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Connecting Patients, Providers, and Payers John D. Halamka MD Connecting Patients, Providers, and Payers John D. Halamka MD

The US Healthcare IT Program • • • Improving quality, safety, efficiency, and reducing The US Healthcare IT Program • • • Improving quality, safety, efficiency, and reducing health disparities Engaging patients and families in their health care Improving care coordination Improving population and public health Ensuring adequate privacy and security protections for personal health information

Physician Goals Core Objective Measure 1. CPOE Use CPOE for more than 60% of Physician Goals Core Objective Measure 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 2. E-Rx for more than 50% 3. Demographics Record demographics for more than 80% 4. Vital Signs Record vital signs for more than 80% 5. Smoking Status Record smoking status for more than 80% 6. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy 7. Labs Incorporate lab results for more than 55% 8. Patient List Generate patient list by specific condition 9. Preventive Reminders Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years

Physician Goals Core Objective Measure 10. Patient Access Provide online access to health information Physician Goals Core Objective Measure 10. Patient Access Provide online access to health information for more than 50% with more than 5% actually accessing 11. Visit Summaries Provide office visit summaries for more than 50% of office visits 12. Education Resources Use EHR to identify and provide education resources more than 10% 13. Secure Messages More than 5% of patients send secure messages to their EP 14. Rx Reconciliation Medication reconciliation at more than 50% of transitions of care 15. Summary of Care Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR 16. Immunizations Successful ongoing transmission of immunization data 17. Security Analysis Conduct or review security analysis and incorporate in risk management process

Hospital Goals Core Objective Measure 1. CPOE Use CPOE for more than 60% of Hospital Goals Core Objective Measure 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 2. Demographics Record demographics for more than 80% 3. Vital Signs Record vital signs for more than 80% 4. Smoking Status Record smoking status for more than 80% 5. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy 6. Labs Incorporate lab results for more than 55% 7. Patient List Generate patient list by specific condition 8. e. MAR is implemented and used for more than 10% of medication orders

Hospital Goals Core Objective Measure 9. Patient Access Provide online access to health information Hospital Goals Core Objective Measure 9. Patient Access Provide online access to health information for more than 50% with more than 5% actually accessing 10. Education Resources Use EHR to identify and provide education resources more than 10% 11. Rx Reconciliation Medication reconciliation at more than 50% of transitions of care 12. Summary of Care Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR 13. Immunizations Successful ongoing transmission of immunization data 14. Labs Successful ongoing submission of reportable laboratory results 15. Syndromic Surveillance Successful ongoing submission of electronic syndromic surveillance data 16. Security Analysis Conduct or review security analysis and incorporate in risk management process

Patient Profile Screen Patient Profile Screen

Patient Profile Screen, cont’d Patient Profile Screen, cont’d

Problems Problems

Medications Medications

Medication History and Reconciliation Medication History and Reconciliation

Reports Reports

External Reports External Reports

Orders Orders

Sheets Sheets

Care Plans Care Plans

Health Information Exchange Mass. Health BIDMC Partners DPH EOHHS NEHEN Nw. HIN e. CW Health Information Exchange Mass. Health BIDMC Partners DPH EOHHS NEHEN Nw. HIN e. CW EHX Statewide HISP Direct gateway services Web portal PKI/certificate mgmt Provider/entity directory Audit log Atrius Safe. Health MD MD Fallon Clinic UMass Memorial MD MD MD

Updated plan Original high-level plan from 12/11/2011 Updated plan as of 10/23/2012 20 Updated plan Original high-level plan from 12/11/2011 Updated plan as of 10/23/2012 20

