1. MASSACHUSETTS eHEALTH COLLABORATIVE HIT Symposium July 2006

2. - 1 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. MASSACHUSETTS COMMUNITY OF E-HEALTH ORGANIZATIONS 197819982003 The convener and educational organization, the business incubator The transactor of administrative (HIPAA transaction) processes The grid of state- wide clinical utilities The last-mile to clinician offices “The Convener” 2004 “The Transactor” “The Grid” “The Last Mile”

3. - 2 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. MAeHC ROOTS ARE IN MOVEMENT TO IMPROVE QUALITY, SAFETY, EFFICIENCY OF CARE Universal adoption of electronic health records MA-SAFE $50M commitment to heath information infrastructure Recognition of “systems” problem Company launched September 2004 –Non-profit registered in the State of Massachusetts CEO on board January 2005 Backed by broad array of 34 MA health care stakeholders

4. - 3 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. 34 ORGANIZATIONS REPRESENTED ON MAeHC BOARD Health plans and payer organizations Alliance for Health Care Improvement Blue Cross Blue Shield of Massachusetts Fallon Community Health Plan Harvard Pilgrim Health Care Massachusetts Association of Health Plans Massachusetts Health Quality Partners Tufts Associated Health Maintenance Organization Healthcare purchaser organizations Associated Industries of Massachusetts Massachusetts Business Roundtable Massachusetts Group Insurance Commission Non-voting members Center for Medicare & Medicaid Services Hospitals and hospital associations Baystate Health System Beth Israel Deaconess Medical Center Boston Medical Center Caritas Christi Fallon Clinic, Inc. Lahey Clinic Medical Center Massachusetts Hospital Association Massachusetts Council of Community Hospitals Partners Healthcare Tufts-New England Medical Center University of Massachusetts Memorial Medical Center Governmental agencies Executive Office of Health and Human Services Healthcare professional associations American College of Physicians Massachusetts League of Community Health Centers Massachusetts Medical Society Massachusetts Nurses Association Consumer, public interest, and labor Health Care for All Massachusetts Coalition for the Prevention of Medical Errors Massachusetts Health Data Consortium Massachusetts Taxpayers Foundation Massachusetts Technology Collaborative MassPRO, Inc. New England Healthcare Institute

5. - 4 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. MAeHC VISION Improve quality, safety, and affordability of health care through: Universal adoption of modern information technology in clinical settings Access to comprehensive clinical information in real- time at the point-of-care Tools for better, more accessible health care… …incorporated into clinical practice… Overcome barriers to promote widespread use of EHRs and associated decision support tools Lack of capital Misaligned economic incentives Immature technology standards …and sustained over time. Develop operational and financing models to foster and sustain state-wide adoption of such technologies and infrastructures

6. - 5 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. MAEHC MISSION: CLINICAL IT ADOPTION THROUGH COMMUNITY EMPOWERMENT

7. - 6 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. PILOT PROJECTS HAVE FOUR MAIN PIECES Quality Cost Productivity Etc. Connectivity Clinical IT implementation/ support Evaluation Quality measurement Pilot evaluation Clinical access to data Data gathering and aggregation Communication Hardware/software Implementation/tech support Systems integration Workflow redesign Decision support Intra-community connectivity Management & coordination Joint oversight and decision- making bodies Multi-stakeholder governance ICCC PSC

8. - 7 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. MAeHC PROJECT TIMELINE Activities20042005200620072008 ACP-MA summit MAeHC launch Community RFA launch Pilot communities announced EHR vendor RFP EHR vendor finalization Physician recruitment Implementation Evaluation Formal Pilot completion

9. - 8 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. EVEN $50M CAN’T GET THE LAST 5% 180 22 149 9 Most didn’t fit MAeHC definition of community Main sources of attrition: Outyear cost Close to retirement Too much of a hassle 149 158 = 94% participation

10. - 9 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. DIVERSE ARRAY OF SETTINGS Offices 350 Patient population (000) 95 43 488 111 41 25 177 Small Med Large 295 85 65445 PCPs Specialists Physicians Almost 450 physicians… …who care for ~500K patients… …in almost 200 offices. Brockton Newburyport N. Adams All Brockton Newburyport N. Adams All Brockton Newburyport N. Adams All

11. - 10 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. HIGHLAND PRIMARY CARE KICK-OFF Docs link up to new record style By Jennifer Heldt Powell Tuesday, March 14, 2006 The end of the paper trail By Ulrika G. Gerth/ ugerth@cnc.com Friday, March 17, 2006 Setting a new record: Local doctors pilot electronic patient history system By Stephanie Chelf Staff Writer

