1. A Feasible Path to Sustainable Community Health Information Infrastructure William A. Yasnoff, MD, PhD, FACMI CEO, Health Record Banking Association William A. Yasnoff, MD, PhD, FACMI CEO, Health Record Banking Association Cerner Healthcare Leadership Forum Orlando, FL October 8, 2006 © 2006

2. 2 2 Outline I. What is the National Health Information Infrastructure (NHII)? II. How does the NHII help address current health care problems? III. Who should fund NHII? IV. How can we organize the creation of the NHII? V. What is the path to HII in communities? I. What is the National Health Information Infrastructure (NHII)? II. How does the NHII help address current health care problems? III. Who should fund NHII? IV. How can we organize the creation of the NHII? V. What is the path to HII in communities?

3. 3 3 © 2006 I. 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 I. 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 Difficult Challenges of NHII n Governance l New organizations l Stakeholder cooperation n Misaligned incentives n Costs l Startup l Ongoing n Technical - how will it work? n Privacy n Standards n Governance l New organizations l Stakeholder cooperation n Misaligned incentives n Costs l Startup l Ongoing n Technical - how will it work? n Privacy n Standards ALL THESE ARE INTERDEPENDENT & CANNOT BE SOLVED SEPARATELY ALL THESE ARE INTERDEPENDENT & CANNOT BE SOLVED SEPARATELY

6. 6 6 © 2006 II. 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

7. 7 7 © 2006 III. Who Should Fund NHII? n Federal Government l Already pays for about half of all health care costs – Medicare – Medicaid – Federal employees – healthcare insurance premium tax deduction l Not considered direct Federal responsibility l High estimated cost (~$150 billion) is major obstacle n Federal Government l Already pays for about half of all health care costs – Medicare – Medicaid – Federal employees – healthcare insurance premium tax deduction l Not considered direct Federal responsibility l High estimated cost (~$150 billion) is major obstacle

8. 8 8 © 2006 III. Who Should Fund NHII? (cont.) n Private Sector l Where healthcare is delivered l No obvious funding approach l Difficult to mobilize stakeholders – First-mover disadvantage – Misaligned incentives – Mistrust l Organization required to handle funds n Private Sector l Where healthcare is delivered l No obvious funding approach l Difficult to mobilize stakeholders – First-mover disadvantage – Misaligned incentives – Mistrust l Organization required to handle funds

9. 9 9 © 2006 IV. How Can We Organize the Creation of the NHII?

10. 10 © 2006 Community Approach to HII n Existing HII systems are local n Health care is local  benefits are local n Facilitates high level of trust needed n Easier to align local incentives n Local scope increases probability of success n Specific local needs can be addressed n Can develop a repeatable implementation process n Parallel implementation  more rapid progress n Existing HII systems are local n Health care is local  benefits are local n Facilitates high level of trust needed n Easier to align local incentives n Local scope increases probability of success n Specific local needs can be addressed n Can develop a repeatable implementation process n Parallel implementation  more rapid progress

11. 11 © 2006 Clinical Encounter Index of where patients have records Temporary Aggregate Patient History Patient Authorized Inquiry Hospital Record Laboratory Results Specialist Record Patient data delivered to Physician LHII System Records Returned Requests for Records Community Clinician EHR System Encounter Data Stored in EHR Pointer to Encounter Data Added to Index

12. 12 © 2006 Index of where patients have records Temporary Aggregate Patient History Authorized Inquiry from LHII Hospital Record Laboratory Results Specialist Record Patient data delivered to other LHII LHII System Records Returned Requests for Records U.S. another LHII

13. 13 © 2006 Problems with scattered data model for community HII n All health information systems must have query capability (at extra cost) l Organizational cooperation challenge (esp. for physicians) l Maintaining 24/7/365 availability with rapid response time will be operationally challenging (& costly) n Searching HII repository is sequential (e.g. for research & public health) n Where is financial alignment & sustainability? n All health information systems must have query capability (at extra cost) l Organizational cooperation challenge (esp. for physicians) l Maintaining 24/7/365 availability with rapid response time will be operationally challenging (& costly) n Searching HII repository is sequential (e.g. for research & public health) n Where is financial alignment & sustainability?

