1. technology and computing

Health Information Exchange in South Carolina:
What is it and what should be done?
W. David Patterson, Ph.D.
Chief, Health and Demographics SC B&CB - SC HIT Coordinator
SCMA Bioethics Retreat, Hilton Head SC
February 3-5, 2012
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SCHIEx – South Carolina Health Information Exchange
A Network of Networks
Background: Why Health Information Exchange?
Vision and History
SCHIEx Technology
How It is Being Used Today (and Tomorrow)
2
BACKGROUND
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Defining Bioethics
The study of the ethical and moral implications of
medical research and practice.
The American Heritage® Science Dictionary Copyright © 2002. Published by Houghton Mifflin. All rights reserved.
A branch of applied ethics that studies the philosophical, social,
and legal issues arising in medicine and the life sciences. It is
chiefly concerned with human life and well-being, though it
sometimes also treats ethical questions relating to the
nonhuman biological environment.
Encyclopedia Britannica, 2008. Encyclopedia Britannica Online.
4
PhysicalPrimary
TherapyCare
Self Regional Hospital
Pain Management
Orthopedist
Rheumatologist
University Hospital
Car Accident
5
6
Medical Errors from Lack of Information: Why
is it an Unsolved Problem?
“In attempting to arrive at the
truth, I have applied
everywhere for information,
but in scarcely an instance
have I been able to obtain
hospital records fit for any
purpose of comparison. If they
could be obtained, they would
enable us to decide many
other questions besides the
one alluded to. They would
show subscribers how their
money was being spent, what
amount of good was really
being done with it, or whether
the money was not doing
mischief rather than good.”
• The lack of immediate access to patient healthcare
information is the source of one-fifth of these errors1.
• 80 percent of errors were initiated by
miscommunication, including missed communication
between physicians, misinformation in medical
records, mishandling of patient requests and
messages, inaccessible records, mislabeled specimens,
misfiled or missing charts, and inadequate reminder
systems2.
Florence Nightingale, 1873
Courtesy: Jodi McDaniel, ONCHIT
1Health
2
Research Institute &GlobalTechnology Center. Reactive to Adaptive:Transforming Hospitals with DigitalTechnology, PriceWaterhouseCoopers. 2005.
Smith, Peter, et. al. “Missing Clinical Information During Primary Care Visits,” The Journal of the American Medical Association. February 2005.
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VISION AND HISTORY
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Vision: The Triple Aim
Institute for Healthcare Improvement (2012). http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx.
The Institute for Healthcare Improvement (IHI) believes that new
designs can and must be developed to simultaneously accomplish
three critical objectives, or what we call the “Triple Aim”:
Improve the health of the population;
Enhance the patient experience of care (including quality, access,
and reliability); and,
Reduce, or at least control, the per capita cost of care.
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Governance
South Carolina’s History:
Incremental & Parallel Paths To Drive Value Chain
DOC and SC
DHHS approve
use of data in
ORS specific
statutes, provisos, core service
and BAA’s & MoU’s construction
under existing
- Data Oversight
authority
Council (DOC)
LRHN
Governance
initiated
(Markle),
“master
agreement” with
ORS to use state
core services
Connecting the
Communities of
Care begins sharing
data among CHC’s,
RHC’s and FMC’s
via a common
BAA/DUA template
DHHS and ORS
develop
automated
agreement
process to allow
access to
Medicaid data by
enrolled
providers
SD DHHS
Appointed SDE
by Governor.
SCHIEx official
statewide
exchange. 11
member IGC
Established
Fee Schedule,
OnRamping
approved by IGC.
NHIN
Coordinating
Cmt Approves
SCHIEx as Node
on NHIN
Claims
2005
2006
2007
2008
2009
2010
2011
Technology
Deep Clinical Data
Existing Data
Warehouse, data
linking and
integration process
serving dozens of
agencies and
organizations
Creation of Core
Network
Services,
including statewide RLS/MPI
from existing
Medicaid and
UB 92/04 data
LRHN connects
to state core
network
services and
deploys
adapters to
create a RHIO
using the state
platform .
Deep Clinical
Data from 22
Providers
Starts Flowing
A “thin” EMR is
deployed that
allowed clinics with
no electronic
system to collect
limited, but
essential clinical
data via SCHIEx.
HRSA AccessNet
Patient Navigation
Goes Live
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SCHIEx data
deployed via
hosted adapter
service and the
SCHIEx viewer is
used to make a
ten year patient
history available
free of charge.
Telepsychiatry
Initiative Goes
Live
CHIPRA
Demonstration
Grant (1 of 10
States) to show
QI using linked
admin/clinical
data exchange.
NwHIN DIRECT
Early
Implementer
MU OnRamp
Test Harness
Deployed.