12. - 11 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. PHYSICIANS “GOING LIVE”, BY COMMUNITY # MDs 20062007 North Adams (55) Newburyport (81) Brockton (305) 97519213325242767121964171441

13. - 12 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. THE GRID AND THE LAST MILE Inter-community connectivity MA-SHARE Intra-community connectivity

14. - 13 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. THE NEXT PHASE: CONNECTING PHYSICIANS Health Information Exchange Patient permission Privacy and security Clinical utility Sustainability

15. - 14 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. NORTH ADAMS HEALTH INFORMATION EXCHANGE ehr HIS eCReRef ePatient Patient portal Patient-specific functions Appointment requests e-visits Clinical summary Other Patient-centric clinical summary Medications Labs Allergies Problems Other eReferrals Secure-messaging between care-givers Tracks and matches outbound/inbound referrals, and outbound/inbound consult reports Physician portal

19. - 18 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. DRIVERS OF BUSINESS SUSTAINABILITY Low Clinical data fields in eHealth Summary Structured, codified dataUnstructured, text High Patient opt-ins Clinical usefulness Low High Physician adoption Labs Medications ProblemsAllergiesMedical/family history Notes Business sustainability threshhold

20. - 19 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. PRIVACY APPROACH SUMMARY (I) MAeHC and communities need to decide what patient notification or consent we will require for data exchange in community pilots Not required for stand-alone EHRs Will be required for data exchange across legal entities Data exchange already happens today Current exchanges happen by fax, phone, mail, email, and remote access Community network could change the scale but probably not scope of that exchange (ie, same type of information will be exchanged but more often) With no “person-in-the-loop”, electronic data access may seem more risky, whether it is or not

21. - 20 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. PRIVACY APPROACH SUMMARY (II) Even though we’re just changing the transport vehicle, we can’t rely on existing notifications and consents to cover exchange over the new network MAeHC commitment to transparency will necessitate some form of patient notification or consent about new network Furthermore, we can’t assume that current entities have gotten patient consent that conforms with MA consent laws– very likely that many have not Notification about the network is not enough – MA law argues for some form of affirmative consent BEFORE disclosing data across legal entities HIPAA Notice of Privacy Practices does NOT count for MA consent MA consent requires affirmative consent for disclosure of clinical information, and a second affirmative consent for disclosure of sensitive information Question before us now is how to get patient consent in a way that is ethically and legally robust and operationally sound

22. - 21 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. ENTITY-BY-ENTITY OPT-IN (REPOSITORY MODEL) Jane Jones Patient visits clinical entity for care and is provided option at first visit to opt-in all clinical data from EACH entity 1 Visit YY YY N 2 Patient chooses which entity’s records to make available to network Consent Jane Jones 3 Name-location index published for entities who have gotten consent Publish Physician views data prior to or during patient visit 4 Retrieve Community Network Jane Jones eCommunity Record June 9, 2006 Visit history xxx Active problem list xxxDr. Jane Brody Current medications xxxSeacoast Cardio Current allergies xxxDr. Jane Brody Recent laboratory results xxxAJ Hospital Recent radiology results xxxAJ Hospital Other xxxXXX

23. - 22 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. Adoption EVALUATION PROGRAM WILL SUPPORT THREE KEY PILOT PROGRAM OBJECTIVES What are the most significant adoption barriers? What are the best ways to overcome them? What are the costs (direct and indirect) of adoption of IT? What are the benefits? How are the costs and benefits distributed across payers, providers, government, patients, ancillaries, etc? How much money will be required to implement statewide? What is general framework of incentives to implement and sustain the model? What are the most effective management strategies for implementing and sustaining in communities? What are the most effective organization models and tactics for implementing and sustaining statewide? Value Replication Efficacy vs Effectiveness

24. - 23 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. WHAT IS ROI? Physician Office Example Return on investment (ROI) = Benefits Costs Quality of care Error rate Patient satisfaction Liability exposure Investment cost Investment time Ongoing cost Revenue loss Physician/staff dissatisfaction Easier to measureHarder to measure Cost saving Time saving Revenue increase Physician/staff satisfaction Easier to measureHarder to measure Quality of care Error rate Patient satisfaction Liability exposure

