The Massachusetts ehealth Institute

The Massachusetts ehealth Institute

MeHI Overview MeHI is designated state agency for: Coordinating health care innovation, technology and competitiveness Accelerating the adoption of health information technologies Promoting health IT to improve the safety, quality and efficiency of health care in Massachusetts Advancing the dissemination of electronic health records systems in all health care provider settings MeHI is a division of the Massachusetts Technology Collaborative, a public economic development agency Connecting providers through the statewide HIE Managing HIE and REC grants from Office of National Coordinator 2 2013 Massachusetts ehealth Institute.

Massachusetts Healthcare IT Drivers Meaningful Use Stage 2 Reporting Starts October 2013 All Provider Requirement January 2017 Physician License Requirement Starts January 2015 2013 2014 2015 2016 2017 Meaningful Use Stage 2 requires use of an HIE, starts in October 2013 Physician Licensing Requirement Starts - January 2015 Massachusetts requires physicians to be proficient in the use of health information technology as a condition of licensure. Proficiency, at a minimum, means demonstrating the skills related to the meaningful use requirements. All Providers on EHRs and the HIE - January 2017 All providers (not just physicians) in the Commonwealth shall implement fully interoperable electronic health records systems that connect through the statewide health information exchange 3 2013 Massachusetts ehealth Institute.

Massachusetts EHR Adoption 89% of Massachusetts physicians are using an EHR/EMR system ranking us #1 in the US.* 56% of eligible healthcare providers in Massachusetts have received Meaningful Use payments ranking us #2 in the U.S.** 62% of Massachusetts office-based providers have adopted a certified EHR system ranking us #4 in the U.S.** 89% of non-federal acute care hospitals in Massachusetts have a certified EHR system ranking us in the Top 12 states*** *Hsiao CJ, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001 2012. NCHS data brief, no 111. Hyattsville, MD: National Center for Health Statistics. 2012. Hyattsville, MD; National Center for Health Statistics, 2012. **CMS Health IT Dashboards. http://dashboard.healthit.gov ***ONC Data Brief. No. 9. March 2013: Adoption of Electronic Health Record Systems among U.S. Non-federal Acute Care Hospitals 2008-2012. 4 2013 Massachusetts ehealth Institute.

Meaningful Use in Massachusetts 5 2013 Massachusetts ehealth Institute.

Massachusetts EHR Incentive Payments 6 2013 Massachusetts ehealth Institute.

MeHI How We Help Awareness Education Qualify Engage Implement Optimize Motivate Communications Webinar Series Regional Meeting Series HIway Newsletter EU-US Conference October 22-23 Adopt Regional Extension Center Recruiting a few new providers Helping providers get to Meaningful Use Medicaid EHR Incentive Program Processing 2013 MU applications HIE Last Mile Program HIway Implementation Grants HIway Vendor Grants Impact ehealth Economic Development ehealth Firm Listing (>150 firms in MA) Workforce Planning Provider and Consumer Research 7 2013 Massachusetts ehealth Institute.

Massachusetts Health Information HIway A collaboration between EOHHS and MeHI to deploy a secure statewide health information exchange. EOHHS leads infrastructure development and operation MeHI leads the Last Mile Program: Connection and adoption Demonstrate measurable improvements in care quality, population health and health care costs Catalyze innovation Funded through ONC and CMS with state matches sustained through private sector contributions 8 2013 Massachusetts ehealth Institute.

Health Information Exchange Progress Decision support through 2-way exchange of data Coordination of care for elderly psychiatric patients Referrals from specialty care to home health Pre-hospital transport care coordination for homeless Care management for Heart Failure patients Discharge summaries from acute care to SNF and Home Health 9 2013 Massachusetts ehealth Institute.

Introducing Massachusetts Success Stories Larry Garber Medical Director for Informatics, Reliant Medical Group 10 2013 Massachusetts ehealth Institute.

