Regional Health Information Organizations (RHIOs)

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• Regional Health Information Organizations (RHIOs)
• The Primary Vehicle for Achieving the National
  Health Information Network (NHIN)
• Presented by Holt Anderson
• Executive Director, NCHICA

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Presentation Outline

• The National Framework
• The Request for Information (RFI)
• Speculative Definitions
• Emerging Models for RHIOs
• NCHICA as one possible RHIO model
• Examples of Collaborative Activities and
  Challenges Incurred
• Q A

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(No Transcript)
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Obstacles to a Universal EHR

• the multitude of industry standards that have yet
  to be harmonized,
• a lack of clear and unambiguous policies about
  data control,
• differing security policies among organizations
  and states,
• the risk that EHR products won't work as
  promised and
• the lack of a business model that creates
  incentives for physician investment and adoption.

David Brailer, ONCHIT, AMIA Conference, April 2005
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Framework for Strategic Action

• Inform clinical practice with use of EHRs
• Interconnect clinicians
• Personalize care with consumer-based health
  records and better information for consumers
• Improve public health through advanced
  biosurveillance methods and streamlined
  collection of data for quality measurement and
  research

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Request for Information

• US Dept. of Health Human Services
• Office of the National Coordinator for Health
  Information Technology

Issued November 15, 2004 Responses by January
18, 2005
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Framework for Strategic Action

• Inform clinical practice with use of EHRs
• Interconnect clinicians
• Personalize care with consumer-based health
  records and better information for consumers
• Improve public health through advanced
  biosurveillance methods and streamlined
  collection of data for quality measurement and
  research

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The RFI

• Addresses goal of interconnecting clinicians by
  seeking public comment and input regarding how
  widespread interoperability of health information
  technologies and health information exchange can
  be achieved.

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Why Interoperability

• Interoperability is necessary
• for compiling the complete experience of a
  patients care
• for maintaining a patient's personal health
  records, and
• for ensuring that complete health information is
  accessible to clinicians as the patient moves
  through various healthcare settings.

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Why Interoperability (cont.)

• Interoperability is needed for clinicians to make
  fact-based decisions so medical errors and
  redundant tests can be reduced.
• Interoperability is also critical to
  cost-effective and timely data collection for
  biosurveillance, quality measurement and clinical
  research.

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NCHICA RFI Response Participants

• Duke Univ Hlth System
• Initiate Systems
• Internet2
• Keane
• LabCorp
• MRNC
• NC DHHS
• NCHIMA

• Physicians EHR
• Robeson Co Med Soc
• RTI International
• Siemens
• Smart Assoc
• Telumenous
• UNC SPH
• Western NC RHIO

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Disclaimer

• The NHIN and RHIOs are a new but important
  concepts
• Definitions are not firm at this time
• Public input is being sought by the Office of the
  National Coordinator for Health Information
  Technology (ONCHIT)

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NHIN

• National Health Information Network (NHIN)
• A supportive, nation-wide, interoperable system
  with the capacity to exchange conveniently and
  securely healthcare information culminating in
  the improvement of consumer health and the
  reduction in healthcare costs.

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RHIO

• Regional Healthcare Information Organizations
  (RHIO)
• A collaborative, consumer-centric organization
  focused on facilitating the coordination of
  existing and proposed e-health initiatives within
  a region, state, or other designated local area.

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Types of RHIOs

• Federations
• Includes large, self-sufficient enterprises
• Agreement to network, share, allow access to
  information they maintain on peer to peer basis
• May develop system of indexing and/or locating
  data (e.g., state or region-wide MPI)

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Types of RHIOs (cont.)

• Co-ops
• Includes mostly smaller enterprises
• Agreement to pool resources and create a
  combined, common data repository
• May share technology and administrative overhead

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Types of RHIOs (cont.)

• Hybrids
• Includes combinations of Federations and Co-ops
• Agreement to network, share, allow access to
  information they maintain on peer to peer basis
• Allows aggregation across large areas (statewide
  or regional

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RHIO Structure

• 501(c)(3) Nonprofit
• Eligible for Federal and State Grants
• Contributions may be tax deductible as charitable
• Issues
• Limit of 20 on income from unrelated business
  activities (i.e. not charitable and educational)
• May need to subcontract or otherwise handoff
  operational aspects of activities

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Key Allies for a RHIO Include

• Covered Entities (Providers, Health Plans,
  Clearinghouses)
• Medical Society
• Hospital Association
• Nurses Association
• Health Information Management Assn.
• Medical Group Managers Association
• Healthcare Financial Management Association
• Association of Local Health Directors
• Association of Pharmacists
• Long-term Care Association
• Association of Health Plans
• QIOs
• Vendors
• Etc., Etc.

