Discharge Notification Across the State of Oregon. Business Plan

Emergency Department and Inpatient Admission/Discharge Notification Across the State of Oregon Business Plan Oregon Health Leadership Council July , 2...
Author: Claud Arnold
0 downloads 0 Views 791KB Size
Emergency Department and Inpatient Admission/Discharge Notification Across the State of Oregon Business Plan Oregon Health Leadership Council July , 2014

Table of Contents Purpose and Description ............................................................................................3 Goals ..........................................................................................................................4 Situational Analysis ...................................................................................................6 History and Alternatives Considered .........................................................................8 Financial Plan ...........................................................................................................10 Risks and Mitigation ................................................................................................13 Implementation Plan ................................................................................................16 Governance and Management..................................................................................17 Measurement ............................................................................................................19 APPENDIX A: Data Flow and Relationships/Governance .....................................20 APPENDIX B: EDIE and EDIE Plus Utility Financing Model ..............................22 APPENDIX C: Optional PreManage Basic Subscription .......................................26 APPENDIX D: Data Set Provided by CMT ............................................................27 APPENDIX E: Frequently Asked Questions...........................................................29

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

2

Purpose and Description

This plan describes the formation of a state-level utility, including the scope, financing plan, governance, and other key elements. The EDIE Plus Utility will enable a common service or utility of patient hospital event information from across the state. The Utility builds off the initiative to bring the Emergency Department Information Exchange (EDIE) to all hospitals in Oregon in 2014, and expands EDIE to include inpatient and discharge information. The utility will provide financial sustainability for EDIE for at least three years (2015-2017), ensuring that EDIE continues to provide real-time notification to emergency department (ED) providers for high utilizers of EDs, as well as notifying of patients admitted with recent inpatient activity. EDIE Plus provides a foundation for providing hospital event notifications to plans, Coordinated Care Organizations (CCOs) serving Oregon’s Medicaid population, local health information exchanges, and providers through a second service, PreManage, also offered by Collective Medical Technologies (CMT), the EDIE vendor. The desired result is that through improved communication and information sharing, hospitals and eventually other providers and health plans will be empowered to provide higher quality care to patients, identify patients at risk for hospital readmission, reduce burdensome duplication of tests, and ultimately reduce reliance on costly EDs through better coordination of care. Value Proposition Emergency Department (ED) visits, with their high overhead costs and reliance on advanced technology, are a main driver of health care costs in Oregon. Due to low reimbursement rates by Medicare and Medicaid, and residually uninsured/charity care patients, hospitals are required to shift costs to commercial patients. Approximately 19% of every dollar billed by hospitals is cost shifting to compensate for these underinsured/uninsured patients.1 EDIE provides a critical tool that once established, can be used to identify patients that over utilize EDs and manage the care of these patients to avoid further ED visits by coordinating the care these patients with their primary care provider. This in turn, will allow for cost savings for health plans and hospitals across the state. Considering the high cost of hospital care, adding this critical information can reduce unnecessary test and procedures, allow hospital providers to make more informed treatment decisions, and connect the dots for complex patients, including connecting to their care team. As hospitals enter risk-sharing arrangements with health plans and CCOs, ensuring that hospital care is well-informed will add value to all parties. Even without risk-sharing arrangements, there is indirect benefit to payers, plans, CCOs and providers when ensuring better, more efficient hospital care. In addition, the EDIE Plus Utility provides the foundation to support PreManage, by notifying outpatient care providers and health plans of ED and inpatient/discharge activity of their patients/members for improved care transitions. EDIE Plus will benefit all Oregon patients by 1

Milliman 2007 Oregon Cost Shift Report, Oregon Hospital and Physician Cost Shift: Payment Level Comparison of Medicare, Medicaid and Commercial Payers, 2009.

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

3

reducing the fragmentation and costs of our healthcare system via real-time notifications to hospitals, and through PreManage, notifications to care teams and case managers resulting in improved communications and coordination of care.