Connectivity
Guide Published
Summary of
Summaries, On
Demand
documents, and
Exchange
powered DIRECT
Guiding Principles … Competing Forces
o Meet federal expectations while keeping it simple for SC providers
o Focus on Stage 1 MU (CMS Meaningful Use) needs and upcoming stage 2
to prioritize activities
o Leverage (EHR MU, REC (SC CITIA), HITSP standards) – work with those
incentivizing and assisting healthcare providers with technology.
o Low barrier to entry while providing glide-path to increasing functionality
o Accommodate diverse views on data sharing preferences, but focus first
on TPO (treatment, payment, and operations)
o Any approach must be sustainable and worth the value – the enemy of
“good” is “better”
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Design Principles
Follows Connecting For Health (Markle) &
NwHIN
•
•
•
•
•
•
•
•
•
•
Decentralized
Federated/Hybrid Architecture
No “Health ID” – Record Location Services
Bottom up and top down
Decoupled development
Scalable and evolvable
No 'rip and replace’
Standards based
Security and Privacy Obsessed
Auditable
Courtesy: Connecting for Health
Markle Foundation
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Complete Transparency
(c)2011 HIMSS
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Our Approach - Summary
Startup
•
One Time Investments Require
Priority Clarity
•
•
•
•
•
•
•
•
Solid foundation for future
applications
Focus on infrastructure
Focus on minimizing ongoing
operating cost impact
Focus on seeding data to unlock
value network effect
Obsess about adoption critical mass
Funded by one-time grant dollars
Subsidize early adopters
Bias toward action (cheap, fast
mistakes)
Ongoing Operations
•
Keep Costs Low
•
•
•
•
•
Don’t compete with collaborators
•
•
•
Self service model
Web based outreach and
education
Leverage existing resources
(state data center)
Pass savings to subscribers
Focus on activities that can only
be provided by HIE
Collaborate with REC and
existing associations
Not to be funded by grant dollars
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TECHNOLOGY
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Standards Based Network of networks
CDC
DoD
Federal Health Architecture
CONNECT 2.4 Compliant Gateway
SSA
C
O
R
E
.
VA
CMS
Other State
Optional
Hosted Applications
HIEs
Clinical Viewer
ePrescribe
ThinEMR
CareCoordinate
.
Pharmacies
Core Connectivity Services
MPI
RLS
Audit/Log
Authentication
Time Server
ORS Hosted Data Assets
. Medicaid
UB92/04
XDS Repo
Provider
Labs
HITSP/IHE Compliant Standards
PIX, XDS/CCD (HL7 2.x), DIRECT
IZ Registry
Integrated
Delivery
System
Community #1
MPI
Community #2
CHCs
Clinics
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Summary – Sharing with SCHIEx
Exchange
Step 1 – Provide Patient Information
Adopting
Site
Patient Identity Feed – ITI-8
Adding patient to domain
SCHIEx SC State
PIX Manager
Step 2 – Provide Documents
Patient Provide and Register
Document Set-b – ITI-41
Adopting
Site
Registering Documents
ITI-42
XDS
Repository
SCHIEx XDS
Registry
PIX: Patient Identifier Cross Reference
XDS.b: Cross Enterprise Document Sharing
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Summary – “Querying” SCHIEx
Exchange
Step 3 – Retrieve Documents
6. Retrieve Document Set Response
1. PIX Query – ITI-9
Adopting Site
HIEBusTM
Interoperability
Services PIX
Manager
HIEBusTM
Interoperability
Services XDS
Repository
5. Retrieve Document Set – ITI-43
2. PIX Update Notification – ITI-10
4. Repository and Document IDs
3. Query Registry – ITI-16
HIEBusTM
Interoperability
Services XDS
Registry
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SCHIEx Direct: Simple 2-layer network
view
Endpoint system
Gateway system
Gateway system
Endpoint system
Discharge@gothamgeneral
Dr.Juan@sunnysidepractice
User perception of transaction
Top layer:
User Perception
Authenticate
Authenticate
Send message
Receive message
Second layer:
Routing
What can be accomplished with
today’s infrastructure?
• Easing workflow and improving reliability requires
automation, meaning machine-to-machine communication
• The more that we want to automate, the more directory
information that needs to be standardized, reliable, and
accurate for machine level readability
• The only information that is standardized, reliable, and
accurate for machine-level readability at a national level
today is information contained in DNS registries
• Capability that builds on DNS registries is fastest and easiest
approach, however:
• Does not allow discoverability
• Has no user-level information
• Has no security
• Does little to ease local workflows – basically a step
above faxing
CURRENT AND FUTURE USES
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www.SCHIEx.org
SCHIEx “Update”
• NwHIN VLER Pilot
• CHIPRA Quality Improvement (QTIP)
• Public Health Participation, Goals, Future Plans
Immunization Registry
ELR
Syndromic Surveillance
Exchange Participant
www.SCHIEx.org
SCHIEx
Early Adopter Program
www.SCHIEx.org
Barriers to Onboarding
o EHR Vendor Technical readiness
ONC Certifications does not equate standards based
interoperability (emerging standards not yet in current releases)
o Large Hospital Systems - cost & technical timeline (integration
work /upgrades to multiple information systems)
o Focus Meaningful Use minimum requirements rather than longterm interoperability goals
“Just a Test” - Medicaid AIU
o “Wait-and See” (MU Stage 2, DIRECT, “wait for NwHIN”, “Who’s
already on?”)
o Reductions in reimbursement (Medicaid Cuts)
www.SCHIEx.org
Solution
o Make it FREE – waive the annual subscription fee, and accept all
providers
o Recruit early adopter CHAMPIONS and offer support, and work to
foster synergy among providers
o Make sure the early adopters are representative of the provider
community
o Geography
o Size
o Practice areas
o Safety net providers
o Vendor products
o Pave the way for later adopters - work through technical
requirements/barriers for onboarding with as many different EHR
vendor products as possible
www.SCHIEx.org
41 Early Adopter Program Applicants
www.SCHIEx.org
Hospital and Physician Group Size
www.SCHIEx.org
157 Total Facilities/Locations
www.SCHIEx.org
17 EHR Systems
Additional information is available at www.SCHIEx.org.