Health Information Exchange & Electronic Health Record (HIeHR) Utility Project. Arizona Medical Information Exchange (AMIE) Proof of Concept Lessons

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1 Arizona Health Care Cost Containment Health System Medicaid Transformation Grant Program Health Information Exchange & Electronic Health Record (HIeHR) Utility Project Health Information Security and Privacy Collaboration (HISPC) National Conference, Bethesda, Maryland March 4-6, 2009 Arizona Medical Information Exchange (AMIE) Proof of Concept Lessons Anita C. Murcko MD, FACP Medical Director, Clinical Informatics & Provider Adoption, AHCCCS

2 Background Medicaid Transformation Grant $11.7 million (February 2007 till November 2009) HIeHR Utility Project in Arizona Three segments 1. Arizona Medical Information Exchange (AMIE) 2. Electronic Health Record (EHR) 3. Database for clinical decision support (CDS) and population health management 2

3 Arizona Medical Information Exchange (AMIE): Status Successful Proof of Concept (Sept-Dec 2008) ~2.5 Million Records (Feb 2009) Labs ~1,600,000 (SonoraQuest) Medication Histories ~850,000 (PBMs) Discharge Summaries ~40,000 (3 largest hospital systems) ~1.7 Million Unique Patients Pilot expansions underway Clinician Users Data Partners Behavioral Health Pilot 3

4 What have we learned about establishing a statewide HIE? 4

5 HIE takes a village. Arizona HISPC Workgroup and products AHCCCS (Medicaid Agency) Steering Committee Arizona Health e-connection Partner Tracks concurrent, iterative, inductive (continuous education for constant hospital staff changes) Executive and Strategic Legal and Contracts Privacy and Security Technical Clinical Public Relations and Outreach 5

6 Big picture. Build Trust. Foundation of any HIE is building social capital, a radius of trust and goodwill, among competing and disparate stakeholders who want to initiate an exchange.

7 Start federated. Clinics Labs Hospitals Pharms/PBMs RHIOs/HIEs RLS HIE Data Secure Internet Viewer EMRs Health Plans AHCCCS ADHS Imaging R L S Record Locator Service (record matching) HIE Connectors/Gateways 7

8 All must understand data elements and data flow. 8

9 Data partners must control their data and systems. 9

10 Interpret statutes in HIE context. TYPE OF HEALTH INFORMATION CITE REQUIREMENT Federal Drug and Alcohol Treatment Information Mental Health Information ARS , et seq. Genetic Testing Information ARS , et seq. HIV and Communicable Disease Information 42 CFR Part 2 Applies only to federal drug and alcohol treatment programs. Permits disclosure without consent for treatment only to medical personnel who have a need for information about a patient for the purpose of treating a condition which poses an immediate threat to the health of any individual and which required immediate medical intervention. 42 CFR ARS , et seq. Permits disclosure without consent to physicians and providers of health, mental health or social and welfare services involved in caring for, treating or rehabilitating the patient. ARS (A)(1). Applies only hospitals with licensed behavioral health facilities. ARS (19). Permits disclosure without consent to an agent or employee of a health care provider if (a) The health care provider performs the test or is authorized to obtain the test result by the person tested for the purposes of genetic counseling or treatment ; (b) the agent or employee provides patient care, treatment or counseling; and (c) the agent or employee needs to know the information in order to conduct the test or provide patient care, treatment or counseling. ARS (6). The statute also permits disclosure to a health care provider that assumes the responsibility to provide care for, or consultation to, the patient from another health care provider that had access to the patient s genetic records. ARS (11). Permits disclosure without consent to an agent or employee of a health facility or health care provider to provide health services to the protected person or the protected person s child or for billing or reimbursement for health services. ARS (A)(3). Communicable disease defined as any disease reportable to ADHS or a county health department. HIV included in this category; no separate requirements for HIV. 10

11 Create then customize standard agreements and policies. Letter of Understanding Participation Agreement, Policies and Procedures Based on Markle Connecting for Health by Arizona HISPC Use for purposes outside treatment off the table for Proof of Concept Business Associate Agreement (BAA) to create testing environment Technical Solutions Entity-specific agreements 11

12 Security is paramount. Technical measures Administrative measures Policies Procedures User Training and Provisioning Monitoring and Audits Penalties 12

13 Tightly control access. User Provisioning and Oversight Highlights Arizona License (MD, DO, PA or NP) Standard HIPAA Privacy provisions State privacy provisions AHCCCS provider contracts Provider Registration Health plan provider contract Participation Agreement & Policies AMIE Training Modules, include penalties for misuse AMIE Viewer Account Management Form AMIE Attestation Screen Each use and print Warnings and Disclaimers Audits (daily, weekly and ad hoc; electronic and manual) 13

14 Demonstrate keen oversight. Utilization Reports Activity by User, Organization Record Types Users by Individual, Organization Login Analysis Audit Reports Manual Review Viewer Administration and Use Ad hoc requests Penalties 14