Goals

Recently published results of CCO transformation efforts in Oregon show that emergency department visits by people served by CCOs have decreased 17% since 2011 baseline data. 2 In 2012, the State of Washington began the implementation of emergency department best practices (EDIE is a best practice). A March, 2014 report from the Washington Health Authority to the Washington State Legislature stated that emergency department visits declined by 9.9% for the Medicaid population and the rate of visits by frequent Medicaid clients (who visited five or more times annually) decreased by 10.7%. 3 Given these results in Oregon and Washington, the following goals were developed for the EDIE Plus Utility: 1. Continue trend of decline in ED utilization by 1% from 1,254,692 visits in 2013 to 1,242,145 by end of 2015 (a reduction of 12,547 visits). This target was developed in consideration of the expanded insured population, early use of ED by the newly covered population, and the capacity of primary care which will likely drive a bump in ED utilization. Reducing total Oregon ED visits by 1% by 2015 leads to a projected savings of $12,158,000.4 2. Match State of Washington ED utilization rates per 1000 population (2011 data) by the end of 2016. This would represent a 6.3% improvement or 79,046 fewer ED visits and health care savings of $76,595,574 based upon an average cost per ED visit of $969.5

2

Oregon's Health System Transformation 2013 Performance Report, June 2014 (available at http://www.oregon.gov/oha/Metrics/Documents/2013%20Performance%20Report.pdf). 3 Report to the Legislature, Emergency Department Utilization: Update on Assumed Savings from Best Practices Implementation (available at http://www.hca.wa.gov/Documents/EmergencyDeptUtilization.pdf). 4 Oregon Association of Hospitals and Health Systems ER Visits – 2013, Oregon DATABANK Program (Oregon ED visits). Based on an average cost per ED visit of $969, see Health, United States, 2012 Chartbook: Special Feature on Emergency Care (available at http://www.cdc.gov/nchs/data/hus/2012/fig29.pdf). The OHLC recognizes that this measure does not account for changes in Oregon’s population. This is a simplistic directional indicator to which adjustments can be made for any change in population. 5 Kaiser Family Health Foundation, Emergency Room Visits per 1000 population. 2011 data, (available at http://kff.org/other/state-indicator/emergency-room-visits/) (Washington/Oregon ED rates); Oregon Association of Hospitals and Health Systems ER Visits – 2013, Oregon DATABANK Program (Oregon ED visits); Health, United States, 2012 Chartbook: Special Feature on Emergency Care (available at http://www.cdc.gov/nchs/data/hus/2012/fig29.pdf) (Average cost per visit).

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

4

3. Meet the Oregon Health System Transformation ED visit benchmark (presently set at 44.4 ED admissions per 1,000 member months) by the end of 2016 for the Oregon Health Plan patient population. This represents a 12% decrease in ED utilization from 2013. The goals represent a broader effort beyond the EDIE technology which includes emergency departments, health plans, CCOs and providers working collaboratively within their communities to improve care coordination focusing on patients who have a pattern of high inappropriate ED usage. The EDIE Governance Board will be responsible for assessing the return on investment of the EDIE Plus Utility to its members and stakeholders. Data will be reported to the Board annually in July, for the previous year, to assess the return on investment for the EDIE Plus Utility and determine if the utility should extend beyond 2017. PreManage PreManage represents the natural evolution from supporting ED and hospital care to supporting care coordination and care teams, using the data collected by the EDIE Plus Utility. While EDIE Plus provides hospital event information for communication among emergency departments and limited, identified care givers, PreManage maximizes the use of this data and allows for population management, care coordination, and follow-up by pushing hospital event data to health plan, CCO and provider groups on a real time basis for their specified member or patient populations. In essence, EDIE Plus provides the foundation of collecting specific hospital event data and the opportunity to share that data more broadly. PreManage provides the mechanism to connect and share that data directly to those interested in/responsible for care management. We have identified three “use packages” where PreManage might be helpful. Though not limited to these three specific uses, they describe the needs expressed through communication with our stakeholders. CMT has agreed to make these three use packages available in Oregon and has set a price for the most basic functionality for each use package. All health plans and CCOs that contribute to the EDIE Plus Utility will be eligible for discounted PreManage package pricing. The Provider Direct package pricing is available to any medical group or clinic. 1. HIE Connect: Oregon has several community Health Information Exchanges (HIEs) that have plans for pushing local hospital event notifications to their users. Adding data collected from all other hospitals in Oregon into an HIE’s current services makes the most sense for their users. Under HIE Connect, CMT provides data feeds to a Health Information Exchange (HIE) and the HIE takes responsibility for pushing data to its stakeholders. The HIE coordinates amongst its stakeholders to provide their lists of patients/members to CMT.

