clinical data exchange?
Sustainability

18. 2 - Establishing the Right Relations
New York (Rochester RHIO)
Budget is covered 2/3 by
payers and 1/3 by hospitals.
Instead of being charged a
RHIO fee, payers are assessed
a hospital fee at patient
discharge to cover RHIO costs.
The hospital then uses these
funds to pay fees to the RHIO.
Payers
Hospitals

19. 3- Driver of Sustainability is Physician Adoption!
Secret to Sustainability?
Common clear voice –
Inland Northwest,
MedVirginia, HealthBridge,
Franciscan HIE
Priority on giving the
leadership physicians the
services they want
Low cost of entry – no
charge for clinical messaging
& inquiry (CCD); charge for
add-ons
Physicians are primary
outreach arm
Physicians will pay for value
(Inland Northwest)
Physicians

20. 4 - Bringing Payers & Providers Together
Indiana (IHIE)
• Quality Health First – uses HIE’s
access to both clinical and claims
data for performance reporting
• 5 payers, 1400 physicians
Minnesota (MN HIE)
• 6 institutions are able to
populate patient data for 84% of
the residents in the state
• Joint sponsorship for 3-year start
up
• 3 hospitals, 2 health plans and
state government
• Why? Avoid the mistakes of the
claims system
Providers
Payers

21. 5 - Innovative Sources of Fees
Michigan (Capital Area RHIO with
help from state-level MiHIN)
• Medicaid
• Michigan Office of State Employees
• Michigan Office of State Retirees
• Board membership
• Public health surveillance & alerts
• University research
Minnesota (MI HIE)
• Clinics
• Long-term care
• Public health
• School districts
Demographics
Other
Resources
Govt.

22. 6 - State Leadership Drives Health Care Transformation
Vermont (VITL)
• Driven from Governor’s Initiative to transform
health care starting with PCMH pilot; also eRX
• HIE is essential to vision
• Used stimulus to bring PCMH, REC, and HIE
under one umbrella
• 7 year legislative HIT fund – funded by % of
claims
Other Regions Focused on
Transformation:
MedVirginia
Inland Northwest in Washington
Govt.
Other
Resources

23. 7 - Longer-term HIEs Look to the Future
Have a vision and
strategy for
transformation
• HIEs as component of
integrated care
Large data bases
• Legacy system “took years
to develop”
• Can support ACOs, PCMH,
care coordination programs,
transitions of care, work
redesign, population-level
outcome measures, etc.
Federal funding to
finance growth
• Beacon, REC, SSA, VA, DoD,
CMS, CDC, NHIN, etc.

24. Putting it all together!
• Government
• Hospitals
• Payers
• Physicians
• Sustainability
• Demographics
• Other Resources

25. What does the future holds?
Aging Demographics Chronic Disease Rising Costs
Provider Shortage
•Baby Boomer Retirements
•Lack of Primary Care
Physicians
Patient/Consumer
Demands
•Increased Physician-Patient
Communications
Legislative Demands
•Meaningful Use
•ACO
•Privacy & Security
25

26. Taking HIE to the Next Level:
Transforming Care Delivery
26

27. Greater Clarity on Where We Are Headed
8/16/2015
27

28. • How did HC Transformation Road Map influence
outreach strategy?
– April 25, 2012 HealthBridge announces HIE to expand
quality improvement analytics
– First customer, Quality Health Network (W. Colorado)
– Key tools
• Infrastructure enhancement to support expanded data
exchange & large data sets – secure & accurate integration
• Analytics engines – ID gaps in care
• Business intelligence -- manage resources, risk, quality,
utilization
• Reporting tools – slice & dice data, multiple reporting req.
8/16/2015
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29. Across the Country
More “Network” Puzzle Pieces in Place
8/16/2015
29
EXAMPLES
Accountable
Care Entities
IDNs
Hospital
Initiatives
Clinical
Teams
NwHIN
Reg. HIEs

30. Network Relationships – Key Points
• Change happens at multiple levels
• All levels are interconnected
• This has accelerated
• More puzzle pieces being filled in – remaining
gaps become obvious
• More people see opportunity and resources
are mobilized
• Greater competition; “arrow in the back”
8/16/2015
30

