ONC ‘Deep Dive’ CallWednesday, October 6

AGENDA

Introductions 3 min

Leadership/Stewardship Dr. Chute 3 min

Infrastructure/Meaningful Use Calvin Beebe 10 min

Broadband John Goodman 5 min

Public Health/Schools Mary Wellik 5 min

Deliberative Democracy Dr. Koenig 5 min

Asthma Intervention Dr. Yawn 5 min

Diabetes Intervention Phase 1 Dr. Montori 5 min

Immunization Pilot Dr. Chaudhry 5 min

Sustainability/Payment Reform Dr. Wood 5 min

IntroductionsIntroductions

Leadership/StewardshipLeadership/StewardshipDr. Christopher Chute

3046260-5

Subject Matter Expert WGs

Office of the National Coordinator of Healthcare IT (ONC)

Federal Steering Committee (FSC) - TBN

Eva

luat

ion

Operations

Mayo & Mayo Health System Leadership

Olmsted Medical Leadership

Winona HealthLeadership

SE MN Beacon Governance

MetricsInfrastructure

Quality Academy

Community & PHEngagement

Cross Beacon / ONC Projects

PracticeImplementation

Dept. of Health & Human Services (DHHS)

National Beacon Communities

Comparative Effectiveness

SE MN Beacon Organization

Project Driven teams

MN Congressional

Offices

REOT

CPCCPQOC

SE MN Schools

SE MN Healthcare

SE MN Public Health

Others

Pro

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Co

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Sta

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ers

Project Initiation Process

Planning Process

Approval to Execute

Public HealthLeadership

ProjectExecution LPH /

SchoolsHIE

ConnectivityData

RepositoryMini-

deliberativeAsthma Phase 1

Broad-band

Diabetes Phase 1

Immun. Pilot

Community Interest Groups

Infrastructure / Meaningful UseInfrastructure / Meaningful UseCalvin Beebe

High Level Data Flows

A

Sources of

B

C

D

E

F

CCD, Action Plans

CCD, Action Plans

CCD, Action Plans

Surveillance Rpts

Surveillance Rpts

Various Reports

Batch Data / HL7(LIFT managed)

G

A

B

C

D

E

F

G

SE MN Server

Data Flow MappingSource Node Document Flows Other flows

A OMC CCDB,C,D,E,F* CDAE (EMR DB / HL7 2.x)

B MCR CCDA,C,D,E,F* CDAE EMR DB

MHS CCDA,C,D,E,F* CDAE EMR DB

C WHS CCDA,B,D,E,F* CDAE (EMR DB / HL7 2.x)

D PH-DOC* CDAA,B,C,F

E Nurse Portal CDAF, (A,B,C)** TBD

F Repository HL7 2.x A,B,CCross Site Data for EMR/PMS

PMS: Population Management System

Repository Requirements

• Correlate patients, students, and PH cases• Identified & anatomized patient access• Merge & unmerge patient EMR data to

accurately identify patient’s for clinical care.• Support complex access authorization matrix to

protected patient information• Easy access to various authorized data sets for

reporting and analytics requirements• Secure, audited, scalable, cost efficient …

Infrastructure Components

• CONNECT 3.1 (Doc. Exchanges)

– w/ HIEOS Open Source

• MIRTH Connect (Repository Loader)

– Interface Engine Open Source

• SE MN Beacon Data Repository options:A. Regenstrief INPC Open Source

B. Mirth Results Open Source

C. Amalga Microsoft Corp

– Regenstrief & Mayo are evaluating the

use of a common repository data model (A,B)

Activities over 90 Days

• CONNECT Code A Thon Rochester, MN• Mayo Health System Population Mgt.• Mayo Clinic Data Trust Mgt.• Public Health Department Review of PH-Doc• Winona Health Service Deep Dive Review

Plans moving forward• Complete assessment of high level functional & technical

requirements for School Nurse Portal solution.– Determine solution provider (MN-HIE / Mayo)

• Review repository requirements with Regenstrief – Select repository solution for SE MN Beacon project

• Specify & acquire server hardware & software assets.