15 Start small. Measure a lot. AMIE Proof of Concept Go-Live September 29, months to clinical record types (all payors) Discharge Summaries (3 Hospital Systems) Medication History (PBM claims aggregator, AHCCCS only) Laboratory Test Results (SQL) ~40 AHCCCS-registered clinician users Diverse practice settings Emergency Departments Clinics Private Offices 15

16 Understand and monitor user needs and environment. Research and discovery Assessment and evaluation Environmental Scan w HSAG HIT License Board Surveys w ASU Provider Focus Groups w Organizations Professional Forums w Organizations Value Analysis 16

17 Engage diverse users. Banner ED GSMC ED Desert Peds Hospitalists Desert Clinic IM & FP Maricopa ED Clinic OB Clinic IM Clinic FP St. Joseph s ED Clinic IM Clinic FP Clinic Homeless Affiliated Practices Cardiac; Renal, GI, IM, Pediatrics Clinic Surgery Clinic Pediatric Cardiac Surgery 17

18 Use frequent and multimodal communication with users. Dedicated website Weekly e-feedback Forms Known Problems and Solutions (KP&S) Reporting a Problem Contacting HIeHR Business Support Training Resources Meeting Event Registration 24/7 Call support 18

19 Understand the benefits-1 Narcotics Seeking and Diversion Clearly it the biggest benefit has been with drug diversion and seeking. Emergency Department Physician The patient visited 32 different doctors and had been prescribed narcotics on average every three days before eventually presenting to the ED. I was able to intercept and provide rehab/social services to this patient. This tool has and will make a world of difference in bettering patient care and overall care at the ED level. Emergency Department Physician 19

20 Understand the benefits-2 Adverse Drug Reactions A patient taking a medicine for seizures thought they had been taken off of it. I was able to clarify that they were indeed still being prescribed that medication. Emergency Department Physician An elderly patient that I had seen for a few years always brought a hand-written list of meds. AMIE showed that she was taking an MAO inhibitor, which was not on her list. This antidepressant medication has many serious medication and food interactions. I had no idea she was taking this medication. I was able to contact all of her consultants and assure that her other prescriptions were safe, and that she is adherent to the dietary restrictions. Internal Medicine Physician 20

21 Understand the benefits-3 Unnecessary Admits & Procedures Discharge summaries are very helpful. Patients often cannot tell you what hospital they were in and in general are poor about providing medical history. Pediatrician AMIE has proven useful for not ordering an additional CT Scan on a patient who presented shortly after an admit to the hospital. Gastroenterologist After finding a discharge summary on a patient I was able to ascertain that the patient lied about being in the hospital recently. I was able to pull the record within minutes and locate all the patient s history. Emergency Department Physician I was able to confirm that my patient had a cardiac workup within 90 days and was able to avoid an admission because of it. Emergency Department Physician 21

22 Understand the benefits-4 Safety and Efficiency Improvements I feel triumphant when I find patient information AMIE. No phones calls, faxes or waiting for data to help me with clinical decisions. Internal Medicine Physician The biggest benefit for me has been around patient safety. The more information you know about the patient the better doctor you will be for them. Surgeon 22

23 Understand the benefits-5 Provide glimpse of the future Very organized and very well thought out something that physicians have wanted for a very long time. Disparate hospitals need this. This is a fantastic effort hope we keep it going forward. Surgeon I think that ultimately this could be probably the most crucial intervention to revolutionize our health care in the state. Internal Medicine Physician 23

24 Clinicians want more. More Data More record types (ED summary, radiology, H/P, Procedures, lab) More data providers (including immunizations) More history (beyond POC three months) More current (especially medication history and labs) More Functionality Display revisions Consume and use electronically Customize by location More Access More users More access, including PDAs 24

25 Use interoperable, modular Services Oriented Architecture. Services Oriented Architecture (SOA) Loosely Coupled Modular Components Web Application Services Oriented Architecture MPI Security Auditing Consent RLS Authentication Reporting RLS 25

26 Individual SOA modules can be upgraded or added with ease. Web-based Clinical Viewer HTML/HTTP(S) Services Oriented Architecture Laboratory Service CDA Web Application Auditing MPI RLS Security Consent CDA Images CDA Clinical Practices CDA Authentication Reporting Medication Histories (PBM) CDA CDA CDA Hospital A Discharge Summaries Hospital B Discharge Summaries Hospital C Discharge Summaries 26

27 Next Steps for Arizona Communication Collaterals Legislative enablers (federal and state) Creative partnerships Expansion of users and data partners Modules Add consent Refine patient and provider matching algorithms Finalize business plan and sustainability model 27

28 Reaching across Arizona to provide comprehensive, quality health care to those in need. Thank you! 28

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30 AMIE Viewer AMIE Web Based Viewer Application

31 Login 31

32 Patient Search 32

33 Attest to patient relationship 33

34 Search results displayed 34