MeHI Regional Meeting Worcester November 4 th, 2013 Reliant Medical Group Atrius Health Larry Garber, M.D. Medical Director for Informatics Reliant Medical Group

Building the foundation for transformation with an EHR and HIE Safety improvements Quality and outcome improvements Efficiency and satisfaction improvements Return on investment 12

Internist at Reliant (AKA Fallon Clinic) x 27 yrs Medical Director for Informatics x 15 years Principle Investigator for $3.5M AHRQ and ONC grants for SAFE Health and IMPACT HIEs in Massachusetts Chair, MAeHC Member ONC HIT Policy Committee s HIE Workgroup and Privacy & Security Tiger Team, and MA HIT Council 13

300+ provider multi-specialty group practice 30 specialties, including Occ Med & Behav Med 23 sites in central Massachusetts 200,000 patients with over 1 Million visits/year Not affiliated with any hospitals Not-for-profit At financial risk for 70% of our patients Member of Atrius Health 14 14

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100% utilization by all physicians and staff Includes the MyChart Personal Health Record for patient engagement 16

Electronic (from legacy repository) Manual Abstraction by dedicated team Document Imaging (scanning/indexing) 17

Prescriptions 22 years Lab Results 16 years Transcribed Visit and Imaging Notes 15 yrs Immunizations, Health Maintenance, Disease Management 15 years EKGs (MUSE) 15 years Allergies 10 years Future Lab and Visit appointments 1 year Over 100 Million Records Preloaded into EHR 18

Allergies Family History Growth chart data Problem Lists 19

Standard for scanning legacy charts defined by clinicians Handwritten notes (e.g. Pediatric CPEs) Graphical results (e.g. PFTs, audiograms) Outside reports (e.g. consultants, MRIs) Indexing at multiple levels Patient Level (10 types, e.g. Advance Directive) Visit Level (20 types, e.g. Outside consults) Procedure Level (150 types, e.g. MRI of Breast) 20

1. Practice Management (Registration/Scheduling/Billing) and Clinical Results Repository 2. Paperless Telephone Messaging and Prescribing 3. Computerized Physician Order Entry/Documentation/Billing in Exam Room 6 month gap between phases gave time for users to become proficient 21

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Let the patient look on Eye contact with the patient Value the computer as a tool Explain what you are doing Logoff and say you are doing so www.youtube.com/watch?v=lzaqejtpzey&hd=1 LEVEL Used with permission of Kaiser Permanente 2004. The Permanente Federation LLC 23

Mostly to document HPI and Medical Decision Making Study showed higher quality notes and increased physician satisfaction with documentation & Epic Hybrid notes are most efficient Notes signed in EHR improved 4 days 45 minutes Average increase of 8 minutes/day/md Saves $7,000/MD/year 24

CareEverywhere to Other Sites to 49 Community MDs Vignette Document Imaging 5 Hospitals (8 SNFs 12/2013) CCDs 1 Home Health Agency Transcription and Dragon Ancillaries (Surescripts, Quest Lab, MUSE EKG, Infinitt PACs + Powerscribe) Mckesson & Patient References 48K Patients Reliant s EHR & Data Warehouse Clark Mailing Service 4 Payers MA DPH Immunization Registry Health Coach Disease Management Registry Clinician References Appt Reminder IVR 25 25

Patients plug home health monitoring devices (e.g. BP, weight, sugar, O 2, etc ) into home computer Automatically loads into Epic EHR via Microsoft HealthVault Batches readings, but sends critical ones 2013 Epic Systems Corporation 26

Hospitals Solo MD s FCHP Ref Lab Imaging Centers PBM Reliant Medical Group 27

FCHP Claims medication list and fill hx FCHP and Reliant claims/billing: Immunizations Health Maintenance Dates (e.g. Mammo, Colonoscopy, CPE, etc ) Disease Management Dates (e.g. HA1c, Retinal Exam, Smoking status, etc ) Past Medical Hx (filtered for chronic & signif. dxs) Past Surgical Hx (filtered for significant procedures) Visit Hx (OV, CPE, Consults, ER, Hospital, SNF, LTC) 28