• Establish CONNECT implementation timelines for each site, work with MN-HIE to obtain security certificates.

• Utilize a mix of SE MN Beacon staff and consulting complete needed development, configuration and implementation of SE MN Repository & CONNECT network

BroadbandBroadbandJohn Goodman

Winona Deep Dive

14

WCTN Partners

Community Partners

A-Vu Media - Project Management- Broadband Projects

Hiawatha Headend Facility- Central Vidyo Servers

Home &Community Options

- Services to the disabled - Remote residential

management

Other Community- Winona County Services

- Winona Housing & Redevelopment- County Jail- Project Fine

Hiawatha Broadband- High Capacity fiber Network

- VPN connections

Video

InternetPhone

Networks

Winona Health- Hospital and Clinics

- Assisted living - Nursing Home

- Home Care- Hospice

Older AdultResidential Services

- St. Anne of Winona - Sauer Memorial- 260 Residents- 70 Diabetics

Primary Partnerswireless

Education- Winona Public Schools (K-12)

- St. Mary’s University- Cotter schools

# of NetworkConnections

80-120

20-40

7-1611-20

8-12

Broadband Technologies

Major technologies employed: – High capacity community based broadband networks– Multimedia pc’s networked with encrypted VPN connections– Proprietary video conferencing technology with custom UI’s– Shared access telemedicine e-suites and kiosks

Key implementation areas requiring assistance in SE MN:– Final design and implementation of the telemedicine e-Suites.– Security requirements to achieve HIPAA compliance for community broadband

locations.– EMR data base access from telemedicine sites.– Medical protocols for initial Juvenile Asthma and Diabetes program

implementation.– Research structure for meaningful use assessment.

Major vendors involved:– Vidyo/Phoenix Systems/ Logitech - Hiawatha Broadband– Cerner - A-Vu Media

Broadband Technologies

Past 90 days:1. Implemented Vidyo central server application at HBC.2. Defined the proposed WCTN and its community partners.3. HCO State License for Remote Monitoring.4. HCO designed medication compliance application for Remote Monitoring

Next 90 days:1. Winona health network plan and Phase 1 implementation.2.Telemedicine prototype with custom UI development project.3. Define initial medical plan for Diabetes and Juvenile Asthma4. Implement HCO medication compliance application

Major risks:1. WH staff time needed for program implementation.2. Unexpected technical issues to develop custom UIs.3. Delays in hiring additional technical staff funded by Beacon.

Public Health / School Public Health / School EngagementEngagementMary Wellik

LPH/School Engagement

Key Stakeholders: Public Health Directors, County Boards, School Boards, & School Nurses

Goal: Beacon provides a unique opportunity for providers and these extended providers to come together in the region to explore alternative models of care particularly in the areas of childhood asthma and diabetes.

Objective: To initiate this relationship, introduce the Beacon program and acquire input into the Beacon provider model network.

LPH/School EngagementLast 90 days:

– Letters to Public Health Directors– Ph-Doc Users group presentations– Public Health Directors Teleconferences w/ media Kits– County Board presentations – all 11 counties– LPH participation in all projects (infrastructure, asthma,

diabetes, etc.)

Next 90 days: – Letters to each school district (~47)– School Board presentations & School Nurse engagement– Refine requirements of school participation & input into

provider network model

Deliberative DemocracyDeliberative DemocracyDr. Barbara Koenig

Deliberative Community Engagement

Overarching Goal:

Deliberative community engagement will allow SE Minnesota BEACON leaders to incorporate community values into project design and governance

Considerations

• Need to balance scientific and technical gains with social concerns -- not just a technical issue, but a social and political one

• Need to address these issues in an open, informed manner, engaging the community before implementation

Deliberative Democracy Examples

• Trial by jury (citizens’ jury)– environmental risk

• Extended to inquiry into contentious issues in science and technology– CDC & MN Dept of Health on avian flu

pandemic planning (resource allocation)

• British Columbia, Canada– Voting Methods

Deliberative Democracy Goals

• Goal is not just to “inform” or “educate” the community

• Not a series of focus groups!