Multi-Stakeholder Governance Model Chair: Secretary Judy Ann Bigby, MD HIT Council Co-Chairs: -John Halamka Multi-Stakeholder Governance Model Chair: Secretary Judy Ann Bigby, MD HIT Council Co-Chairs: -John Halamka -Manu Tandon HIE-HIT Advisory Committee Facilitator: -Micky Tripathi Business Analyst: -Mark Belanger Legal & Policy Workgroup Technology & implementation Workgroup Finance & sustainability Workgroup Consumer and public Provider engagement & adoption workgroup Co-Chairs: -Wendy Mariner -Gillian Haney Co-Chairs: -John Halamka -Manu Tandon Co-Chairs: -Andrei Soran -Steve Fox Co-Chairs: -Jessica Costantino -Kathleen Donaher Co-Chairs: -Michael Lee, MD -Dirk Stanley, MD Facilitator: -Ray Campbell Facilitator: -David Delano Facilitator: -Micky Tripathi Facilitator: -Christina Moran Facilitator: -Mark Belanger Business Analyst: -Christina Moran Business Analyst: - Christina Moran

Analytics via Expert Query • • • Hospital Analytics group Community Practice Analytics group Analytics via Expert Query • • • Hospital Analytics group Community Practice Analytics group Includes data cleansing, validity checking and creating repeatable queries Databases and data marts governed by a multistakeholder governance committee Primarily for Care Management, Government reporting, and Population Health

Analytics via Self Service • Web-based graphical tool to query BIDMC’s Clinical Data Repository Analytics via Self Service • Web-based graphical tool to query BIDMC’s Clinical Data Repository • Includes 2 million patients and 200 million “facts” (e. g. , demographics, diagnoses, medications, lab tests, and procedures) from 1997 to the present • Aggregate counts (e. g. , preliminary data for grant proposals, population studies, etc. ) do not require an IRB protocol • With IRB approval, data sets can be obtained with help from the Decision Support team

Self Service Web Interface Self Service Web Interface

Analytics via Repeatable Reports • • Parameter driven web-based reports in Performance Manager Acceleration Analytics via Repeatable Reports • • Parameter driven web-based reports in Performance Manager Acceleration of business intelligence capabilities with SQL Reporting and Analysis Services Dedicated expert consultant devoted to implementation Primarily for clinical and administrative operational support

Analytics via Outsourced Community Quality Repository and Claims Registry • • Combines BIDMC, HMFP, Analytics via Outsourced Community Quality Repository and Claims Registry • • Combines BIDMC, HMFP, BIDPO, APG, API data into a single clinical care respository Used for all our Meaningful Use Measures, PQRS reporting, and AQC contract Also creates data marts of clinical data to support all payer claims data warehouse run by HDS Primarily for Pioneer ACO and Managed Care efforts

Patient-Level Information Assets BIDPO QDC - - Patient-Level Information Assets BIDPO QDC - -

Provider Metrics and Measures Measure sets: • 35 Contract Incentive Measures • 44 NQF Provider Metrics and Measures Measure sets: • 35 Contract Incentive Measures • 44 NQF Meaningful Use Measures • 24 PQRS Measures • 31 Pioneer ACO Measures Qualified registry for the CMS 2010 PQRS program Certified as an ONC-ATCB (CCHIT) certified as a modular EHR for Eligible Providers for all 44 MU Stage 1 measures - -

Provider Measure Scorecard Slide title Massachusetts e. Health Collaborative © MAe. HC. All rights Provider Measure Scorecard Slide title Massachusetts e. Health Collaborative © MAe. HC. All rights reserved. - -

Analytics via Innovative Pilots • • • Natural Language Processing for intelligent searching of Analytics via Innovative Pilots • • • Natural Language Processing for intelligent searching of free text Query. Health Pop. Health

Universal Availability of PHRs • • • Tethered (Patientsite and e. CW Patient Portal) Universal Availability of PHRs • • • Tethered (Patientsite and e. CW Patient Portal) Non-Tethered (Healthvault and others) Open. Notes

Required PHR Functionality • • Secure Messaging with Provider Access to all records Convenience Required PHR Functionality • • Secure Messaging with Provider Access to all records Convenience Transactions Request Appointments Medication Refills Referrals to Specialists Education Disease specific content Links to medication information Diagnostic test explanations • • •

Decision Support Service Providers Decision Support Service Providers

Questions? 10 17 Questions? 10 17