February 2011 HHS/ONC awarded $1.7M HIE Challenge Grant to state of MA run by Reliant Medical Group: Improving Massachusetts Post-Acute Care Transfers (IMPACT) 29 29

Update Consolidated CDA to better support transitions across the continuum of care Develop software to acquire, view, edit, and send these data elements Integrate and validate these tools in Worcester County Measure outcomes 30 30

9/2011 Selection Criteria: High volume of patient transfers with other pilot sites Experience with Transitions of Care tools/initiatives 16 Winning Pilot Sites: St Vincent Hospital and UMass Memorial Healthcare Reliant Medical Group (formerly known as Fallon Clinic) and Family Health Center of Worcester (FQHC) 2 Home Health agencies (VNA Care Network & Overlook VNA) 1 Long Term Acute Care Hospital (Kindred Parkview) 1 Inpatient Rehab Facility (Fairlawn) 8 Skilled Nursing and Extended Care Facilities 31 31

Beaumont Rehabilitation of Westborough Christopher House of Worcester Holy Trinity Nursing & Rehab Jewish Healthcare Center LifeCare Center of Auburn Millbury Healthcare Center Notre Dame LTC Worcester Rehabilitation & Health Care Center 32 32

Sites with EHR or electronic assessment tool use these applications to enter data elements LAND ( Local Adaptor for Network Distribution) acts as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR (live since 10/2012) Non-EHR users complete all of the data fields and routing using a web browser to access their Surrogate EHR Environment (SEE) (golive 12/2013) 33 33

Phase 1 Send and Receive Pushing patient information using Direct Connect via EHR or Webmail Can use LAND & SEE to facilitate connection Live since October 2012 Phase 2 Search and Retrieve Building the Relationship Listing Service Cross-organizational query and retrieval of patient records, starting in 2014 34 34

Starting November 2013 30 seconds after ED registration, Reliant s CCD is automatically loaded into ED s EHR St. Vincent Hospital ADT for Reliant Patients Reliant Medical Group s Epic EHR CCD with SVH MRN CCD with SVH MRN Outside Record Icon in MedHost Bedboard 35

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ER and hospital Discharge Notes file into EHR as well as InBasket of PCP and Case manager ER and hospital lab/rad/procedure notes file silently into EHR, EXCEPT for those resulted after discharge which also go to physician InBasket 37

Special message in ED note triggers copy of message to move to top of note and routing to PCP InBasket 38

Hospital ADT monitored for hospital discharges 3 Days later, EHR checks to see if follow-up appointment took place or is scheduled If none, an InBasket message is automatically sent to PCP s appointment secretary 39

3 Days after hospital discharge, medication claims data are reviewed along with past and future labs Alerts sent to PCP s InBasket suggesting dose checking, monitoring or discontinuation 40

90,000 preventable life-threatening or fatal ADEs in the elderly yearly nationwide Warfarin is the most common cause of preventable life-threatening or fatal ADEs 1.4% of Reliant s levels overly thin (Gurwitz JH, Garber LD, Bates DW, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289:1107-1116. 2003.) 41

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Automatically generated Automatically sent to Anticoag Clinic InBasket Anticoag clinic makes sure follow-up INR ordered 2013 Epic Systems 45

IVR calls to remind patients of upcoming lab tests just prior to expected date Alerts when patient calls or is seen that they have overdue labs that have been ordered already Letters to patients who no-show labs If 25% overdue (e.g. 1 month late on a 4 month f/u or 3 months late on a 1 year f/u) Letter automatically sent to patient from EHR 46

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Where do you start? 2013 Epic Systems 49

