Metro DC Health Information Exchange (MeDHIX) Characteristics, Challenges, Lessons Learned

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Thomas L. Lewis and Leta Kajut, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1 MB).

Slide 1

Metro DC Health Information Exchange (MeDHIX)

Characteristics, Challenges, Lessons Learned
Thomas L. Lewis, MD
Leta Kajut, RN, BS, BSN, MHA
Center for Community Based Health Informatics
September 9, 2008

Slide 2

The Center for Community-Based Health Informatics

Support efforts to achieve greater safety, efficiency, quality, access, and consequently better health care for more people through thoughtful use of health information technology.

• Supporting an integrated system of care within clinics using a shared electronic medical record.
• Building a health information exchange to share information among safety-net providers and with mainstream health care organizations; and
• Fostering partnerships and collaborations among local, regional, and national organizations engaged in similar activities.

Slide 3

Focus and Goals

• Safety net clinics serving low income, uninsured individuals.
• Community hospitals.
• Community organizations.
• Multi-state Health Information Exchange.
• Many partners.
• Connect safety net clinics to mainstream health care providers.

Slide 4

Health Care Information Data Flow and Benefits

• Quality, Safety, and Efficiency benefits occur at each level.

Benefits accrue vertically—(Shows three, yellow steps)

• Link Safety Net Clinics to Mainstream Healthcare.
• Link Safety Net Clinics Together in cohesive system of care.
• Establish Safety Net Information Technology (IT) Infrastructure in each clinic.

Slide 5

What is MeDHIX?

• Metro DC Health Information Exchange.
• For connecting safety net providers in the Metro DC area.
• For continuity of care.
• For sharing data with other providers.
• Participating clinics in Montgomery County; Washington, DC; Prince Georges County; Northern Virginia.

Slide 6

MeDHIX Care Continuity Goals—Phase 1

• Enhance patient safety, quality, and efficiency of care.
  • Share safety net clinic data with hospital emergency departments.
  • "ED-MC Connect" medical homes identification project.
• Continuity of care: identify a patient's medical home.
• System design that protects patient privacy.
• Conform to multijurisdictional privacy regulations.
• Easy to use, Web based access.
• Pertinent information to facilitate care.

Slide 7

Current MeDHIX Model

The diagram shows an illustration of MeDHIX surrounded by three hospitals, one clinic and a cylinder with five ovals extending from it representing CHLCare and clinics. Arrows point from the main clinic and three hospitals towards the MeDHIX. A black circle encompasses MeDHIX and two of the hospitals. This circle constitutes the "Proxy Server." With a line linking MeDHIX to CHLCare, a yellow circle encompasses CHLCare with the five clinics. This circle constitutes the "Sub Network Organization."

Slide 8

MeDHIX is an Information Bridge

The diagram shows:

• Safety Net Clinics:
  • Clinics in Montgomery County, MD; DC; and Virginia Counties.
  • Use CHLCare.
• Health Information Exchange (HIE):
  • Laboratory provider.
• Hospital Emergency Departments:
  • Hospitals A, B, and C.
• All link to MeDHIX Exchange:
  • Enterprise Service Bus.
  • Routing and Transformation.
  • Data Storage-edge servers.
• A Health Information Exchange to link Safety Net clinics to mainstream healthcare.
• Using CHLCare to make a single connection to MeDHIX, simplifying data exchange.
• Linking to Quest Diagnostics for Lab Results.

Slide 9

CHLCare (Electronic Health Record [EHR]) Current Capabilities

• Developed collaboratively with safety-net clinics to meet their needs.
• CHLCare in production since July '03.
• Deployed by 15 clinic organizations at over 35 clinic locations.
  • Montgomery and Prince Georges Counties, DC, Northern Virginia.
• Prior electronic data converted and added to database.
• Shared database with 250,000 visit records for 80,000 patients.
• Content includes:
  • Patient demographics.
  • Encounter data, including ICD9 and CPT codes.
  • Patient appointment scheduling.
  • Specialty referrals.
  • Picture ID cards.
  • Visit planner.
  • Extensive patient clinical reports and clinic management reports.
  • Clinical quality assurance data, e.g. diabetes quality measures.
  • Additional clinical data at the option of individual clinics, e.g. allergies, labs.

