Health Information Exchange in South Carolina: What is it and what should be done? W. David Patterson, Ph.D. Chief, Health and Demographics SC B&CB - SC HIT Coordinator SCMA Bioethics Retreat, Hilton Head SC February 3-5, 2012 1 SCHIEx – South Carolina Health Information Exchange A Network of Networks Background: Why Health Information Exchange? Vision and History SCHIEx Technology How It is Being Used Today (and Tomorrow) 2 BACKGROUND 3 Defining Bioethics The study of the ethical and moral implications of medical research and practice. The American Heritage® Science Dictionary Copyright © 2002. Published by Houghton Mifflin. All rights reserved. A branch of applied ethics that studies the philosophical, social, and legal issues arising in medicine and the life sciences. It is chiefly concerned with human life and well-being, though it sometimes also treats ethical questions relating to the nonhuman biological environment. Encyclopedia Britannica, 2008. Encyclopedia Britannica Online. 4 PhysicalPrimary TherapyCare Self Regional Hospital Pain Management Orthopedist Rheumatologist University Hospital Car Accident 5 6 Medical Errors from Lack of Information: Why is it an Unsolved Problem? “In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison. If they could be obtained, they would enable us to decide many other questions besides the one alluded to. They would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good.” • The lack of immediate access to patient healthcare information is the source of one-ﬁfth of these errors1. • 80 percent of errors were initiated by miscommunication, including missed communication between physicians, misinformation in medical records, mishandling of patient requests and messages, inaccessible records, mislabeled specimens, misﬁled or missing charts, and inadequate reminder systems2. Florence Nightingale, 1873 Courtesy: Jodi McDaniel, ONCHIT 1Health 2 Research Institute &GlobalTechnology Center. Reactive to Adaptive:Transforming Hospitals with DigitalTechnology, PriceWaterhouseCoopers. 2005. Smith, Peter, et. al. “Missing Clinical Information During Primary Care Visits,” The Journal of the American Medical Association. February 2005. 7 VISION AND HISTORY 8 Vision: The Triple Aim Institute for Healthcare Improvement (2012). http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx. The Institute for Healthcare Improvement (IHI) believes that new designs can and must be developed to simultaneously accomplish three critical objectives, or what we call the “Triple Aim”: Improve the health of the population; Enhance the patient experience of care (including quality, access, and reliability); and, Reduce, or at least control, the per capita cost of care. 9 Governance South Carolina’s History: Incremental & Parallel Paths To Drive Value Chain DOC and SC DHHS approve use of data in ORS specific statutes, provisos, core service and BAA’s & MoU’s construction under existing - Data Oversight authority Council (DOC) LRHN Governance initiated (Markle), “master agreement” with ORS to use state core services Connecting the Communities of Care begins sharing data among CHC’s, RHC’s and FMC’s via a common BAA/DUA template DHHS and ORS develop automated agreement process to allow access to Medicaid data by enrolled providers SD DHHS Appointed SDE by Governor. SCHIEx official statewide exchange. 11 member IGC Established Fee Schedule, OnRamping approved by IGC. NHIN Coordinating Cmt Approves SCHIEx as Node on NHIN Claims 2005 2006 2007 2008 2009 2010 2011 Technology Deep Clinical Data Existing Data Warehouse, data linking and integration process serving dozens of agencies and organizations Creation of Core Network Services, including statewide RLS/MPI from existing Medicaid and UB 92/04 data LRHN connects to state core network services and deploys adapters to create a RHIO using the state platform . Deep Clinical Data from 22 Providers Starts Flowing A “thin” EMR is deployed that allowed clinics with no electronic system to collect limited, but essential clinical data via SCHIEx. HRSA AccessNet Patient Navigation Goes Live 10 SCHIEx data deployed via hosted adapter service and the SCHIEx viewer is used to make a ten year patient history available free of charge. Telepsychiatry Initiative Goes Live CHIPRA Demonstration Grant (1 of 10 States) to show QI using linked admin/clinical data exchange. NwHIN DIRECT Early Implementer MU OnRamp Test Harness Deployed. Connectivity Guide Published Summary of Summaries, On Demand documents, and Exchange powered DIRECT Guiding Principles … Competing Forces o Meet federal expectations while keeping it simple for SC providers o Focus on Stage 1 MU (CMS Meaningful Use) needs and upcoming stage 2 to prioritize activities o Leverage (EHR MU, REC (SC CITIA), HITSP standards) – work with those incentivizing and assisting healthcare providers with technology. o Low barrier to entry while providing glide-path to increasing functionality o Accommodate diverse views on data sharing preferences, but focus first on TPO (treatment, payment, and operations) o Any approach must be sustainable and worth the value – the enemy of “good” is “better” 11 Design Principles Follows Connecting For Health (Markle) & NwHIN • • • • • • • • • • Decentralized Federated/Hybrid Architecture No “Health ID” – Record Location Services Bottom up and top down Decoupled development Scalable and evolvable No 'rip and replace’ Standards based Security and Privacy Obsessed Auditable Courtesy: Connecting for Health Markle Foundation 12 Complete Transparency (c)2011 HIMSS 14 Our Approach - Summary Startup • One Time Investments Require Priority Clarity • • • • • • • • Solid foundation for future applications Focus on infrastructure Focus on minimizing ongoing operating cost impact Focus on seeding data to unlock value network effect Obsess about adoption critical mass Funded by one-time grant dollars Subsidize early adopters Bias toward action (cheap, fast mistakes) Ongoing Operations • Keep Costs Low • • • • • Don’t compete with collaborators • • • Self service model Web based outreach and education Leverage existing resources (state data center) Pass savings to subscribers Focus on activities that can only be provided by HIE Collaborate with REC and existing associations Not to be funded by grant dollars 15 TECHNOLOGY 16 Standards Based Network of networks CDC DoD Federal Health Architecture CONNECT 2.4 Compliant Gateway SSA C O R E . VA CMS Other State Optional Hosted Applications HIEs Clinical Viewer ePrescribe ThinEMR CareCoordinate . Pharmacies Core Connectivity Services MPI RLS Audit/Log Authentication Time Server ORS Hosted Data Assets . Medicaid UB92/04 XDS Repo Provider Labs HITSP/IHE Compliant Standards PIX, XDS/CCD (HL7 2.x), DIRECT IZ Registry Integrated Delivery System Community #1 MPI Community #2 CHCs Clinics 17 Summary – Sharing with SCHIEx Exchange Step 1 – Provide Patient Information Adopting Site Patient Identity Feed – ITI-8 Adding patient to domain SCHIEx SC State PIX Manager Step 2 – Provide Documents Patient Provide and Register Document Set-b – ITI-41 Adopting Site Registering Documents ITI-42 XDS Repository SCHIEx XDS Registry PIX: Patient Identifier Cross Reference XDS.b: Cross Enterprise Document Sharing 18 Summary – “Querying” SCHIEx Exchange Step 3 – Retrieve Documents 6. Retrieve Document Set Response 1. PIX Query – ITI-9 Adopting Site HIEBusTM Interoperability Services PIX Manager HIEBusTM Interoperability Services XDS Repository 5. Retrieve Document Set – ITI-43 2. PIX Update Notification – ITI-10 4. Repository and Document IDs 3. Query Registry – ITI-16 HIEBusTM Interoperability Services XDS Registry 19 SCHIEx Direct: Simple 2-layer network view Endpoint system Gateway system Gateway system Endpoint system [email protected] [email protected] User perception of transaction Top layer: User Perception Authenticate Authenticate Send message Receive message Second layer: Routing What can be accomplished with today’s infrastructure? • Easing workflow and improving reliability requires automation, meaning machine-to-machine communication • The more that we want to automate, the more directory information that needs to be standardized, reliable, and accurate for machine level readability • The only information that is standardized, reliable, and accurate for machine-level readability at a national level today is information contained in DNS registries • Capability that builds on DNS registries is fastest and easiest approach, however: • Does not allow discoverability • Has no user-level information • Has no security • Does little to ease local workflows – basically a step above faxing CURRENT AND FUTURE USES 22 www.SCHIEx.org SCHIEx “Update” • NwHIN VLER Pilot • CHIPRA Quality Improvement (QTIP) • Public Health Participation, Goals, Future Plans Immunization Registry ELR Syndromic Surveillance Exchange Participant www.SCHIEx.org SCHIEx Early Adopter Program www.SCHIEx.org Barriers to Onboarding o EHR Vendor Technical readiness ONC Certifications does not equate standards based interoperability (emerging standards not yet in current releases) o Large Hospital Systems - cost & technical timeline (integration work /upgrades to multiple information systems) o Focus Meaningful Use minimum requirements rather than longterm interoperability goals “Just a Test” - Medicaid AIU o “Wait-and See” (MU Stage 2, DIRECT, “wait for NwHIN”, “Who’s already on?”) o Reductions in reimbursement (Medicaid Cuts) www.SCHIEx.org Solution o Make it FREE – waive the annual subscription fee, and accept all providers o Recruit early adopter CHAMPIONS and offer support, and work to foster synergy among providers o Make sure the early adopters are representative of the provider community o Geography o Size o Practice areas o Safety net providers o Vendor products o Pave the way for later adopters - work through technical requirements/barriers for onboarding with as many different EHR vendor products as possible www.SCHIEx.org 41 Early Adopter Program Applicants www.SCHIEx.org Hospital and Physician Group Size www.SCHIEx.org 157 Total Facilities/Locations www.SCHIEx.org 17 EHR Systems Additional information is available at www.SCHIEx.org.
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