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

5

2. Provider Direct: Hospital event notification has immense value to providers managing a patient panel; enabling outreach and follow up by providers to ensure the best possible outcomes. Under Provider Direct, CMT provides direct notifications to a provider, practice, or group where the providers have identified their patient panel and uploaded that panel to CMT. This model allows provider groups to directly subscribe to PreManage, which may be needed in cases where a health plan or CCO has not sponsored notifications to that provider group under the Health Plan/CCO Direct option below. 3. Health Plan / CCO Direct: Hospital event notification also has immense value to health plans and CCOs managing health care for members with complex care needs. Under Health Plan/CCO Direct, CMT provides data to the health plan or CCO for its identified membership base. Data use agreements are between hospital, health plans / CCO and CMT. Health Plan / CCO determines use of data with its provider panel, including direct notification of care management information to provider panel if desired. Several CCOs are investing in care management platforms and technologies to share care plans across team members, manage care, and share key information on patients. Adding hospital event data to these HIT tools already in use makes the most sense for those CCO’s users. Depending on the HIT technology, the HIE Direct package may make sense for these CCOs. In all three models there is nothing that restricts parties from sharing financing arrangements to achieve economies of scale or simplify single source PreManage functionality. For example, multiple health plans /CCOs that work with the same provider group may want to combine their respective membership so the provider group has single means to improve care management for all health plans. In this example, CMT takes responsibility for negotiating pricing based on total membership with the collective parties. The PreManage subscription is a contractual relationship between CMT and the organization receiving the notifications and the financing of PreManage is solely the responsibility of the purchaser. CMT data use agreements with each hospital via the EDIE Plus Utility would need to allow for each of the three uses, which could be accomplished through an amendment to existing contracts.

Situational Analysis

The current state of health information technology (HIT) adoption and utilization in Oregon is varied, depending on region or affiliation to a health system or specific EHR. Utilization of Electronic Health Records Between January 2011 and June 2014, more than 5,500 eligible providers in Oregon received more than $260 million in Medicaid/Medicare EHR Incentive Program payments. Across the EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

