1. Connecting Payers, Providers, and Patients A Journey of Innovation John D. Halamka MD May 28, 2012

2. The Need for Innovation Universal adoption of usable electronic health records Frictionless Healthcare Information Exchange Turning data into information, knowledge and wisdom Engaging patients and families in ways that add value Protecting privacy

4. 4 Universal adoption of usable electronic health records Getting the data in The ideal form factor Integration with workflow Leveraging the power of the care team Agile continuous improvement of the products

5. 5 Patient Profile Screen 5

6. 6 Problems 6

7. 7 Medications 7

8. 8 Medication History and Reconciliation 8

9. 9 Reports 9

10. 10

11. 11 Care Plans

12. 12 Frictionless Healthcare Information Exchange The “View” Approach The “Push” Approach The “Pull” Approach

13. The Massachusetts Statewide Health Information Exchange Berkshire Health System AtriusNEHENSafeHealth Fallon Clinic UMass Memorial Statewide HISP Secure Certificate Management Web Portal Provider/Entity Directory Audit log BIDMCPartners Direct Gateway Services EOHHSNwHIN MD MassHealthDPH

14. Basic Commonwealth HIE Services Provider directory Certificate repository DIRECT gateway Web portal mailbox Repository of physician names, entities, affiliations, and security credentials Repository of security certificates for authorized users of HIE services Adaptor that transforms messages from one standard to another without decrypting the message Secure, encrypted mailbox for users without standards-compliant EHR “Lookup” services “Message-handling” services HIE Services

15. Users have 2 ways to connect Provider directory Certificate repository DIRECT gateway Web portal mailbox HIE Services User types 2 methods of accessing HIE services EHR connects directly Browser access to webmail inbox Physician practice Hospital Long-term care Other providers Public health Health plans Labs and imaging centers

16. Accelerating Use of HIE Value of statewide HIE network and services will increase exponentially with the number of users Removing adoption barriers is key to increasing number of users –Up-front cost and difficulty of system integration is significant barrier to adoption to most users, especially small practices and safety-net providers Can address this barrier through a variety of means Align all funding streams to maximize opportunities for synergy Leverage existing assets Build services where the users are Lower the cost and ease the difficulty of using the statewide HISP

17. Roadmap for Statewide HIE Program Create infrastructure to facilitate data aggregation/analysis Will support Medicaid CDR and quality measure infrastructure Will support vocabulary translation services (lab, RX) Increasing cost and complexity Facilitate normalization and aggregation Enable queries for records Information Highway Create infrastructure to enable secure transmission (“directed exchange”) of clinical information Will support exchange among clinicians, public health, and stand-alone registries Focus on breadth over depth Analytics and Population Health Create infrastructure for cross-institutional queries for and retrieval of patient records Search and Retrieve Phase 2 Phase 3 Phase 1

18. The Reality of Vendor Products EHR vendor roundtable held on December 16, 2011 –Over 20 vendors participated in 4-hour session –Mix of ambulatory, hospital, and HIE vendors Goal was to understand vendors current and near-future interoperability capabilities and get feedback on MA approach Findings –There is wide variation in vendor interoperability capabilities –Few if any vendors have production Direct-enabled systems in place today –There are no standardized approaches to integration with centralized provider directories or PKI infrastructure –All of the vendors supported a centrally coordinated approach to interface development and deployment

19. 19 Turning data into information, knowledge and wisdom Centralized or distributed databases? Prospective or retrospective reporting? Structured or non-structured data capture?

20. BIDPO QDC A Centralized Database

21. Distributed Databases

22. 22 Distributed Databases

23. 23 Prospective Reporting

24. Retrospective Reporting

25. 25 Structured Data Capture VITAL SIGNS: Blood pressure 110/70. Height 5 feet 3-1/2 inches, weight 122 pounds, and BMI is 21.5. CURRENT MEDICATIONS: 1. Docusate sodium 100 mg b.i.d. 2. Ferrous sulfate 325 mg b.i.d. 3. Magnesium oxide 400 mg b.i.d. 4. Aspirin 81 mg daily. 5. Plavix 75 mg daily. 10

