1. A New Patient-centric and Sustainable Path to Achieving Health Information Infrastructure William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors William A. Yasnoff, MD, PhD, FACMI Managing Partner, NHII Advisors Kentucky eHealth Board Meeting Frankfort, KY February 21, 2006 © 2006 NH I I ADVISORS

2. 2 2 © 2006 NH I I ADVISORS Outline I. What is the National Health Information Infrastructure (NHII)? II. How does the NHII help address current health care problems? III. How can we organize the creation of the NHII? IV. 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. How can we organize the creation of the NHII? IV. What is the path to HII in communities?

3. 3 3 © 2006 NH I I ADVISORS 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 NH I I ADVISORS 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 NH I I ADVISORS 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

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

7. 7 7 © 2006 NH I I ADVISORS 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

8. 8 8 © 2006 NH I I ADVISORS 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 Info Exchange Records Returned Requests for Records Community Clinician EHR System Encounter Data Stored in EHR Pointer to Encounter Data Added to Index

9. 9 9 © 2006 NH I I ADVISORS Index of where patients have records Temporary Aggregate Patient History Authorized Inquiry Hospital Record Laboratory Results Specialist Record Patient data delivered Info Exchange Records Returned Requests for Records U.S. Other Info Exchange

10. 10 © 2006 NH I I ADVISORS 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?

11. 11 © 2006 NH I I ADVISORS Operational Community HIIs NameData Storage Financially sustainable? Spokane, WACentralYES South Bend, IN CentralYES Indianapolis, IN CentralNot yet Number of operational community HII systems using scattered model: NONE

12. 12 © 2006 NH I I ADVISORS Key Problems of Community HIIs l Privacy assurance for consumers l EHR incentives for physicians l Financial sustainability l Ensuring cooperation of health care institutions l Adoption and gradual improvement of standards l Privacy assurance for consumers l EHR incentives for physicians l Financial sustainability l Ensuring cooperation of health care institutions l Adoption and gradual improvement of standards How can these problems be solved?

13. 13 © 2006 NH I I ADVISORS IV. What is the Path to HII in Communities?

14. 14 © 2006 NH I I ADVISORS Complete Electronic Patient Information Stakeholder cooperation Financial Sustainability Public Trust Components of a Community Health Information Infrastructure

15. 15 © 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

16. 16 © 2006 NH I I ADVISORS Requirements 1. Financial incentives to create good business case for outpatient EHRs

17. 17 © 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

18. 18 © 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)

19. 19 © 2006 NH I I ADVISORS Complete Electronic Patient Information n Need single access point for electronic information n Requirement #2: Central repository for storage

20. 20 © 2006 NH I I ADVISORS Requirements 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage

21. 21 © 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

22. 22 © 2006 NH I I ADVISORS Requirements 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own information 1. Provide financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own information

23. 23 © 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

24. 24 © 2006 NH I I ADVISORS Requirements 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own information 4. Solution must appeal to consumers so they will pay 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own information 4. Solution must appeal to consumers so they will pay

25. 25 © 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

26. 26 © 2006 NH I I ADVISORS Requirements 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own information 4. Solution must appeal to consumers so they will pay 5. Patients must control all access to their information

27. 27 © 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

28. 28 © 2006 NH I I ADVISORS Requirements 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own 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. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own 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

29. 29 © 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

30. 30 © 2006 NH I I ADVISORS Requirements 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own 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. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own 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

31. 31 © 2006 NH I I ADVISORS eHealthTrust™ Model n All information for a patient (from all sources) stored in single eHealthTrust “account” controlled by that patient n Charge $60/year/patient ($5/mo) l Paid by patient, payer, or purchaser n All data sources contribute at patient request (per HIPAA) n Operating Cost < $20/year/patient n Payments to clinicians for submitting standard electronic clinical info provides incentives for EHR acquisition (~$3/encounter)** n All information for a patient (from all sources) stored in single eHealthTrust “account” controlled by that patient n Charge $60/year/patient ($5/mo) l Paid by patient, payer, or purchaser n All data sources contribute at patient request (per HIPAA) n Operating Cost < $20/year/patient n Payments to clinicians for submitting standard electronic clinical info provides incentives for EHR acquisition (~$3/encounter)** **patent pending