31. WHIO – Health Analytics Exchange
Transformation opportunities and risks for Wisconsin given
WHIO, HITECH and HC reform?
• State-wide claims exchange – includes nearly all payers, Med
Society, Hospital Association, and 5 health systems
• Participants can compare quality outcomes across all other
participants using de-identified data
• Processes and policies in place to agree to
– Measures
– Access to data
– Consensus-based decision making process
8/16/2015
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32. Transformation opportunities and risks?
• Common management for QIO, REC, and HIE
• QIO highly respected by hospitals, other stakeholders
• REC very successful working with docs
• HIE – key players with live data in short time frame; others in queue
• Three long-standing ACO look-alikes – hospital, 2 practices
• Major payer has majority of private market, wants transformation
• Consortium of self-insureds also major player (e.g. casinos)
• Many practices very high-level of IT adoption
• Yet, high level of paper-based practices of 1-2 docs, hard to reach
• State ranks near bottom of health outcomes nationally
8/16/2015
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33. HealthLINC, Bloomington, IN
What Are Opportunities & Risks?
– Small innovative HIE serving
South Central Indiana
– Surrounded by 5 sustainability
HIEs
– High-level MD adoption, MU
– Starting care coord. model with
self-insured employer
– Planning ED alerts for behavioral
health
– Parent health system working on
system-wide ACO
– Will have access to data and
analytics of nation’s two largest
HIEs
8/16/2015
33

34. Physicians in Michigan: Should We Join
Health System Networks? As Employees?
Opportunities and Risks?
– BCBS Systems of Care Program
with P4P – around 36 groups,
5,000 physicians
– Other health plans also
– 42,000 licensed physicians
– MiHIN Shared Services will link 6+
HIEs
– University Medical Center tells
physicians: “You will use HIE”
– Health systems actively recruiting
employed physicians
8/16/2015
34

35. Potential Partners -- Gap Analysis
Their Readiness to Lead Transformation
Potential Leader Partner
Size of organization Large Small
Experienced with PCMH, coordinated care
models, ACO look-alikes
On medical home path Not on path
Supports certified EMR, MU and beyond Yes Limited
Actively exchanging data across organizations Yes No
Uses performance measures Yes, use them Limited use
Have enough volume of patients and business to
be successful
Yes No
Can support pay-for-performance agreements Yes No
Can support at-risk agreements Yes No
Uses analytic tools to measure risk Yes No
Has leadership capacity to transform Yes No
8/16/2015
35

36. Regional Network Puzzle Pieces
New Jersey, Delaware Valley, & Delaware
What are Opportunities and Risks?
– HIEs – Foundation Being Built
• DHIN – one of original in US -- 90% Adoption-Immunization Sharing
• Pennsylvania eHealth Collaborative-Authority Approved-130+ Stakeholders
• NJ Health Information Network
– Regional Extension Centers -- achieving goals in all three regions
• New Jersey –6157 members, 4120 live on EHR, 1128 Meaningful Users
• PA REACH East – 3351 members, 2466 live on HER, 1164 Meaningful Users
• Quality Insights of DE – 1375 members, 1239 live on EHR 1239, 349 Meaningful Users
– ACOs – Building Transformation Models
• Renaissance Health Network (SE Pennsylvania)
• Barnabas Health ACO-North (New Jersey)
• 140+ Formed across USA
– Other Successes
• ACO look-alikes
• IDN, Private and Community HIEs
• PCMH and other patient-centric models
• Quality initiatives-Chronic Disease-Immunization
• Consumer, payer, other stakeholder engagement
• Mobile devices, broad band, telemedicine and more
• Direct/HISPs-PA providing funding
• Other?
36

37. Thank You!
PAeHI Team
Chris Cavanaugh, EdD, Executive Director
William (Buddy) Gillespie, Chair BCX
Committee
Sharon Dorogy, Chair, PAeHI
Ken Coburn, MD, Co-Chair HIE
Committee
Steven Fox, JD, Chair Policy Committee
Robert Torres, State HIT Coordinator
www.paehi.org
New Heights Consulting and
Strategies for Tomorrow
Camilla Hull Brown, MBA, Principal &
Founder, Strategies for Tomorrow, Inc.
Denise Reeser, MBA, Managing Principal,
New Heights Consulting, LLC
Presentation for
Making Magic with Medicine, Technology, and
Innovation Conference
New Jersey and Delaware Valley HIMSS Chapters
October 4-5, 2012
© 2012 PAeHI 37