Health Information Exchange and the National Agenda May 2008 Kelly Cronin Director, Programs and Coordination Office of the National Coordinator for Health Information Technology (ONC)

2May 2008 HIE and the National HIT Agenda Where are we? Challenges Overcoming the barriers Moving toward a connected network of networks – the NHIN –Trial implementations –Accreditation and certification –Develop the business case Where do we go from here?

3May 2008 Key Health IT Components to Enable Transformation Electronic Health Records (EHR) Personal Health Records (PHR) Population Health Information (Public Health, Quality Improvement, Research) A Robust, Interoperable, Health IT Environment that brings together: Standards (Data, Technical and Security) Interoperable Health Information Exchange Network (Nationwide Health Information Network - NHIN)

Governance Pieces of the Puzzle Necessary for Transformation of Health and Care through HIT Privacy & Security Policies Standards in HIT Products Nationwide Health Information Network Adoption of Interoperable Health IT

5May 2008 Status of HIE – Findings from eHI Survey 125 initiatives reported on stage of development in the 2007 survey –20 are just getting started (stage 1 or 2) –68 are in the process of implementation (stage 3 or 4) –32 are operational (stage 5, 6 or 7) –5 are no longer moving forward 15% fewer participating than in HIEs exchanging data (Stages 5-7) 25% dependent on grants (or don’t know) 75% rely on results delivery (but other sources important as well)

6May 2008 Funding Sources for RHIOs in 2007 Funding SourceOverallAdvanced Hospitals24%58% Public Payors21%38% Physician Practices16%46% Laboratories13%33% Private Payors10%46% Philanthropic9%29%

7May 2008 Services Offered in 2007 ServiceOverallAdvanced Results Delivery30%75% Clinical Documentation27%63% Enrollment or Eligibility Checking26%54% Consultation/Referral21%54% Alerts to Providers19%48% Disease or Chronic Care Management18%32% Disease Registries14% QI Reporting for Clinicians12% Reminders12%33%

8May Operational Initiatives: Sources of Revenues Funding Source Hospitals58%54% Payers – Private46%19% Physician Practices46%33% Payers – Public38%18% Laboratories33%42% Federal Government29%17% Philanthropic Organizations29%21% State or Local Government21%26% Purchasers/Employers17%0% Pharmacies13%11% Pharmaceutical Companies4%6%

9May 2008 State Level HIE - An Evolving Landscape 4. Operating 3. Early Implementation 2. Foundational 1. Early Planning State/Regional Contracts (6) Medicaid Transformation Grants – HIE/EHR focus (15) NHIN Trial Implementation (9)

10May 2008 Major Challenges for All HIE Initiatives Challenge Developing Sustainable Business Model88%91% Securing Funding88%80% Defining Value for Users of the HIE89%81% Privacy79%85% Engaging Clinicians80%82%

11May 2008 Challenges: Sustainability of HIE No silver bullet to get to viable business model Need to be market savvy and develop HIE services that meet a customer need and deliver value No obvious demand for HIE with current reimbursement system –But an increasing number of RHIOs are in the red –Successful RHIOs are inducing demand by providing services that demonstrate value –Know your customer – don’t build it and expect they will come –Need business acumen and good market research to develop a viable, marketable services Social capital is essential for effective governance and sustainability

12May 2008 Challenges: Value Proposition Needs to be defined according to type of service and from each stakeholders perspective –i.e., results reporting for hospitals Are the costs and benefits of each function/service for each stakeholder different at a regional and state level? –Some providers, employers or plans might only have a regional interest Data suggests that hospitals are deriving value more often than other stakeholders Employers seem least likely to be engaged

13May 2008 Value from a higher level perspective Health information exchange can: –Produce cost savings from decreased redundancy In duplicated care In the costs of data sharing –Enable quality improvement and Medicare payment reform by making clinical (not just claims) data available for performance measurement and reporting –Support public health and emergency preparedness including situational awareness and response management

14May 2008 What is the problem we are trying to solve? Market forces have not realized the potential of electronic health information exchange –Fee for service payment system provides no incentives to share data –Cost savings don’t accrue to those who need to invest –Proprietary, one to one, relationships are easier to create technically and legally –Public health does not get the data it needs – it’s viewed as a government, not a private sector responsibility –The tipping point for participating in data exchange has not been achieved

15May 2008 Different models for exchanging health information Network Type Examples Example Benefits Biggest Challenge Organizational Integrated delivery systems, hospital chains Effort of exchanging data internally is aligned with business outcomes Extra-organizational exchange is needed for care provided in other organizations Geographic RHIOs, jurisdictional HIEs Non-proprietary exchange Struggle to achieve sustainable business models Personally Controlled Health data banks: Microsoft, Google, Intel Consumer access to, and control of, health information Based on point to point connections, have challenges in supporting provider data access

