1. Health Information Infrastructure: What, Why, and How William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors Rural Telecon ‘06 Little Rock, AR October 24, 2006 © 2006 NH I I ADVISORS

2. 2 2 © 2006 NH I I ADVISORS I. Patient Records in Today’s Health Care “System” n Most records are paper n Records are created where care is given and left there (in many locations, potentially worldwide) n No one has access to their complete health records n Collecting all the records not easy or helpful since they are mostly paper n RESULT: Health care practiced in mostly “information free” zone n Most records are paper n Records are created where care is given and left there (in many locations, potentially worldwide) n No one has access to their complete health records n Collecting all the records not easy or helpful since they are mostly paper n RESULT: Health care practiced in mostly “information free” zone

3. 3 3 © 2006 NH I I ADVISORS II. What is the NHII? n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n “Anywhere, anytime health care information and decision support” n NOT a national database of medical records n Comprehensive knowledge-based network of interoperable systems n Capable of providing information for sound decisions about health when and where needed n “Anywhere, anytime health care information and decision support” n NOT a national database of medical records

4. 4 4 © 2006 NH I I ADVISORS II. What is the NHII? (continued) n Includes not only systems, but organizing principles, procedures, policies, and standards, e.g. l Organization & governance l Alignment of financial incentives l Operational policies l Message & content standards n Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII n Includes not only systems, but organizing principles, procedures, policies, and standards, e.g. l Organization & governance l Alignment of financial incentives l Operational policies l Message & content standards n Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII

5. 5 5 © 2006 NH I I ADVISORS III. How does NHII help address current health care problems? A. Improving Healthcare Delivery at Point of Care (Improving Quality) l Complete patient information l Decision support B. Reducing Costs & Achieving Efficiencies l Eliminate duplicate tests & imaging l Eliminate duplicate communication channels (labs, x-rays, etc.) C. Support Public Health Initiatives & Biosurveillance l Automated disease reporting l Automated syndrome reporting A. Improving Healthcare Delivery at Point of Care (Improving Quality) l Complete patient information l Decision support B. Reducing Costs & Achieving Efficiencies l Eliminate duplicate tests & imaging l Eliminate duplicate communication channels (labs, x-rays, etc.) C. Support Public Health Initiatives & Biosurveillance l Automated disease reporting l Automated syndrome reporting

6. 6 6 © 2006 NH I I ADVISORS IV. How Can We Organize the Creation of the NHII?

7. 7 7 © 2006 NH I I ADVISORS Complete Electronic Patient Information Stakeholder cooperation Financial Sustainability Public Trust Components of a Community Health Information Infrastructure

8. 8 8 © 2006 NH I I ADVISORS Complete Electronic Patient Information n Most information is already electronic: Labs, Medications, Images, Hospital Records n Outpatient records are mostly paper l Only 10-15% of physicians have EHRs l Business case for outpatient EHRs weak n For outpatient information to be electronic, need financial incentives to ensure that physicians acquire and use EHRs n Requirement #1: Financial incentives to create good business case for outpatient EHRs

9. 9 9 © 2006 NH I I ADVISORS Complete Electronic Patient Information n Need single access point for electronic information n Option 1: Gather data when needed (scattered model) l Pro: 1) data stays in current location; 2) no duplication of storage l Con: 1) all systems must be available for query 24/7/365; 2) each system incurs added costs of queries (initial & ongoing); 3) slow response time; 4) searching not practical; 5) huge interoperability challenge (entire U.S.); 6) records only complete if every possible data source is operational

10. 10 © 2006 NH I I ADVISORS Complete Electronic Patient Information n Need single access point for electronic information n Option 2: Central repository l Pro: fast response time, no interoperability between communities, easy searching, reliability depends only on central system, security can be controlled in one location, completeness of record assured, low cost l Con: public trust challenging, duplicate storage (but storage is inexpensive)