32. 32 © 2006 NH I I ADVISORS Clinical Encounter eHealthTrust™ Clinician EHR System Encounter Data Entered in EHR Encounter Data sent to eHealthTrust ™ Patient Permission? NO DATA NOT SENT Clinician Inquiry Patient data delivered to Clinician YES $3 payment Clinician’s Bank Secure patient health data files eHealthTrust™

33. 33 © 2006 NH I I ADVISORS eHT Model Meets Requirements 1. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own 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. Financial incentives to create good business case for outpatient EHRs 2. Central repository for storage 3. Patients must request their own 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

34. 34 © 2006 NH I I ADVISORS eHealthTrust Advantages 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 patent 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 eHealthTrust™ member gets immediate benefit from complete records l Benefits not contingent on critical mass 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 patent 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 eHealthTrust™ member gets immediate benefit from complete records l Benefits not contingent on critical mass

35. 35 © 2006 NH I I ADVISORS How does eHealthTrust Architecture Assure Security? n Clinical server (“cubbyhole server”) l Ultra-secure “separation kernel” – Subset of secure operating system – Each user has hardware-enabled “virtual machine” that cannot impact others l Only operation is retrieval of one record – User then logged off l No searching possible l No database software l Hacker worst case: one record retrieved n Research server has copy of clinical data l No phone lines or network connections l Access requires physical presence l Standard database software l Consumer permission required for searching – Bulk of searching revenue --> consumer n Clinical server (“cubbyhole server”) l Ultra-secure “separation kernel” – Subset of secure operating system – Each user has hardware-enabled “virtual machine” that cannot impact others l Only operation is retrieval of one record – User then logged off l No searching possible l No database software l Hacker worst case: one record retrieved n Research server has copy of clinical data l No phone lines or network connections l Access requires physical presence l Standard database software l Consumer permission required for searching – Bulk of searching revenue --> consumer

36. 36 © 2006 NH I I ADVISORS eHealthTrust Stakeholder Benefits n Purchasers l Individuals – Lower cost, higher quality care – Complete medical records under their control l Employers & Gov’t (Medicaid/Medicare) – Lower cost, higher quality care n Practitioners l Financial incentives for EHRs l Access to complete patient records n Providers l Access to complete patient records l Increased efficiency n Payers l Availability of complete aggregate data needed to monitor care n Purchasers l Individuals – Lower cost, higher quality care – Complete medical records under their control l Employers & Gov’t (Medicaid/Medicare) – Lower cost, higher quality care n Practitioners l Financial incentives for EHRs l Access to complete patient records n Providers l Access to complete patient records l Increased efficiency n Payers l Availability of complete aggregate data needed to monitor care

37. 37 © 2006 NH I I ADVISORS Strategy for Funding eHealthTrust™ n Issue two RFPs l 1) Vendor builds eHealthTrust in exchange for long-term guaranteed operations contract (Vendor owns software) l 2) Non-exclusive licenses to integrate eHealthTrust information with web-based health information services ( startup funds) 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 two RFPs l 1) Vendor builds eHealthTrust in exchange for long-term guaranteed operations contract (Vendor owns software) l 2) Non-exclusive licenses to integrate eHealthTrust information with web-based health information services ( startup funds) 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

38. 38 © 2006 NH I I ADVISORS SUMMARY A New Patient-centric and Sustainable Approach to HII I. Central Community Repository II. Paid for and Controlled by Patients III. Solves Key Problems l Privacy Assurance for Consumers l EHR incentives for physicians l Financial Sustainability l Cooperation by health care institutions l Adoption and Gradual Improvement of Standards I. Central Community Repository II. Paid for and Controlled by Patients III. Solves Key Problems l Privacy Assurance for Consumers l EHR incentives for physicians l Financial Sustainability l Cooperation by health care institutions l Adoption and Gradual Improvement of Standards

39. 39 © 2006 NH I I ADVISORS Questions? William A. Yasnoff, MD, PhD, FACMI william.yasnoff@nhiiadvisors.com 703/527-5678 For more information: www.ehealthtrust.com www.yasnoff.com