16May 2008 Collaborative Governance Needed Across Jurisdictions With varying approaches to HIE, multi-stakeholder governance is needed at the regional, state and national level There is currently no coordination of HIE governance across jurisdictions to eventually reach interoperability on a technical and policy level –Some state level governance entities coordinate with RHIOs but not all –No explicit coordination exists between national and state level governance –National governance has been informal through AHIC and Secretary Leavitt’s leadership No oversight mechanisms exist to ensure accountability of HIE –State governments are increasingly interested in accountability and mechanisms to protect consumers –Accreditation and model data sharing agreements could support trust among stakeholder involved with HIE and protect consumer interests

17May 2008 Some Solutions to Challenges Improve business case at regional, state and national level –Stakeholder specific value propositions –State and federal policy changes Advance governance of HIE –Establish national level governance –Promote effective governance models at state level –Consider oversight mechanisms such as accreditation to support interoperability of policies/data sharing agreements Identify and adopt common standards and specifications for health information exchange

18May 2008 Where are we going? What projects and efforts are advancing HIE?

19May 2008 State-level Health Information Exchange Consensus Project State-level HIE governance role is primary Ensure that HIE develops as a public good Serves all statewide stakeholders and data needs Reduces technology investments and other costs State-level HIE governance entity is a public-private partnership entity Sits between state government and the health sector and industry Involves state government, but independent of state government Addresses public and private sector interests, blends investments Mechanism for coordination of HIE policies and practices State governments play important roles Designating authority to a state-level HIE governance entity Providing resources: start up and ongoing Leveraging public programs, policy levers to create incentives for HIE Statewide technical approaches can vary and will likely evolve Size, market characteristics, resources, stages

20May 2008 State-level HIE Leadership Forum In 2008, a forum will be established for all states to share information among peers who are responsible for leading state level efforts to advance HIE Enable peers to learn from each other and share progress, challenges, and creative ways to advance statewide agendas The forum will foster better understanding and coordination of many related but separate projects to advance HIE including HISPC, HITSP, NHIN, CCHIT, and AHIC 2.0

21May 2008 State Alliance for e-Health Examination of Financing, Accountability and Oversight Models to Sustain Health Information Exchange –To inform Governors and State Legislators about the various models for financing and ensuring accountability –A key financial consideration: appropriate role for states in providing oversight and support –Final report to the Alliance in August 2008

22May 2008 The AHIC Successor – Why Change? Continuity of leadership is needed to sustain the momentum gained over the past 24 months –Government transition occurs every four years –Uncertainty under new leadership places momentum at risk Sustainable business model is needed to support perpetual operation –Congressional appropriations are a cyclical model Decisive action is needed keep pace with large scale innovation and transformation –Government is necessarily a deliberate process

23May 2008 AHIC 2.0 – What It Will Do… Provide continuity -- accelerate and coordinate current AHIC interoperability initiatives Provide strong leadership in –determining priorities –harmonizing interoperability standards –certifying products and systems to those standards –overseeing and facilitating the NHIN –establishing criteria for assuring interoperability, privacy and security Construct and champion a balanced view –that takes into account the needs of all stakeholder groups

24May 2008 NHIN Trial Implementations Awards to 9 state & regional Health Information Exchanges (HIEs) and another 6 grants to other entities Forming the NHIN Cooperative to implement, test, and demonstrate core services by September 2008 –Support of consumer access controls –Lookup and retrieval of clinical information –Exchange of patient summary records Test implementations of the first 7 priority scenarios –Lab result reporting ; medication history exchange; quality and public health, etc. Expanding to include other types of HIEs, such as –Multi-community Integrated Delivery Systems –Health plans –Health data banks

25May 2008 NHIN Business Model Contract awarded to nine HIEs for trial implementations of inter-HIE connectivity Contract requirement to develop business model Emphasis on HIE-to-HIE sustainability. Considerations may include: –What are the business drivers for inter-HIE connectivity? –Sourcing of core services (in-house, outsource, some services being provided by a state-level HIE, etc.) –Costs to obtain core services –Source of funds for start-up costs and ongoing funding options –What is the value proposition for each participant in the transaction? –How does cost and benefit distribution work for a transaction that has participants residing in more than one HIE?

26May 2008 Other Federal Activities Addressing Sustainability Six state HIE initiatives with State and Regional Demonstration Project contracts from AHRQ are informing business model development using the eHI Value and Sustainability Model AHRQ sponsored case studies of stakeholder engagement in HIEs and the impact on sustainability Thirteen state Medicaid agencies are using their Centers for Medicare and Medicaid Services Medicaid Transformation Grant awards to advance HIE efforts within their states. State-level HIE Consensus project will address the Value Proposition for each Stakeholder participating in a state-level HIE

27May 2008 Important Next Steps to Advance Sustainable HIE Coordinated research agenda –NGA, eHI, AHIMA, HHS, and other partners work together to answer key questions State and federal policy development to support sustainability –Commonwealth report called for mandates for providers to participate in interoperable networks AHIC 2.0 established - national governance State Forum established to facilitate state level approached to HIE governance

28May 2008 Health IT is a key enabler for us ALL to get: The Ultimate Reason for Health IT The quality of health we want and deserve The quality and value of health care services we demand

29May 2008 For More Information: