1. Health Information Exchange: Myths, Mirages and Reality Donald P. Connelly, MD, PhD University of Minnesota September 8, 2008 2008 AHRQ Annual Conference

2. Information Gaps in the Emergency Dept. Gaps are frequent - 32% of visits Gaps are consequential Very important or essential 48% Somewhat important 32% Prolong the ED stay Increase costs Redundant testing & repeated MD assessments Stiell A et al. CMAJ 2003; 169:1023-8.

3. Rationale for sharing an abstract instead of the entire record Contents are bounded & defined Patients “get it.” They understand the value of a concise clinical abstract for themselves and their providers Avoiding sensitive content means easier consenting & wider use A better first step for a public wary of confidentiality breaches While not the entire record, clinicians endorse the abstract as having high clinical value The abstract’s succinctness is preferred by some emergency room physicians Interoperability across vendor platforms should be easier

4. “My Emergency Data” Abstract Patient Information Contact Information Primary Care MD & Clinic Advance Directives Current Problem List Current Medications Allergies Immunizations Surgical History Family Medical History Alcohol and Tobacco use

5. Our setting The Twin Cities’ healthcare delivery market is highly concentrated into a few large healthcare systems (i.e., an oligopoly) Our project’s health system partners are: Allina Hospitals and Clinics Fairview Health Services HealthPartners Each partner system has adopted Epic as its primary EMR vendor

6. The highway mirage

7. Heightened privacy concerns and changing laws Minnesota privacy law is especially stringent Patient consent is required for nearly all disclosures, including treatment Limited exception to consent requirement Medical emergency Record movement within “related” health care entities Written consent (signed & dated) is required

8. Heightened privacy concerns and changing laws (continued) Minnesota’s new 2007 privacy law facilitated HIE Allowed representation of consent Apportioned liability for inappropriate disclosure Defined record locater service (RLS) RLS clause presumed a centralized model Global opt-out option is required Partners’ EMR software doesn’t appear to comply Litigation leery lawyers Interstate clinical information transfer is even more problematic

9. Slow and circuitous uptake of interoperability standards Continuity of Care Document (CCD) standard approved in slow-to-develop SDO compromise in early 2007 AHIC endorsed HITSP’s recommendation of the CCD standard EHRVA included CDA/CCD in their interoperability roadmap The EMR vendor’s interoperability business model continues to evolve A single-vendor dominant, universal-sharing model Working with CCD for multi-vendor sharing The great EMR-PHR debate

10. MN HIE (Minnesota’s Health Information Exchange) Participation in MN HIE’s formation was important to ensure a public-private solution Proof of concept using e-prescribing history was demonstrated early Commitment to use MN HIE to transport abstract made last fall Pilot use of MN HIE scheduled near end of grant period and limited to e-prescribing Broad acceptance, sustainability and privacy remain as key challenges

11. Healthcare systems respond to external drivers Local healthcare competition has heightened over the past few years Profitability is in a down cycle in our local competitive, low margin setting Four of our six healthcare system board members have moved on including one of our strongest advocates for “It’s the patient’s data” Electronic information sharing very strong in terms of administrative claims data sharing but still nascent for clinical data

12. North Dakota Capitol Building

13. Crossing the wide Missouri

14. Grandma’s house

15. Changing culture, work, & relationships takes time Privacy is a societal issue – citizens, legislators, and stakeholders are now engaged Interoperability standards are new and need some evolution The business case for clinical information sharing must be made. Use it to solve real problems and demonstrate its value This all takes time. Have patience. You can’t do it all.

16. HIE takes collaborative effort

17. Acknowledgements The many dedicated and committed participants from Allina Hospitals and Clinics Fairview Health Services HealthPartners University of Minnesota Our project’s Board members AHRQ This project was funded in part under Grant Number UC1 HS016155 from the Agency for Healthcare Research and Quality, US Department of Health and Human Services.