26. 26 Unstructured Data Capture MEDICATIONS: 1. He currently takes 3% hypertonic saline nebs twice daily. 2. Pulmozyme 2.5 mg nebs twice daily. 3. He takes Bactrim 5 mL twice daily every Friday, Saturday, Sunday for PCP prophylaxis. 4. He takes Zithromax 2.5 mL once daily every Friday, Saturday, Sunday for neutrophil modulation. 5. He takes Zyvox 600 mg one tablet twice daily but is stopping on 9/12. 11

27. 27 The Role of Natural Language Processing and other evolving tools

28. 28 Engaging Patients and Families Tethered and non-tethered personal health records Home care devices Creating value - Open Notes, Passport to Trust

29. 29 Protecting Privacy The challenge of BYOD Protecting data at the server and the client Respecting patient privacy preferences

30. 30 The Anonymizer Name: Rob Smith DOB: 6/7/1972 cd5dced41028cb7ea51d52a888089d73 00c9782a552a2d09b1b85e0d0db52ef3 7f2b6e48ea7d042bbe85e46ef2107da4 Anonymizer Rob Smith 6/7/1972 Robert 7/6/1972 1972 0d06b31faa7c44682d770706640465d2 B5e341a4b0cdf0e8de7b6f957818d746 bd0ec72f2424729efa7baac9a636970a Variants

31. 31 M. Randal Smith DOB: 06/07/74 713 731 5577 Mark Randy Smith DOB: 06/07/74 123 Main Street 713 731 5577 Lab Results Outcomes Record #A-701 Record #B-9103 Observations Re-Constructed Identities FEATURES: Mark Randy Smith, M. Randal Smith 123 Main Street 713 731 5577 DOB 06/07/74 Sensors Patient Identifiers Are First Anonymized

32. 32 Lab Results Outcomes Record #A-701 Record #B-9103 Cd5dced41028cb … 00c9782a552a2 … 7f2b6e48ea7d0 … … 0d06b31faa7c… B5e341a4b0c… 00c9782a552… … Patient Identifiers Are First Anonymized Observations Re-Constructed Identities FEATURES: Mark Randy Smith, M. Randal Smith 123 Main Street 713 731 5577 DOB 06/07/74 Sensors

33. 33 Cd5dced41028cb … 00c9782a552a2 … 7f2b6e48ea7d0 … … 0d06b31faa7c… B5e341a4b0c… 00c9782a552… … Identity Resolution Occurring Post Anonymization Lab Results Outcomes Record #A-701 Record #B-9103 Observations Re-Constructed Identities Sensors FEATURES: Mark Randy Smith, M. Randal Smith 123 Main Street 713 731 5577 DOB 06/07/74

34. 34 FEATURES: Mark Randy Smith, M. Randal Smith 123 Main Street 713 731 5577 DOB 06/07/74 Cd5dced41028cb … 00c9782a552a2 … 7f2b6e48ea7d0 … … 0d06b31faa7c… B5e341a4b0c… 00c9782a552… … Patient Linkage Data is Not Stored in Clear Text Lab Results Outcomes Observations Re-Constructed Identities Sensors Record #A-701 Record #B-9103

35. 35 FEATURES: Cd5dced41028cb7ea51… 00c9782a552a2d09b1b… 7f2b6e48ea7d042bbe8… … Cd5dced41028cb … 00c9782a552a2 … 7f2b6e48ea7d0 … … 0d06b31faa7c… B5e341a4b0c… 00c9782a552… … Patient Linkage Data is Stored Anonymized Lab Results Outcomes Observations Re-Constructed Identities Sensors Record #A-701 Record #B-9103

36. 36 Record #A-701 Matches Record #B-9103 Discovery M. Randal Smith DOB: 06/07/74 713 731 5577 Mark Randy Smith DOB: 06/07/74 123 Main Street 713 731 5577 Lab Results Outcomes Record #A-701 Record #B-9103 Observations Sensors Policy Controls Maximizing Discovery - Minimizing Disclosure!

37. 37 The Challenges We Face V = Volatility. The nature and dynamics of change, and the nature and speed of change forces and change catalysts. U = Uncertainty. The lack of predictability, the prospects for surprise, and the sense of awareness and understanding of issues and events. C = Complexity. The multiplex of forces, the confounding of issues and the chaos and confusion that surround an organization. A = Ambiguity. The haziness of reality, the potential for misreads, and the mixed meanings of conditions; cause-and-effect confusion.

38. 38

39. Questions? http://geekdoctor.blogspot.com jhalamka@caregroup.harvard.edu