25. - 24 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. MAeHC QUALITY DATA WAREHOUSE 1. Breast Cancer Screening 2. Colorectal Cancer Screening 3. Cervical Cancer Screening 4. Tobacco Use # 5. Advising Smokers to Quit 6. Influenza Vaccination 7. Pneumonia Vaccination 8. Drug Therapy for Lowering LDL Cholesterol# 9. Beta-Blocker Treatment after Heart Attack 10. Beta-Blocker Therapy – Post MI 11. ACE Inhibitor /ARB Therapy# 12. LVF Assessment# 13. HbA1C Management 14. HbA1C Management Control 15. Blood Pressure Management# 16. Lipid Measurement 17. LDL Cholesterol Level (<130mg/dL) 18. Eye Exam 19. Use of Appropriate Medications for People w/ Asthma 20. Asthma: Pharmacologic Therapy# 21. Antidepressant Medication Management 22. Antidepressant Medication Management 23. Screening for Human Immunodeficiency Virus# 24. Anti-D Immune Globulin# 25. Appropriate Treatment for Children with Upper 26. Appropriate Testing for Children with Pharyngitis 1. Breast Cancer Screening 2. Colorectal Cancer Screening 3. Cervical Cancer Screening 4. Tobacco Use # 5. Advising Smokers to Quit 6. Influenza Vaccination 7. Pneumonia Vaccination 8. Drug Therapy for Lowering LDL Cholesterol# 9. Beta-Blocker Treatment after Heart Attack 10. Beta-Blocker Therapy – Post MI 11. ACE Inhibitor /ARB Therapy# 12. LVF Assessment# 13. HbA1C Management 14. HbA1C Management Control 15. Blood Pressure Management# 16. Lipid Measurement 17. LDL Cholesterol Level (<130mg/dL) 18. Eye Exam 19. Use of Appropriate Medications for People w/ Asthma 20. Asthma: Pharmacologic Therapy# 21. Antidepressant Medication Management 22. Antidepressant Medication Management 23. Screening for Human Immunodeficiency Virus# 24. Anti-D Immune Globulin# 25. Appropriate Treatment for Children with Upper 26. Appropriate Testing for Children with Pharyngitis CLINICAL MEASURES FOR PHYSICIAN PERFORMANCE AQA Recommended Starter Set

26. - 25 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. WHY DON’T WE JUST LET THE MARKET TAKE CARE OF THIS? Current system pays for quantity, not quality Physicians not trained or compensated to reduce fragmentation of care Few if any incentives to reduce inefficiency, which rations care away from the under-served No obvious place for consumers to voice their concerns about quality, safety, and protection of privacy We have a societal interest in how implementation happens Bad systems and/or bad implementations offer little, if any, value Collective action and public goods barriers will prevent effective interoperability “In the long run, we’re all dead....”

27. 26 LEVELS OF HEALTH INFORMATION EXCHANGE LevelDescriptionExamples 1 Non-electronic dataMail, phone 2 Machine-transportable data PC-based and manual fax, secure e-mail of scanned documents 3 Machine-organizable data Secure e-mail of free text or incompatible/proprietary file formats, HL-7 message 4 Machine-interpretable data Automated entry of LOINC results from an external lab into a primary care provider’s electronic health record No PC/information technology Fax/Email Structured messages, non-standard content/data Structured messages, standardized content/data

28. - 27 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. TECHNICAL STANDARDIZATION IS ONLY THE BEGINNING... Percent Source:Center for Information Technology Leadership, MAeHC calculations 19% Fax/email 5% Structured messages 76% Standardized content Technical coordination Policy coordination Process coordination Community coordination Technical coordination Policy coordination Process coordination Community coordination

29. - 28 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. EARLY LESSONS LEARNED... This can get done on a large scale, and it can get done collaboratively Building the program is more difficult than originally anticipated Fixed cost that we can leverage going forward The market is shifting – getting attention of vendors somewhat harder than before Affordability isn’t the only barrier to physician adoption Starting the conversation creates a community – already seeing synergies Where are we offering greatest value? Funding Practice catalyst – facilitators/navigators Community catalyst – wholesale vs retail Forcing HIE

30. - 29 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved....SUGGEST SOME LESSONS ABOUT HOW TO EXTEND THE MODEL IN THE FUTURE Community is an effective level of organization (“wholesale vs retail”) Self-defined, cohesive. Accept accountability for its members, apply peer pressure, and appeal to local pride Efficient to serve logistically Natural unit for establishing health information exchange Central coordination and active intervention are key success factors Reduced costs for hardware, software, implementation Dramatic reduction in failure rate Speedier rollout and recovery of physician productivity Application of best practices to realize the systems’ potential The Golden Rule applies (“whoever has the gold makes the rules”) Direct funding increases compliance with best practices, including standardization, structured data capture Minimizes “paving over the cow-paths” Enables community-wide benefit of HIE

31. - 30 - Massachusetts eHealth Collaborative Slide title © MAeHC. All rights reserved. www.maehc.org www.maehc.org Micky Tripathi, PhD MPP President & CEO mtripathi@maehc.org 781-434-7905 mtripathi@maehc.org