a feasible path to sustainable community health information infrastructure william a. yasnoff, md,...

A Feasible Path to Sustainable Community

Health Information Infrastructure

A Feasible Path to Sustainable Community

Health Information Infrastructure

William A. Yasnoff, MD, PhD, FACMICEO, Health Record Banking Association

Cerner Healthcare Leadership ForumOrlando, FL

October 8, 2006

© 2006

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

22 © 2006



OutlineOutline

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?

33 © 2006



I. What is the NHII?I. What is the NHII?

Comprehensive knowledge-based network of interoperable systems

Capable of providing information for sound decisions about health when and where needed

“Anywhere, anytime health care information and decision support”

NOT a national database of medical records

Comprehensive knowledge-based network of interoperable systems

Capable of providing information for sound decisions about health when and where needed

“Anywhere, anytime health care information and decision support”

NOT a national database of medical records

44 © 2006



I. What is the NHII? (continued)I. What is the NHII? (continued)

Includes not only systems, but organizing principles, procedures, policies, and standards, e.g. Organization & governance Alignment of financial incentives Operational policies Message & content standards

Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII

Includes not only systems, but organizing principles, procedures, policies, and standards, e.g. Organization & governance Alignment of financial incentives Operational policies Message & content standards

Individual provider Electronic Health Record (EHR) systems are only the building blocks, not NHII

55 © 2006



Difficult Challenges of NHIIDifficult Challenges of NHII Governance

New organizations Stakeholder cooperation

Misaligned incentives Costs

Startup Ongoing

Technical - how will it work? Privacy Standards

Governance New organizations Stakeholder cooperation

Misaligned incentives Costs

Startup Ongoing

Technical - how will it work? Privacy Standards

ALL THESE ARE INTERDEPENDENT& CANNOT BE SOLVED SEPARATELY

ALL THESE ARE INTERDEPENDENT& CANNOT BE SOLVED SEPARATELY

66 © 2006



II. How does NHII help address current health care problems?

II. How does NHII help address current health care problems?

A. Improving Healthcare Delivery at Point of Care (Improving Quality) Complete patient information Decision support

B. Reducing Costs & Achieving Efficiencies Eliminate duplicate tests & imaging Eliminate duplicate communication

channels (labs, x-rays, etc.)C. Support Public Health Initiatives &

Biosurveillance Automated disease reporting Automated syndrome reporting

A. Improving Healthcare Delivery at Point of Care (Improving Quality) Complete patient information Decision support

B. Reducing Costs & Achieving Efficiencies Eliminate duplicate tests & imaging Eliminate duplicate communication

channels (labs, x-rays, etc.)C. Support Public Health Initiatives &

Biosurveillance Automated disease reporting Automated syndrome reporting

77 © 2006



III. Who Should Fund NHII?III. Who Should Fund NHII? Federal Government

Already pays for about half of all health care costs

– Medicare– Medicaid– Federal employees– healthcare insurance premium

tax deduction Not considered direct Federal

responsibility High estimated cost (~$150 billion)

is major obstacle

Federal Government Already pays for about half of all

health care costs– Medicare– Medicaid– Federal employees– healthcare insurance premium

tax deduction Not considered direct Federal

responsibility High estimated cost (~$150 billion)

is major obstacle

88 © 2006



III. Who Should Fund NHII? (cont.)III. Who Should Fund NHII? (cont.)

Private Sector Where healthcare is delivered No obvious funding approach Difficult to mobilize stakeholders

– First-mover disadvantage– Misaligned incentives– Mistrust

Organization required to handle funds

Private Sector Where healthcare is delivered No obvious funding approach Difficult to mobilize stakeholders

– First-mover disadvantage– Misaligned incentives– Mistrust

Organization required to handle funds

99 © 2006



IV. How Can We Organizethe Creation of the

NHII?

1010 © 2006



Community Approach to HIICommunity Approach to HII

Existing HII systems are local Health care is local benefits are local Facilitates high level of trust needed Easier to align local incentives Local scope increases probability of

success Specific local needs can be addressed Can develop a repeatable implementation

process Parallel implementation more rapid

progress

Existing HII systems are local Health care is local benefits are local Facilitates high level of trust needed Easier to align local incentives Local scope increases probability of

success Specific local needs can be addressed Can develop a repeatable implementation

process Parallel implementation more rapid

progress

1111 © 2006


are needed to see this picture.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

RecordsReturned

Requests for Records

Community

Clinician EHRSystem

Encounter Data Stored

in EHR

Pointer to Encounter

Data Added to Index

1212 © 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

RecordsReturned

Requests for Records

U.S.

anotherLHII

1313 © 2006



Problems with scattered data model for community HIIProblems with scattered data model for community HII

All health information systems must have query capability (at extra cost) Organizational cooperation

challenge (esp. for physicians) Maintaining 24/7/365 availability

with rapid response time will be operationally challenging (& costly)

Searching HII repository is sequential (e.g. for research & public health)

Where is financial alignment & sustainability?