• Seeks genuine discussion among representative community members, and,

• Citizens make non-binding recommendations about implementation, governance, & long-term community oversight

Deliberative Democracy Goals

• Not simply to let different perspectives or points of view be expressed, but,

• To make real trade-offs and compromises, encouraging the formulation of recommendations to guide interventions and EHR data use

Large Group Deliberation

Small Group Sessions

Deliberative Community Engagement

Past 90 Days:– Dependency: County Board Endorsements– Logistics of engagement activities (2 part structure)– Developing content & speaker guides– Coordination with public affairs/communications

Next 90 Days (4 Community Discussions):– Oct 30: Rochester – (Seat of Olmsted County) – Oct 31: Winona – (Seat of Winona County) – Nov 13: Red Wing – (Seat of Goodhue County) – Nov 14: Austin – (Seat of Mower County) – Based on above, plan “full engagement” for spring 2011

Deliberative Community Engagement

Key Features of Initial Events:

• Representative sample of disinterested lay participants

• Involve “local conveners”

• Professional moderators

• Expert stakeholders available (as consultants)

– Privacy, Promise of enhanced EHR, etc.

Asthma InterventionAsthma InterventionDr. Barbara Yawn

Asthma Intervention Initiation—Clinical Transformation

Milestones: – Established cross-region asthma focus project team– Identify initial asthma intervention (begin with AAP)– Discuss longer term asthma intervention requiring widespread

EHI support

Next 90 days: – Identify schools and health care facilities willing to participate.– Identify appropriate AAPs and methods to share

– Identify champions in schools and healthcare sites

• Risks– Lack of time and interest by clinical staff– Failure to identify appropriate contacts such

as parent champions– Declaring victory too soon

Asthma Data and performance metrics

• Milestones completed– Sent in baseline data from 3 sites– Began discussion with MN Community Measures– Considered patient reported metrics

• Milestones next 90 days– Develop intervention related metrics– Develop outcome metrics– Develop community acceptable patient reported

metrics

Asthma data and Performance metrics

• Risks– MN Community Measure denied request for

research exemption– Reluctance to require another clinical

endeavor without clear results to suggest this will make a difference in outcomes

– People still living in their silos

Diabetes InterventionDiabetes InterventionDr. Victor Montori

Patient centered diabetes care

Goals To know - at any time - what is the quality of life and

functional status (along with disease control metrics) of patients (described by their demographic and health literacy characteristics), in SE MN.

To implement tailored patient decision aids to enhance patient involvement in clinical decisions about primary and secondary prevention of cardiovascular events.

Patient centered diabetes care

Approach – health measuresCollect health literacy, health-related quality life and functional

status information at the point of care (public health nurse visit, clinics and hospitals) and at the point of existence (home, workplace).

Using these data will enable:• The SE MN Map of Diabetes Control, Health and Function• Stratification of patients by patient-reported and disease-

control measures and health literacy for prioritized/tailored interventions

Patient centered diabetes care

Approach – decision aidsImplement the following patient-tailored decision aids into the

Beacon-integrated electronic environment, for use during patient-clinician interactions of different types:

- Statin Choice (primary prevention)

- Aspirin Choice (primary prevention)

- Diabetes medication cards (A1c target + drug selection)

- AMI Choice (secondary prevention)

Capture use and outcomes in usual clinical settings across the continuum of care

Patient centered diabetes care

Deliverables/Milestones (Phase 1) 2010

Sep - Constitute cross-region diabetes group

Oct - Resourcing & planning

Nov - Design health + literacy metrics (PRO), decision aids (DA)

2011

Feb - Pilot implementation of PRO collection and DAs

Mar – Check ease, rate of use; data quality; iterate and scale up

Later - Display diabetes map, assess correlations, evaluate impact of DAs and other interventions on health and function

Elements of success (or its opposite)

Dependencies– Phased technology infrastructure– Engagement of public health and other partners

Potential Collaborations - Center for innovation, KER UNIT, Healthcare delivery

research program, Beacon partners

Risks – Constrained resources, tight timelines, large community.– Inadequate evaluation

Patient centered diabetes care

Immunization PilotImmunization PilotDr. Rajeev Chaudhry

Mayo Clinic Immunization PilotData & Performance Measurement

• Goal: Pilot to utilize HIT to improve Influenza and Pneumonia vaccination delivery for patients with Asthma and Diabetic patients in primary care practices.