14. 14 © 2006 Examples of Community HII NameData Storage Spokane, WACentral South Bend, INCentral Indianapolis, INCentral Fishkill, NYCentral Bellingham, WACentral Cincinnati, OHCentral Number of operational community HII systems using scattered model: NONE

15. 15 © 2006 V. What is the Path to HII in Communities? Requirements  Vision of Completed System  Path to Development Requirements  Vision of Completed System  Path to Development Clearly Articulating Requirements and Envisioning the Completed System is Essential for Effective Progress

16. 16 © 2006 Complete Electronic Patient Information Stakeholder cooperation Financial Sustainability Public Trust Components of a Community Health Information Infrastructure

17. 17 © 2006 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 Requirement #1: Provide financial incentives to create good business case for outpatient EHRs

18. 18 © 2006 Requirements 1. Provide financial incentives to create good business case for outpatient EHRs

19. 19 © 2006 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

20. 20 © 2006 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)

21. 21 © 2006 Complete Electronic Patient Information n Need single access point for electronic information n Requirement #2: Central repository for storage

22. 22 © 2006 Requirements 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage

23. 23 © 2006 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 all information Stakeholder cooperation

24. 24 © 2006 Requirements 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information

25. 25 © 2006 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

26. 26 © 2006 Requirements 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay

27. 27 © 2006 A.Public Trust = Patient Control of Information n Requirement #5: Patients must control all access to their information Public Trust

28. 28 © 2006 Requirements 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information

29. 29 © 2006 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

30. 30 © 2006 Requirements 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information 6. Governing institution must be self-regulating community-owned non-profit 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information 6. Governing institution must be self-regulating community-owned non-profit

31. 31 © 2006 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

32. 32 © 2006 Requirements 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information 6. Governing institution must be self-regulating community-owned non-profit 7. Technical architecture must prevent information loss and misuse 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information 6. Governing institution must be self-regulating community-owned non-profit 7. Technical architecture must prevent information loss and misuse

33. 33 © 2006 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)

34. 34 © 2006 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

35. 35 © 2006 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™

36. 36 © 2006 HRB/eHT Meets Requirements 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information 6. Governing institution must be self-regulating community-owned non-profit 7. Technical architecture must prevent information loss and misuse 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request all information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information 6. Governing institution must be self-regulating community-owned non-profit 7. Technical architecture must prevent information loss and misuse

37. 37 © 2006 HRB/eHealthTrust™ Advantages n Uses Existing Infrastructure l Current EHR systems can be converted into HRBs n Easily Integrated with l Patient-entered information l Patient education information l Patient reminders l Patient-provider electronic communication n Promotes Gradual Standards Adoption l Initial standard enforced through HRB Association l Reimbursement policy can improve standard over time (e.g. to increase coding) n Provides Transition from Paper Records l Fax images of paper records stored l Metadata facilitates some indexing n Immediate Realization of Benefits l Each HRB/eHealthTrust member gets immediate benefit from complete records l Benefits not contingent on critical mass n Uses Existing Infrastructure l Current EHR systems can be converted into HRBs n Easily Integrated with l Patient-entered information l Patient education information l Patient reminders l Patient-provider electronic communication n Promotes Gradual Standards Adoption l Initial standard enforced through HRB Association l Reimbursement policy can improve standard over time (e.g. to increase coding) n Provides Transition from Paper Records l Fax images of paper records stored l Metadata facilitates some indexing n Immediate Realization of Benefits l Each HRB/eHealthTrust member gets immediate benefit from complete records l Benefits not contingent on critical mass

38. 38 © 2006 Strategy for Initial HRB/ eHealthTrust™ Funding n Issue RFP l Vendor builds eHealthTrust in exchange for long-term guaranteed operations contract (Vendor owns software) n Engage purchasers to enroll beneficiaries to guarantee operational revenue l Need about 100,000 subscribers to break even (~$6 million/year revenue) n Once system operational, market to individual consumers through physicians n Issue RFP l Vendor builds eHealthTrust in exchange for long-term guaranteed operations contract (Vendor owns software) n Engage purchasers to enroll beneficiaries to guarantee operational revenue l Need about 100,000 subscribers to break even (~$6 million/year revenue) n Once system operational, market to individual consumers through physicians

39. 39 © 2006 Win-Win for Stakeholders n Consumers l Lower cost, higher quality care l Complete medical records under their control n Providers l Financial incentives for EHRs l Access to complete patient records n Payers & Purchasers l Availability of complete aggregate data needed to monitor care l Lower cost, higher quality care n Consumers l Lower cost, higher quality care l Complete medical records under their control n Providers l Financial incentives for EHRs l Access to complete patient records n Payers & Purchasers l Availability of complete aggregate data needed to monitor care l Lower cost, higher quality care

40. 40 © 2006 SUMMARY Path to HII in Communities I. Community Health Record Bank(s) II. Paid for and Controlled by Patients III. Solves Key Problems  Privacy Assurance for Consumers  EHR incentives for physicians  Financial Sustainability  Cooperation by health care institutions  Adoption and Gradual Improvement of Standards IV. Win/Win for All Stakeholders I. Community Health Record Bank(s) II. Paid for and Controlled by Patients III. Solves Key Problems  Privacy Assurance for Consumers  EHR incentives for physicians  Financial Sustainability  Cooperation by health care institutions  Adoption and Gradual Improvement of Standards IV. Win/Win for All Stakeholders

41. 41 © 2006

42. 42 © 2006 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