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

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

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. 3

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 4

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 San Diego

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

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

Meaningful Use

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

Improve Cost, Quality, and Population Health 10

Health IT

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

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

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

San Diego County ED patients and visits by type of user: PatientsTotal Visits^ Type of User*N%N% Infrequent User (<6 visits) 895, ,592, Frequent User (6-20 visits) 28, , Super User (>=21 visits) 1, , Total925, ,016, *Based on number of visits in a one year period of time between January 2008 and December ^Includes all visits between January 2008 and December ED Visits in San Diego

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

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

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 19

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 including field 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 20

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 21 Test Innovative Approaches

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

ImageTrend MN EMS Hub San Diego San Diego, CA

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

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

Field Electronic Record & NLP Alerts 26 Test Innovative Approaches

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

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

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

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

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% 31

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. 32

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

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)

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 35

EMR/HIE Devices - Geneva Healthcare

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

Expandable EP Window IDCO Profile Data Embedded EKG

NSF , Information & Intelligent Systems – Project Dates: 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

DELPHI

Multiple sources of health data Webified hospital medical 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) 41 SANDAG

Messaging/Notification System can utilize ADT moment or patient index list to generate message/notification and recipient – Secure direct 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 42

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

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|

Community Governance 45 Independent entity established Initial board slate with representation from major healthcare providers in San Diego Dan GrossSharp COORob Smith, MDVA CMO Albert OriolRady CIOT. GehringCEO, SDCMS David Guss, MDUCSD DEM ChairN. MacchioneHHSA Director Bill SpoonerSharp CIOL. FerrariAnthem/BC Joe Traube, MDScripps CMIOJ. Burritt, RNKaiser S. EscobozaCEO, HASDICN. DiazCEO, CHG S. O’KaneCEO, CCCR. BrownCEO, Scripps Green

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

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 47

Questions? Adel A. Al-Marshad, MD