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Reliant had two patients where lung nodules were incidentally found on abdominal CT scans at other institutions for diverticulitis and appendicitis, and were not followedup until metastatic cancer was diagnosed 1-2 years later 53

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More than 900 patients currently tracked in Pulmonary Nodule Registry Certified reminder letters for overdue patients, those that refuse testing, and patients who leave our network No patients with follow-up failures in 4 years 56

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The total economic burden of diabetes in the United States is estimated at $245 billion, a 41% increase from 2007 1 Reliant s Diabetes HbA1c Screening Rate and Control Rate did not change significantly with EHR implementation 1. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033 1046. 58

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Just prior to patient visits During patient visits In between patient visits 60

EHR guidelines automatically suggest testing based on age, gender, diagnoses, meds, smoking history, and existing orders/results Staff draft orders & physician signs if they agree 2013 Epic Systems 61

Nurses automatically receive Epic InBasket message 1 week prior to next visit Records interval hx, educates and checks labs 2013 Epic Systems Corporation 62

order Last date Next But doesn t ask for an order if it s not due or already ordered 2013 Epic Systems Corporation 63

Barometer of Actionable Deficiencies 64

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Lower Health Care Costs Reliant Medical Group s Medicare Diabetics Costs are less than 96% of the best group practices in the nation! 68 68

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Have the right person do the work Use the right tools Re-use data whenever possible 73

In order of preference: 1. The computer (last note, history, results, keyboard macros) 2. The patient (patient portal or forms) 3. The nurse triaging problem on phone 4. The medical assistant that rooms patient 5. The doctor assisted by speech recognition 6. The doctor assisted by transcriptionist 7. The doctor typing 8. A scribe typing 74

MA rooms patient and always enters: Chief Complaint(s) Allergies/Medications (including OTC) Preferred Pharmacy Pends medications that need renewals Full Social and Family History Vital signs Rooming note Review of Systems and starts MD s note 75

No Enchilada MA does their own rooming note MD does their own note from scratch Half Enchilada MA loads rooming note + template for MD note MD does Make me the author and finishes note Whole Enchilada MA loads rooming note + template for MD note MA copies last physical exam from last CPE MD does Make me the author and finishes note 76

Payer/visit/patient-specific template guides visit 2013 Epic Systems Corporation 77

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64% Very Satisfied with Computers (AMGA Avg = 60%) 82 82 82

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Reliant s Charge Error Queues were excessively large Medicare Advantage RAF score was 1.06 yet DxCG was 1.13 and Potential RAF score (based on all prior diagnoses) was 1.4 85

Payer/visit/patient-specific coding guidance to physicians 2013 Epic Systems Corporation 86

Payer/visit/patient-specific coding guidance to physicians 2013 Epic Systems Corporation 87

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Our Medicare Wellness coding compliance rate by physicians has increased: 10% in Feb 2011 98% in Feb 2012 This has: reduced provider frustration with the documentation and coding processes reduced billing rework reduced patient complaints improved revenue by $300,000 89

V codes can t be used with regular visits V codes must be used with preventive visits E Codes can never be primary This has reduced the charge review work queue 90% from $4 million (27,993 claims) to $557,000 (2526 claims) 90

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Increased Medicare Advantage HCC coding compliance rate over 3 years: 20% 45% 84% with a corresponding revenue increase by >$2 Million/year, shared between payer and Reliant Medical Group 92

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Reliant s RAF (HCC) Scores $16 Million increased revenue! 96

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Reliant Medical Group has undergone a clinical practice transformation enabled by a properly configured, implemented and optimized EHR and HIE with analytics and clinical decision support Using a talented team, user feedback, and reporting from the EHR, we have: Eliminated steps that are no-longer necessary Improved steps using EHR's ability to leverage patient and medical information Shifted work to lower-paid staff with physician-specific preferences Shifted work to the EHR Creating new processes that were only possible because of the Epic EHR and HIEs 98