Slide 10

MeDHIX Initial Plan: Year 1

• "Quick Connect:"
  • Partner with a large regional medical center.
  • Use their proprietary data aggregation and display tools.
  • Accelerate safety net learning and participation.
  • Gain early understanding of benefits and challenges.
  • CHLCare connection to bring "critical mass" of data quickly.
• View data using light weight, low cost browser based technology in the safety net clinics.
• Review and reconcile differing privacy regulations in 3 jurisdictions (Maryland, DC, Virginia).
• Develop easily understood data sharing and governance agreements for participating organizations and patients.

Slide 11

MeDHIX Initial Plan: Year 1

• Await outcome of the Office of the National Coordinator (ONC) Nationwide Health Information Network (NHIN) Demonstration Projects to:
  • Learn from national efforts.
  • Use ONC/NHIN standards based technical architecture.
  • Minimize risk of misdirected expenditures.
• Explore open source solutions for safety net HIE.
• Build relationships with regional safety net providers, hospitals, and community organizations.
• Expand and improve the content of safety net EHRs.
• Implement at least 1 hospital <-> safety net clinic HIE.

Slide 12

MeDHIX Initial Plan: Year 2

• Move from proprietary to standards based infrastructure:
• Partner to implement open source solutions for safety net HIE.
• Expand HIE to two hospital emergency rooms (ERs) and safety net clinic shared EHR.
• Assess relative value of data elements to providers.
• Explore perceptions, barriers, benefits of HIE to various organizations and providers.

Slide 13

MeDHIX Initial Plan: Year 3

• Expand HIE to multiple hospital ERs.
• Expand HIE to include multiple EHRs.
• Consider HIE with pro bone specialty providers.
• Assess relative value of data elements to providers.
• Explore perceptions, barriers, benefits of HIE to various organizations and providers.

Slide 14

MeDHIX Actual Experience: Year 1

• Successfully viewed hospital ER data from a safety net clinic using Quick Connect approach.
• Jointly, with DC Primary Care Association, began a project to choose an EHR for selected DC safety net clinics.
• Generated substantial interest in the benefits of HIE for safety net populations.
• Focus on a region wide HIE approach.
• Good progress on regional privacy understanding.

Slide 15

MeDHIX Year 2: Proof of Principle Meets Reality

• Quick Connect partner insisted on thick client.
• MPI probabilistic match algorithm inadequate for safety net patients.
• Quick Connect partner sold product to commercial vendor, with complete change in product direction and goals.
• NHIN prototypes informative but not definitive national model or comprehensive standards.
• One set of safety net clinics not ready for HIE; focus was on EHR selection and adoption, a multi-year project.

Slide 16

MeDHIX Year 2: Proof of Principle Meets Reality

• Community hospitals added new prerequisites for safety net providers for patient identification and Health Insurance Portability and Accountability Act (HIPAA) protection.
• New project to issue photo IDs to safety net patients.
  • Meets hospital need for positive patient identification.
  • Facilitate and authenticate exchange of protected health information.
• Recurrent legal issues, costs, and lack of consensus concerning patient privacy and access to PHI.
  • New organizations raise previously resolved issues.
  • New members of existing organizations revisit old issues.
  • Delays implementation.
  • Fear, unwillingness, or excuse not to participate.
  • Unnecessarily high legal expenses.

Slide 17

MeDHIX Year 2: Proof of Principle Meets Reality

• Interest of participants in HIE waxes and wanes.
  • Other institutional priorities, IT and non-IT related.
  • Near term needs trump longer term, more hypothetical projects.
• Stark exemption unintended consequences.
  • Shifted hospital focus away from regional HIE.
  • Opportunity to tie physicians to a hospital through EHR subsidy.
  • Limited resources and competitive pressures undercut HIE.
• Hospital trust relationships.
  • Larger competitor institutions not trusted as HIE operator.
  • Unrelated litigation affected HIE collaboration among hospitals.

Slide 18

MeDHIX Year 2: Proof of Principle Meets Reality

• Population-stratified perceived benefits of HIE.
  • Widely held view that HIE for safety net patients will lead to better quality care and cost reductions. Shared view of hospitals and safety net clinics. (cost/benefit analysis perceived as positive).
  • No clear consensus that similar HIE benefits will accrue to insured patients who have strong ties to their personal physicians, smaller numbers of providers, better provider communication of health information, and established HIE methods.
  • Risk to privacy perceived as outweighing benefits for cost and quality for insured patients. (risk/benefit analysis not always positive; disclosure may place patients or the hospital at risk).
• Closely held clinical information still seen as a competitive advantage by some providers.