All health information systems must have query capability (at extra cost) Organizational cooperation

challenge (esp. for physicians) Maintaining 24/7/365 availability

with rapid response time will be operationally challenging (& costly)

Searching HII repository is sequential (e.g. for research & public health)

Where is financial alignment & sustainability?

1414 © 2006



Examples of Community HIIExamples of Community HIIName Data Storage

Spokane, WA Central

South Bend, IN Central

Indianapolis, IN Central

Fishkill, NY Central

Bellingham, WA Central

Cincinnati, OH Central

Number of operational community HII systems using scattered model: NONE

1515 © 2006



V. What is the Path toHII 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

Clearly Articulating Requirements and Envisioning the Completed System is

Essential for Effective Progress

1616 © 2006



CompleteElectronicPatientInformation

Stakeholder cooperation

FinancialSustainability

PublicTrust

Components of a Community Health

Information Infrastructure

1717 © 2006




Most information is already electronic: Labs, Medications, Images, Hospital Records

Outpatient records are mostly paper Only 10-15% of physicians have EHRs Business case for outpatient EHRs weak

Requirement #1: Provide financial incentives to create good business case for outpatient EHRs

1818 © 2006



RequirementsRequirements1. Provide financial incentives to create good

business case for outpatient EHRs1. Provide financial incentives to create good

business case for outpatient EHRs

1919 © 2006




Need single access point for electronic information Option 1: Gather data when needed (scattered model)

Pro: 1) data stays in current location; 2) no duplication of storage

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

2020 © 2006




Need single access point for electronic information Option 2: Central repository

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

Con: public trust challenging, duplicate storage (but storage is inexpensive)

2121 © 2006




Need single access point for electronic information Requirement #2: Central repository for storage

2222 © 2006




business case for outpatient EHRs2. Central repository for storage

1. Provide financial incentives to create good business case for outpatient EHRs

2. Central repository for storage

2323 © 2006



Voluntary Impractical Financial incentives

Where find $$$$$? Mandates

New Impractical Existing

– HIPAA requires information to be provided on patient request

Requirement #3: Patients must request all information

Stakeholder cooperation

2424 © 2006




business case for outpatient EHRs2. Central repository for storage3. Patients must request all information


2. Central repository for storage3. Patients must request all information

2525 © 2006



Funding options Government

– Federal: unlikely– State: unlikely– Startup funds at best

Healthcare Stakeholders– Paid for giving care– New investments or transaction

costs difficult Payers/Purchasers

– Skeptical about benefits– Free rider/first mover effects

Consumers– 72% support electronic records– 52% willing to pay >=$5/month

Requirement #4: Solution must appeal to consumers so they will pay

FinancialSustainability

2626 © 2006




business case for outpatient EHRs2. Central repository for storage3. Patients must request all information4. Solution must appeal to consumers so they

will pay


2. Central repository for storage3. Patients must request all information4. Solution must appeal to consumers so they

will pay

2727 © 2006



A. Public Trust = Patient Control of Information

Requirement #5: Patients must control all access to their information

PublicTrust

2828 © 2006





will pay5. Patients must control all access to their

information




information

2929 © 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

PublicTrust

3030 © 2006






information6. Governing institution must be self-regulating

community-owned non-profit





community-owned non-profit

3131 © 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

PublicTrust

3333 © 2006



Health Record Banking ModelHealth Record Banking Model All information for a patient stored in

Health Record Bank (HRB) account Patient (or designee) controls all access

to account information [copies of original records held elsewhere]

Each HRB has three interfaces: Withdrawal window - record access Deposit window - receives new info Search window - authorized requests

When care received, new records sent to HRB for deposit in patient’s account

All data sources contribute at patient request (per HIPAA)

All information for a patient stored in Health Record Bank (HRB) account

Patient (or designee) controls all access to account information [copies of original records held elsewhere]

Each HRB has three interfaces: Withdrawal window - record access Deposit window - receives new info Search window - authorized requests

When care received, new records sent to HRB for deposit in patient’s account

All data sources contribute at patient request (per HIPAA)

3434 © 2006



eHealthTrust™ Business Model for Health Record BankingeHealthTrust™ Business Model for Health Record Banking