Because of the EHR, HIEs, clinical decision support, and analytics, we improved the quality, outcomes, safety, efficiency of, and satisfaction with, healthcare delivery 99

Lawrence.Garber@ReliantMedicalGrou p.org 100

Coordinating and Improving Care through the Mass HIway Sean Kennedy Mass ehealth Institute Director, Health Information Exchange

Agenda Health Information Exchange 101 Overview of the Statewide HIE - the Mass HIway Introduction to the Last Mile Program Example Use Cases Questions 102

Health Information Exchange 101

Health Information Exchange 101 Electronic sharing of health information among varied healthcare systems while maintaining meaning HIE Model Types o Push vs. pull (query) - Consent implications Content standards o o Create and display capabilities (C-CDA, CCD/C32 or CCR) Common MU data set (data frequently exchanged) Transport standards o Transmit and receive capabilities Health Information Service Provider o Certificate discovery, message delivery, Direct address provisioning The MA state-wide HIE o The Mass HIway 1. Patient name 2. Sex 3. Date of birth 4. Race ** 5. Ethnicity ** 6. Preferred language 7. Care team member(s) 8. Allergies ** 9. Medications ** 10. Care plan 11. Problems ** 12. Laboratory test(s) ** 13. Laboratory value(s)/result(s) ** 14. Procedures ** 15. Smoking status ** 16. Vital signs NOTE: Data requirements marked with a double asterisk (**) also have a defined vocabulary which must be used. 104

HIE & Meaningful Use MU Stage 2 objectives with an exchange component Patient engagement Transitions of care Public health reporting e-prescribing Lab results reporting MU2 rules combine CMS MU (care coordination) objectives and measures with new ONC EHR technology certification requirements to support standards-based information exchange that satisfy these objectives EHR technology certified to the 2014 Edition EHR certification criteria that meets all the objectives for which they plan to attest is a pre-requisite 105

Mass HIway Overview Benefits Governance Security + Privacy Roadmap Services

107 October 16, 2012: Golden Spike Day!

Mass HIway Hub for Health Information Exchange The Mass HIway enables the secure electronic exchange of health information among diverse participants in the Commonwealth: Payer Pharmacy Patient Labs Mass HIway Acute & Post-acute Care Public Health Long-term Post-Acute Care Ambulatory Care The Benefits of HIE Improve & streamline care coordination Fewer medical errors/improved patient safety Reduce duplication Supports achieving Meaningful Use Reduce costs throughout the care delivery system Ease & improve public health reporting & analytics Foundation for Accountable Care Organizations & value-based healthcare models 108

Governance and Advisory Groups HIT Council Consumer Advisory Group Provider Advisory Group Technology Advisory Group Legal & Policy Advisory Group 109

Mass HIway Trust Fabric The Mass HIway trust fabric is achieved through the combination of technical security standards + legal policies to which all participants agree. SECURITY Encryption Authentication TRUST PRIVACY Participation Packet Patient Consent 110

Mass HIway Roadmap PHASE 1 Send + Receive PHASE 2 Search + Retrieve 2012-2013 State assumes HISP role Directed exchange of electronic health information Provider can push health information to another provider 2013-2014 Query-based exchanged enabled (Master Person Index, Relationship listing service, Consent database) Development of DPH registries, analytical repositories Patient-directed exchange 111

Mass HIway Connection Options & Services User Types Physician Practice Hospital Long-term Care Public Health Health Plans Labs /Pharmacy CONNECTION OPTIONS Webmail... LAND (Local Adaptor for Network Distribution).... Direct (EHR or local gateway)... HIway Services Secure Messaging Participant Directory Secure Web Mail Message Transformation Certificate Repository 112

Mass HIway Last Mile Program Mission Goals Environment Approach & Initiatives

Last Mile Program Mission Grow adoption of the Mass HIway by all eligible participants, while catalyzing innovation ultimately demonstrating measurable improvements in care quality, population health and health care costs 114