Slide 19

MeDHIX Year 2: Proof of Principle Meets Reality

• HIE data sharing boundaries:
  • Comfortable sharing data already being shared.
  • Reluctant to share data not already being shared.
  • Preference for role as silent partner in day to day HIE.
  • Do not want responsibility for managing database inquiries.
  • Will not permit direct access to their databases.
    • Vendor contractual constraints.
    • Firewall management and security concerns and costs.
  • Unwilling to incur added support costs for HIE without clear benefits.
  • Willing to incur at most small implementation costs.
• Probabilistic matching of patients not accepted.
  • "Don't show me data that might not be for this patient."
  • "I don't have time to sort out "possible matches."

Slide 20

MeDHIX Year 2: Proof of Principle Meets Reality

• Clinical data sharing observations.
  • Safety nets and ERs may differ from other providers.
  • "Complete" record not necessarily the best.
  • "eChart synopsis most useful.
    • Name of clinic providing care.
    • Patient demographics.
    • Encounter history, problem list.
    • Allergies, meds, recent labs, if available.
    • 1-2 pages maximum; too much information a deterrent to use.
    • Discharge summaries of high value to safety net clinics.
  • Images less useful initially, especially in safety net clinics.
• Printable eChart most useful in some ER settings.
  • Ease of integration with ER workflow.
  • Legal concerns of non-repudiation: "what did you know and when did you know it?"

Slide 21

MeDHIX Year 2: Proof of Principle Meets Reality

• Comprehensive, complex solutions.
  • May be favored by large institutions.
  • Unnecessary and inhibiting in smaller settings.
  • Costly in $, time, and support.
    • High end graphics work station (thick client).
    • Multiple security patches; too much support expertise.
    • Too much space required.
    • Most data not needed; too much time to learn.
• Different providers value clinical data differently.
• Ease of use vs. complex privacy constraints.
  • Multiple jurisdictions with conflicting requirements.
  • Need to document compliance and exceptions easily.

Slide 22

MeDHIX Year 3: Problem Resolution for ER Project

• Picture ID Card developed/deployed to safety net patients.
  • Addresses concerns identified earlier.
  • Well received by patients and clinics.
  • Implementation challenges with largely volunteer clinic staff.
• Open source HIE enterprise service bus architecture tested.
• Quest laboratory <-> safety net clinic result link deployed.
• eChart content, design, testing complete.
• Community hospital ER <-> safety net clinic collaboration defined.

Slide 23

Patient "Dashboard"

The slide shows a screen shot from CHLCare's Web site with a tab opened to "Patient."

Slide 24

Specific Phase 1 Capabilities

• eChart:
  • Synopsis of the patient's medical record.
  • Web accessible.
• Picture ID card.
• Quest electronic laboratory result link.

Slide 25

ID Card

The slide shows a sample ID card, a screen shot of an eChart, and an illustration of someone being rushed into a hospital on a gurney. The sample ID card has a red circle around the members ID number and a line linking it to the E-chart which pulls up the member's medical history during an emergency situation, as shown in the illustration.

Slide 26

ID Card Design

The slide shows a sample ID card containing the following information:

• Issued Date.
• Gender and Date of Birth.
• Identifies Safety Net Community.
• Medical, Home, and Contact Number.
• Patient Information.
• CHLCare ID and Indication of Membership in the Health Information Exchange.
• Disclaimer to insure no misunderstandings' as to the intent of the card occurs.
• Return to Address.
• Magnetic Swipe contains CHLCare ID.

Slide 27

MeDHIX eChart

The slide shows a screen shot of a Summary page from a patient's eChart. This lists the patient's basic information, allergies, problem list, and medications being taken.

Slide 28

Primary Care Coalition: Design and Implementation

The slide shows a screen shot of a Lab page from a patient's eChart.

• Current Design—Still Evolving.