Charge $5/patient/month ($60/year) Paid by patient, payer, or purchaser

Operating Cost < $20/year/patient Payments to clinicians for submitting

standard electronic clinical info provides incentives for EHR acquisition (~$3/encounter)* $10-20K/year for EHR system

Charge $5/patient/month ($60/year) Paid by patient, payer, or purchaser

Operating Cost < $20/year/patient Payments to clinicians for submitting

standard electronic clinical info provides incentives for EHR acquisition (~$3/encounter)* $10-20K/year for EHR system

*patent pending

3535 © 2006


are needed to see this picture.Clinical Encounter

Health Record Bank

Clinician EHRSystem

Encounter Data Entered in EHR

Encounter Data sent to

Health Record Bank

PatientPermission?

NODATA NOT

SENT

Clinician Inquiry

Patient data delivered to

Clinician

YES

$3 payment

Clinician’s BankSecure patient

health data files

Health Record Bank / eHealthTrust™

3737 © 2006



HRB/eHealthTrust™ AdvantagesHRB/eHealthTrust™ Advantages Uses Existing Infrastructure

Current EHR systems can be converted into HRBs Easily Integrated with

Patient-entered information Patient education information Patient reminders Patient-provider electronic communication

Promotes Gradual Standards Adoption Initial standard enforced through HRB Association Reimbursement policy can improve standard over

time (e.g. to increase coding) Provides Transition from Paper Records

Fax images of paper records stored Metadata facilitates some indexing

Immediate Realization of Benefits Each HRB/eHealthTrust member gets immediate

benefit from complete records Benefits not contingent on critical mass

Uses Existing Infrastructure Current EHR systems can be converted into HRBs

Easily Integrated with Patient-entered information Patient education information Patient reminders Patient-provider electronic communication

Promotes Gradual Standards Adoption Initial standard enforced through HRB Association Reimbursement policy can improve standard over

time (e.g. to increase coding) Provides Transition from Paper Records

Fax images of paper records stored Metadata facilitates some indexing

Immediate Realization of Benefits Each HRB/eHealthTrust member gets immediate

benefit from complete records Benefits not contingent on critical mass

3838 © 2006



Strategy for Initial HRB/ eHealthTrust™ FundingStrategy for Initial HRB/ eHealthTrust™ Funding

Issue RFP Vendor builds eHealthTrust in

exchange for long-term guaranteed operations contract (Vendor owns software)

Engage purchasers to enroll beneficiaries to guarantee operational revenue Need about 100,000 subscribers to

break even (~$6 million/year revenue) Once system operational, market to

individual consumers through physicians

Issue RFP Vendor builds eHealthTrust in

exchange for long-term guaranteed operations contract (Vendor owns software)

Engage purchasers to enroll beneficiaries to guarantee operational revenue Need about 100,000 subscribers to

break even (~$6 million/year revenue) Once system operational, market to

individual consumers through physicians

3939 © 2006



Win-Win for StakeholdersWin-Win for Stakeholders Consumers

Lower cost, higher quality care Complete medical records under their

control Providers

Financial incentives for EHRs Access to complete patient records

Payers & Purchasers Availability of complete aggregate

data needed to monitor care Lower cost, higher quality care

Consumers Lower cost, higher quality care Complete medical records under their

control Providers

Financial incentives for EHRs Access to complete patient records

Payers & Purchasers Availability of complete aggregate

data needed to monitor care Lower cost, higher quality care

4040 © 2006



SUMMARYPath to HII in CommunitiesSUMMARYPath to HII in Communities

I. Community Health Record Bank(s)II. Paid for and Controlled by PatientsIII. Solves Key Problems

Privacy Assurance for Consumers EHR incentives for physicians Financial Sustainability Cooperation by health care institutions Adoption and Gradual Improvement of

StandardsIV. Win/Win for All Stakeholders

I. Community Health Record Bank(s)II. Paid for and Controlled by PatientsIII. Solves Key Problems

Privacy Assurance for Consumers EHR incentives for physicians Financial Sustainability Cooperation by health care institutions Adoption and Gradual Improvement of

StandardsIV. Win/Win for All Stakeholders

4242 © 2006



Questions?Questions?

William A. Yasnoff, MD, PhD, [email protected]/527-5678

For more information:www.healthbanking.orgwww.ehealthtrust.com

www.yasnoff.com

For more information:www.healthbanking.orgwww.ehealthtrust.com

www.yasnoff.com

a feasible path to sustainable community health information infrastructure william a. yasnoff, md,...

Documents