11. 11 © 2006 NH I I ADVISORS Complete Electronic Patient Information n Need single access point for electronic information n Requirement #2: Central repository for storage

12. 12 © 2006 NH I I ADVISORS n Voluntary Impractical n Financial incentives l Where find $$$$$? n Mandates l New Impractical l Existing – HIPAA requires information to be provided on patient request n Requirement #3: Patients must request their own information Stakeholder cooperation

13. 13 © 2006 NH I I ADVISORS n Funding options l Government – Federal: unlikely – State: unlikely – Startup funds at best l Healthcare Stakeholders – Paid for giving care – New investments or transaction costs difficult l Payers/Purchasers – Skeptical about benefits – Free rider/first mover effects l Consumers – 72% support electronic records – 52% willing to pay >=$5/month n Requirement #4: Solution must appeal to consumers so they will pay Financial Sustainability

14. 14 © 2006 NH I I ADVISORS A.Public Trust = Patient Control of Information n Requirement #5: Patients must control all access to their information Public Trust

15. 15 © 2006 NH I I ADVISORS B.Trusted Institution  Via regulation (like banks) impractical  Self-regulated  Community-owned non-profit  Board with all key stakeholders  Independent privacy oversight  Open & transparent  Requirement #6: Governing institution must be self-regulating community- owned non-profit Public Trust

16. 16 © 2006 NH I I ADVISORS C.Trustworthy Technical Architecture  Prevent large-scale information loss  Searchable database offline  Carefully screen all employees  Prevent inappropriate access to individual records  State-of-the-art computer security  Strong authentication  No searching capability  Secure operating system  Easier to secure central repository: efforts focus on one place  Requirement #7: Technical architecture must prevent information loss and misuse Public Trust

17. 17 © 2006 NH I I ADVISORS Health Record Banking Model n All information for a patient stored in Health Record Bank (HRB) account n Patient (or designee) controls all access to account information [copies of original records held elsewhere] n Each HRB has three interfaces: l Withdrawal window - record access l Deposit window - receives new info l Search window - authorized requests n When care received, new records sent to HRB for deposit in patient’s account n All data sources contribute at patient request (per HIPAA) n All information for a patient stored in Health Record Bank (HRB) account n Patient (or designee) controls all access to account information [copies of original records held elsewhere] n Each HRB has three interfaces: l Withdrawal window - record access l Deposit window - receives new info l Search window - authorized requests n When care received, new records sent to HRB for deposit in patient’s account n All data sources contribute at patient request (per HIPAA)

18. 18 © 2006 NH I I ADVISORS eHealthTrust™ Business Model for Health Record Banking n Charge $5/patient/month ($60/year) l Paid by patient, payer, or purchaser n Operating Cost < $20/year/patient n Payments to clinicians for submitting standard electronic clinical info provides incentives for EHR acquisition (~$3/encounter)*  $10-20K/year for EHR system n Charge $5/patient/month ($60/year) l Paid by patient, payer, or purchaser n Operating Cost < $20/year/patient n Payments to clinicians for submitting standard electronic clinical info provides incentives for EHR acquisition (~$3/encounter)*  $10-20K/year for EHR system *patent pending

19. 19 © 2006 NH I I ADVISORS Clinical Encounter Health Record Bank Clinician EHR System Encounter Data Entered in EHR Encounter Data sent to Health Record Bank Patient Permission? NO DATA NOT SENT Clinician Inquiry Patient data delivered to Clinician YES $3 payment Clinician’s Bank Secure patient health data files Health Record Bank / eHealthTrust™

20. 20 © 2006 NH I I ADVISORS Questions? William A. Yasnoff, MD, PhD, FACMI william.yasnoff@nhiiadvisors.com 703/527-5678 For more information: www.healthbanking.org www.ehealthtrust.com www.yasnoff.com For more information: www.healthbanking.org www.ehealthtrust.com www.yasnoff.com