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RHIO Management
VIDEO CLIP
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• NCHICA as One Possible RHIO Model

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NCHICA Background

• Established in 1994 by Executive Order of
  Governor
• 501(c)(3) nonprofit - research education
• 250 members including
• Providers
• Health Plans
• Clearinghouses
• State Federal Government Agencies
• Professional Associations and Societies
• Research Organizations
• Vendors and Consultants
• Mission Improve healthcare in NC by
  accelerating the adoption of information
  technology

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Terms of Membership

• A fundamental purpose of NCHICA is to
• facilitate the development of a statewide
  healthcare information network incorporating
• open architecture
• interoperable systems, and
• reconfigured information systems.

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Terms of Membership (cont.)

• Applicant agrees to support the following
  principles
• to foster interoperability and open-systems
  architecture
• to work in good faith to integrate existing
  healthcare information systems
• to provide expert personnel to support the
  activities of NCHICA in the spirit of
  collaboration
• to support policies adopted by NCHICA to protect
  intellectual property
• to encourage a competitive environment for the
  development of the information,
  telecommunications, and telemedicine industries
  in North Carolina consistent with NCHICA's
  purposes.

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Successes and Challenges Raised in NCHICA Projects
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Characteristics of Projects

• All have evolved from earlier efforts
• All are statewide efforts
• All involve public and private sector
• All build toward a North Carolina Local Health
  Information Infrastructure and are positioned to
  connect into national PHIN and NHIN efforts
• Expectation is for continued evolution and
  refinement

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Statewide Master Person Index

• 1994 Goal
• Develop Voluntary Patient Information Locator
  (VPIL) so that records could be accessed for care
• Business / Policy
• Shared customer lists
• Legal
• Privacy Liability
• No State or Federal Laws covering electronic
  health info
• Consumer
• Privacy
• Technical
• Availability of standardized MPIs from all
  providers and sectors
• Synchronizing databases
• Standards for data

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Statewide Master Person Index

• Lessons Learned
• Technology is the easy part
• Business and Policy Considerations are much
  harder and Show Stoppers
• Develop clinical leadership for project with
  technologists in support role

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HIPAA Efforts

• 1995-1999 Privacy Confidentiality Focus Group
• Model Privacy Legislation
• 1998-2003 HIPAA Implementation Planning Task
  Force
• 1998-Present
• Privacy Work Group
• Security Work Group
• Transactions, Code Sets and Identifiers Work
  Group
• Privacy Security Officials Work Group
• Deliverables Compliance tools, model documents,
  education and training programs
• and, method of building community consensus

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Statewide Immunization Registry

• 1998 Goal
• Combined registry of public and private
  childrens immunization records from multiple
  sources available via secure Internet
• Business / Policy
• Internet access to public health database
• Legal
• Privacy and Security
• Non-stigmatizing data
• Consumer
• Well understood need
• Technical
• Data quality and matching entries from different
  sources
• Move from mainframe to server with SSL Web
  technology and authentication

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Statewide Immunization Registry
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Statewide Immunization Registry Status

• Combined Database
• Public Health
• BCBSNC
• Kaiser Permanente (historical)
• 2M Children
• 20M doses
• 425 sites 2250 authenticated users
• 90 Local Public Health Departments
• 335 Private Providers, Schools, State of TN

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New Statewide Immunization Registry
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Statewide Immunization Registry

• Lessons Learned
• Choose project with clear benefits
• Find clinical champions
• Enlist CEO-level champions
• Share the load
• Celebrate success
• PKI is not like falling off a log
• Proof is in the utility of the project and user
  demand for sustaining it past pilot stage

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Statewide Emergency Dept. Database

• 1999 Goal
• Standardize and electronically collect clinical
  data from emergency departments for
• Best Practice Development Community Assessments
• Public Health Surveillance (2001)
• Business / Policy
• Participation Agreement covering access and use
  of data
• Legal
• Privacy and Security
• No state mandate for collection of certain data
  elements with identifiers (Limited Data Set and
  Data Use Agreement)
• Consumer
• Collected and transmitted to aggregation point as
  deidentified data
• Technical
• Standards for data elements (CDCs DEEDS
  Standard)
• Mapping of systems so extracts could be
  transformed into DEEDS
• No standards for coding of Chief Complaint and
  First Report of Injury

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Status as of 1-31-2005
Statewide Emergency Dept. Database

• Data from 24 hospitals
• 4000 visit records per day on average
• Total Number of Visits 1.6M
• Total Number of Patients 875K
• Total Number of Final Diagnosis Codes 4.2M
  
• Total Number of Cause of Injury Codes 478K
• NCHA now involved to accelerate collection from
  all 124 hospitals with EDs across NC

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Statewide Emergency Dept. Database

• Lessons Learned
• Provide neutral table for collaboration
• Make it easy for IT Departments to provide data
• Keep it simple and cheap
• Expect new opportunities for data use
• Professional associations are better at policy
  issues than technology implementation
• While HIPAA is permissive, providing information
  voluntarily (e.g. without safe harbor) makes
  legal counsel very uncomfortable