Slide 29

Understanding Legal Constraints

MeDHIX does not display sensitive data initially

• Integrates a process for accessing sensitive data.
  • Opt in vs. opt out.
  • Mental health, substance abuse, HIV data.
• Document successive levels of patient permission.
  • To access sensitive data.
  • Hospital policy override ("break the glass").

Slide 30

Understanding Legal Constraints

The slide shows a portion of a disclaimer with a red circle around, "Data provided may not represent the complete patient history. Confirm all information with the patient and solicit additional information."

• The electronic record is probably not a complete historic depiction of the medical record.

Slide 31

Understanding Legal Constraints Mental Health, Drug Abuse, HIV not displayed

The slide shows a screen shot of a patient's eChart with red text stating, "Sensitive Data associated with Mental Health, Drug Abuse, and HIV are not displayed," and a circle around, "Authorize Sensitive."

• Sensitive Data Management.

Slide 32

Understanding Legal Constraints Authorization and Consent Recording

The slide shows a screen shot of a patient's eChart with the "Statement of Authorization to View Sensitive Data" opened.

• Sensitive Data Management.

Slide 33

Understanding Legal Constraints Patient has chosen not to share data

The slide shows a screen shot of an eChart-Metro DC Health Information Exchange page where a patient's name has been selected, but circled in red, shows that the patient has opted out of sharing data electronically.

Slide 34

Stakeholder Concerns Related to Process

• Measuring safety, quality, efficiency benefits of HIE difficult.
• Enthusiasm for HIE; legal, operational, financial concerns.
• Direction, time course, and benefits of HIE hard to discern.
• Balancing pressing hospital IT needs with HIE collaboration.
• Return on investment (ROI) clear for hospital IT; ROI speculative for HIE.
• HIE planning and technology investment substantial.

Slide 35

Hospital Concerns, Limitations, and Constraints

• Constraints imposed by existing HIS contracts.
  • Security.
  • Prohibition of non-vendor code.
  • Change in liability/responsibility contract clauses.
• "Invisible Partner" in HIE.
  • Need to limit time, resources, cost of HIE participation.
• Adaptation should be HIE responsibility; little or no change for hospital.
• Legal liability for privacy/confidentiality breaches.
• Business risk for privacy/confidentiality breaches.

Slide 36

Stakeholder Observations on the Value of HIE

• When it is integrated into day-to-day business processes.
  • Not an easy or inexpensive task.
  • Requires considerable staff time and sophistication.
• When it becomes a standard mechanism for multi-provider communication and care coordination.
• When data affecting a treatment decision is made available that would not have been known using traditional methods.
• Value propositions for one organization do not always equate to value for another.
• The "grand vision" must be coupled to a practical ROI.

Slide 37

Some Final Thoughts about Elephants

• A critical mass of clinical data essential for successful HIE.
  • A special challenge for safety net clinics (staff, $$).
  • Limited safety net EHR data -> little or value to hospital or consultants.
  • No return of discharge summaries or consultant notes -> no value to safety net clinics.
• Shifting from opt-in to opt-out if legally sound, but is uncomfortable for many organizations.
• The greatest benefits of HIE are likely to come from both individual and system wide practice re-design, not from HIE itself.

Slide 38

Regional Health Information Technology Activities

Too Many Regional Health Information Organizations (RHIOs)?

• National Capital Area RHIO (DC RHIO).
• Pediatric Regional Health Information Network.
• DC Medicaid Transformation Grant.
• INOVA EHR activities and regional implications.
• Northern Virginia RHIO.
• NOVA Scripts Central.
• DC Primary Care Association EHR Project.

Slide 39

Regional Health Information Technology (Health IT) Activities

Too Many RHIOs?

• Maryland Governor's Health IT Advisory Committee Report.
• Maryland Citizen-Centric Health Information Exchange.
• Maryland statewide HIE plan.
• PCC AHRQ funded MeDHIX project.
• Maryland Community Health Centers EHR plans.
• PCC Montgomery County EHR Assessment Activities.

Slide 40

Contact Information

• Tom Lewis
  • tom_lewis@primarycarecoalition.org
  • 301-628-3418
• Leta Kajut
  • leta_kajut@primarycarecoalition.org
  • 301-628-3429
• Charity Dorazio
  • Charity_dorazio@primarycarecoalition.org
  • 301-628-3411
• Guy Fisher
  • Guy_fisher@primarycarecoalition.org
  • 301-628-3423