Last Mile Program Our Environment Barriers EHR technology interfaces & product timelines Consumer on-ramps & workflows Consent infrastructure Evolving HIway infrastructure Evolving policies (consent, HISP-HISP) HIway awareness Enablers Chapter 224 force of law to require connectivity (patients, providers, etc) Pioneer Accountable Care Organizations (ACOs) Meaningful Use Incentives HIway Implementation Grants HIway Interface Grants Penalties Chapter 224 Penalties for non-participation in HIE (1/1/2017) CMS readmission penalty Community-based care transition programs BORIM meaningful use licensure (1/1/2015) Patient Centered Medical Home (PCHM) Mergers & Acquisitions Innovation & outcome funding 115

Last Mile Program Initiatives Connection Adoption Impact Healthcare Implementation & Support Community of Practice HIway Interface Grant Program HIway Implementation Grant Program Outreach - Education 116

117 Mass HIway Get Connected

Connection Pricing Tier Category One-time Setup Fee LAND HIE Services (per node) Annual Services Fee Direct (XDR/SOAP or SMTP/SMIME) HIE Services (per node) Direct Webmail HIE Services (per user) Tier 1 Large hospitals $2,500 $27,500 $15,000 $240 Health Plans $2,500 $27,500 $15,000 $240 Multi-entity HIE $2,500 $27,500 $15,000 $240 Tier 2 Small hospitals $1,000 $15,000 $10,000 $240 Large ambulatory practices (50+) $1,000 $15,000 $10,000 $240 Large TLCs $1,000 $15,000 $10,000 $240 ASCs $1,000 $15,000 $10,000 $240 Non-profit affiliates $1,000 $15,000 $10,000 $240 Tier 3 Small LTC $500 $4,500 $2,500 $120 Large behavioral health $500 $4,500 $2,500 $120 Large home health $500 $4,500 $2,500 $120 Large FQHCs (10-49) $500 $4,500 $2,500 $120 Medium ambulatory practices (10-49) $500 $4,500 $2,500 $120 Tier 4 Small behavioral health $25 $250 $175 $60 Small home health $25 $250 $175 $60 Small FQHCs (3-9) $25 $250 $175 $60 Small ambulatory practices (3-9) $25 $250 $175 $60 Tier 5 Small ambulatory practices (1-2) $25 $60 $60 $60 118

HIway Use Case Examples

Referral PCP to Specialist or Hospital Referral PCP Consult Note Specialist Specialist PCP 120

Discharge Summary Hospital to Care Team Specialist PCP SNF 121

ED Notification Hospital to PCP Referring Physician PCP 122

How our Grantees plan to use the HIway? Use Case ranking by type Receive Send Receive Care Summary Receive Referral Request Receive Discharge Summary Receive Lab Results Receive Lab Orders Receive Imaging Notifications Receive Hospital Discharge Notification Receive ED Visit Summary 1 1 1 1 1 5 5 13 0 5 10 15 Send Hospital Discharge Summary Send Hospital Discharge Notification Send Lab and Radiology Orders Send Hospital Admission Notification Send enrollment/admission and disenrollment/dicharge data to MDPH Send ED Admission Notification Send CANS Data to MDPH 8 12 20 Use Case Types Send Care Summary Send Referral Request Send Lab Results Medication Reconciliation Send Imaging Notifications 1 1 1 1 1 1 2 2 2 6 9 17 0 10 20

Connect with MeHI & Last Mile Massachusetts ehealth Institute 617-371-3999 617-725-8938 (fax) info@maehi.org Twitter - @massehealth MeHI Community - www.thehitcommunity.org/mehi/ www.mehi.masstech.org Mass HIway Last Mile Program 1.855.MA-HIWAY (1.855.624.4929) Option 1 MassHIway@masstech.org mehi.masstech.org/what-we-do 124