• Baseline data for one primary care practice:– Asthma Influenza rate = 53% Asthma Pneumonia vaccination rate = 38%– Diabetic Influenza rate = 55% Diabetes Pneumonia vaccination rate = 75%

• Scope:

1. To test utilization and efficacy of a newly developed population based HIT system ( advanced registry--Amalga) for improving delivery of immunizations for asthma and diabetic patients

2. To test utilization and efficacy of a newly developed point of care Clinical Decision Support System (GDMS) to improve practices to deliver vaccinations for patients seen in the clinic with Asthma and Diabetes

3. To learn from the pilot the primary care practices needs for HIT to advance the care of patients with chronic conditions.

Mayo Clinic Immunization PilotData & Performance Measurement

Past 90 days:– Identified baseline metrics for asthma and diabetes patients using HIT across SE MN practices– Completed development of a point of care decision support system (GDMS) to identify patients with

chronic conditions and provide decision support for providers for adult patients who need vaccinations during any visit in practice

– Completed development of a population management system (Amalga) to identify population of patients who are due for vaccinations for a primary care practice. Integrated the system with state registry.

– Initiated planning for a pilot with current HIT for vaccination needs for patients with Asthma and Diabetes for 2010 flu season

Next 90 days:– Initiate pilot at one practice with current HIT – Employ PDSA cycles to optimize processes of care and also to enhance the HIT for SE MN Beacon

population management – Invite all practices in SE MN to initiate pilots during current flu season with their existing HIT – Study impact of HIT on delivery of vaccinations to at risk population– Identify opportunities to enhance HIT ( SE MN repository for population management and reporting) and

processes of care for vaccinations delivery– Test utilization of patient portal to notify patients and provide online access for care– Study patient preferences for notification, access and vaccination delivery

Mayo Clinic Immunization PilotData & Performance Measurement

• Risks:

– Inadequate vaccination supply

– Lack of adequate access at practices to accommodate the patients who need vaccinations (access for patients, convenience, hours of operation for vaccination administration)

– HIT unable to serve the needs of practices at both point of care and population level

– Inability to reconcile vaccination information from other sources (e.g. retail vaccination administration and other practices)

– Capacity of practice to utilize new HIT and incoporate process redesign

– Lack of standardization of processes among practices

– Patient Portal ability to alert patients and provide online access

Clinical Transformation

• Types of resources are available:– Study impact of HIT on care delivery ( Health Care Policy and Research)

– SE MN Beacon team for sharing pilot results (lessons learned etc.) with partner practices

– Quality academy for multi disciplinary teams that need training

• Provider landscape:– Group practices ( Mayo Clinic Rochester , Mayo Clinic Health System, Winona Health,

Olmsted Medical Center)

– Public Health

• Next 90 days:– Immediate goals are to apply processes and HIT point of care clinic decision support

systems and population management systems in primary care practices that will impact immunization rates

Sustainability/Payment ReformSustainability/Payment ReformDr. Douglas Wood

Sustainability & Payment Reform

Experience:• Minnesota has now implemented coordination of care payments for practices that have been

certified by the state dept. of health as health care homes (started 7/1/2010)• Minnesota has implemented baskets of care, or episode based payment, for several conditions,

including pediatric asthma and pediatric preventive services, effective 3/1/2010• Next Minnesota payment reforms will come in 2012 (in planning now)

Engaged partners: • Minnesota has an active effort underway in the Health Care Access Commission (work groups

appointed by the legislature) to evaluate additional payment models to incorporate into exchange (s) by 2012; this includes legislators, large systems, health plans, physicians, large businesses

Milestones:• No new payment reform implementations have occurred in the past 90 days, nor are planned in

the immediate next 90 days.

Risks:• Biggest current risk for payment reform in Minnesota is the November election, where all state

office holders and the entire legislature are up for election; the outcome could influence direction of state implementation of health care reforms

BEACON WEBSITE

www.semnbeacon.org