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NC Public Health Initiatives

• NC-PHIN
• North Carolina Public Health Information Network
• NC-HAN
• North Carolina Health Alert Network

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Vision Framework for the Future
NC-PHIN

• Automated electronic reporting of data
• Secure Internet pipeline for reporting
  information
• Consistent user interfaces
• Common data definitions
• Reusable software components
• Shared analysis and dissemination methods, e.g.,
  outbreak detection algorithms
• Secure, HIPAA-compliant data warehouse
• Established set of technical standards acceptable
  and adopted by preparedness partners

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NC-PHIN Components

• Health Alert Network NC-HAN
• Epi-X (secure interactive communications with CDC
  and other states)
• Enhanced Public Health Surveillance
• Electronic Disease Reporting
• Hospital Data (ICD-9, UB92 Admin. Data)
• Syndromic Surveillance
• Hospital Clinical Data
• Poison Control Center
• PreMIS
• Aberrancy Detection
• Medical Examiner Data

• Program Area Modules
• TB
• Hepatitis
• Meningitis
• HIV/STD
• Vaccine Preventable Diseases
• Immunization Registry
• Multi-Hazard Threat Database
• GIS
• Electronic Laboratory Results (LRN)
• Vital Records Automation

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Public Health Initiatives

• Lessons Learned
• HAN starts us on the path to connectivity
• Connectivity drives additional opportunities
• Use immunization registries to drive
  public-private connections
• EHRs have potential of improving surveillance
  capabilities and improving population and public
  health

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North Carolina Healthcare Quality Initiative
Improving Healthcare in North Carolina by
Accelerating the Adoption of Information
Technology
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NC Healthcare Quality Initiative

• Goal
• Phase I - Provide list of medications at point of
  encounter to save time, improve accuracy of
  treatment and avoid medication errors
• Include ability to automate refills, e-Rx, and
  access to formularies
• Phase II Electronic handling of Lab and
  Radiology data
• Business / Policy
• Access to data from health plans, PBMs,
  pharmacies and other providers
• Cost of operation Sustainability
• Legal
• Privacy and Security (limit use to Treatment)
• Rights to data Liability
• Consumer
• Who has been looking for and at my information?
• Drugs for behavioral health, communicable
  diseases, etc.
• Technical
• Accessing records from multiple sources and
  linking same patient data

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Medications Management

• Key attributes
• Saves clinicians time (10-40 of encounter)
• Improves patient safety
• Leads to automating medication refills
• Leads to e-Prescribing
• Example Medicare Population
• 20 have 5 or more chronic conditions
• Those 20 see on average 13.5 different
  physicians per year
• Potential for prescribing errors, duplication of
  orders, tests, etc.
• Chronic Care accounts for 70-80 of expenditures

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Medications Management Initiative

• Important data in emergent cases
• Frequently not available
• Identifies current medical conditions
• Avoids inappropriate drug-drug interactions
• Currently kept by different repositories
• Pharmacy claims
• Health Plans
• Patients
• Requires policy and technology solutions
• Privacy and Security considerations
• Business and collaboration considerations
• Technology issues
• Data Quality
• Networked databases
• Data repository vs. Portal technology

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Medications Management Initiative
Community Medication History Portal
Electronic Prescriptions Refills
Presentation
Web portal
eRx
EHR
EAI
Data Integration
INQUIRY HISTORY DATABASE
IDENTITY HUB
Transaction Services
RxHUB
SureScripts
Direct
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NC HC Quality Initiative - Project Management
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Proposal Development Teams

• Technology
• Technical approach, diagrams
• Clinical Integration
• Clinician role and adoption and consumers role,
  adoption, satisfaction
• Business / Finance
• Business Model, budgets and justification
• Policy
• Role of patients, agreements
• Metrics
• Assess value of project
• Coordination
• Executive Summary, letters of commitment, etc.

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Values for the Transition

• Keep the health and safety of the individual as
  the core objective.
• Use RHIOs as an opportunity and vehicle to
  transform healthcare into a more effective and
  efficient system.
• Promote clinical and business benefits of
  information technology and secure communications .

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Generating RHIO Proposals for Funding

• Lessons Learned
• Understand the requirements from the funder e.g.
• Contract or Grant
• WMOB Subcontracting
• Principal Investigator
• Cognizant Auditing Agency
• Time commitment of team to develop proposal
• Limited capabilities of volunteers with primary
  responsibilities elsewhere
• Technical Clinical Expertise
• Policy and Business Requirements
• Privacy Security
• Shared information among competitors
• Commitments from top executives (private and
  government)
• Educate and Obtain Commitment

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The Race Goes to the Swift
VIDEO CLIP
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Thank You

• Holt Anderson, Executive Director
• Holt_at_nchica.org [phone] ext. 27
• North Carolina Healthcare Information and
  Communications Alliance, Inc. www.nchica.org

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Questions ?