6

state, 42% of all physicians (MDs), physician assistants, and nurse practitioners, and nearly all of Oregon’s hospitals have adopted certified electronic health records (EHRs) and received incentive payments, making Oregon a national leader in EHR adoption and implementation. Oregon’s EHR vendor landscape is varied – more than 90 EHR vendors are in use amongst providers receiving incentives and 10 EHR vendors are in use amongst Oregon’s hospitals, with Epic dominating some regions and the hospital environment. Behavioral health and long-term care providers are typically not eligible for payments under the Medicare and Medicaid EHR Incentive Programs, and many have not implemented EHRs. Health Information Exchange In response to local connectivity needs, local HIEs have developed across the state to facilitate exchange of patient information between providers. Some are organization-centric and some are community-based. Significant “white space” exists due to geographic and/or service gaps. Although a number of health plans, CCOs, health systems, and local HIEs offer care coordination tools for providers and care team members, providers may be expected to use multiple care coordination tools or log in to multiple systems to manage different patients. Integrating information into existing systems and interoperability between systems will continue to be important as the HIE/HIT environment and investments in Oregon evolve. Oregon’s current HIE environment includes • CareAccord®: Oregon’s statewide HIE operated by OHA, providing Direct secure messaging to any provider or member of the health care team in Oregon; • Four regional HIEs including Central Oregon HIE (Bend), Jefferson HIE (Medford), Gorge Health Connect (The Dalles), and Bay Area Community Informatics Agency (Coos Bay); • Vendor-specific solutions such as Epic Care Everywhere, • A few organization-specific HIEs, where larger health systems have invested in HIE technology • CCO investments in new care coordination, population management, and HIE technology with new Transformation Funds allocated by the legislature in 2013 • Direct secure messaging is being added into EHRs starting in 2014-2015 for hospitals, providers, health systems seeking to meet Meaningful Use requirements. Hospital Notifications OHA conducted listening sessions and convened an HIT Task Force in 2013 to identify the critical HIT infrastructure needed to support a transformed health care system with new expectations for care coordination, accountability, and new models of paying for performance. Statewide availability of hospital notifications to providers, plans, CCOs and care coordinators was identified nearly universally by stakeholders as a high-value, high priority service. All 16 CCOs agreed that OHA should invest in state-level HIT infrastructure, including hospital notifications, as well as other foundational and support services (such as a statewide provider directory, support for statewide Direct secure messaging and CareAccord, and EHR/meaningful use technical assistance to Medicaid practices) to support local efforts and fill gaps where no efforts exist. EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

7

Although some communities have established hospital notifications from their local hospitals to the community providers or HIE, these communities do not have access to notifications for hospital events for their patients outside of their community hospitals. For entities that are establishing hospital notifications locally or providing other HIT/HIE tools for providers to use, it is particularly important that statewide hospital event data can be integrated into their tools and user experience.

History and Alternatives Considered OHLC’s Evidence Based Best Practice Committee and the initial EDIE partnership The Evidenced Based Best Practice Committee (EBBP) of the Oregon Health Leadership Council (OHLC) and the medical directors of OHLC’s member plans identified ED utilization as a major focus area for reducing waste in the health system given that costly ED care is a major cost driver among commercial, Medicare and Medicaid populations as well as patients without coverage. The group felt that inappropriate use of Emergency Departments was a major source of waste and detracted from making Oregon’s Patient-Centered Primary Care Homes as effective as possible. The EBBP then explored options for addressing ED utilization and identified EDIE as a promising approach in place in Washington State. As a result of this work, in 2013, OHLC formed a voluntary partnership with OHA, the Oregon Association of Hospitals and Health Systems (OAHHS), the Oregon Chapter of the American College of Emergency Physicians (OCEP) and the OHLC health plans to implement EDIE in Oregon. The OHA provided a grant to support about half of the first year’s cost contingent upon at least 75% of Oregon hospitals agreeing to implement EDIE, and OHLC and its member plans supported the remaining costs. By the end of 2013, OHLC had succeeded in commitments from all 59 Oregon hospitals to implement EDIE in 2014. The Washington Experience The EBBP research on Emergency Department best practices led to the discovery that the State of Washington was a clear leader in bringing information technology to help deal with this problem. In Washington, the state became so concerned about rising ED costs among the Medicaid population that it tried to restrict the number of ED visits that its Medicaid population could use. The medical community responded that there was a better way to reduce these costs and developed seven best practices. One of the most promising pieces they embraced was the EDIE system. Washington has successfully implemented EDIE with near universal adoption by the state’s hospitals. In 2013, the state estimated annual savings of $33.6 million as a result of EDIE and other best practices. OHLC discussed the possibility of building an ED Information System into Epic, however, uniformly the technology experts contacted indicated that it will be some time before Epic could address this issue, especially the aspect of providing notifications to clinics or hospitals that are not on the Epic system. In addition, as currently structured, the Epic system does not EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

8

provide the support that emergency department physicians need – such as a simple care history with only pertinent information at the time of ED care. Many Oregon Health Systems also have hospitals in Washington, including Legacy, Adventist, PeaceHealth and Providence. EDIE already has built interfaces with these systems so speed of implementation and cost of implementation could be reduced if CMT was selected as a vendor. In addition, several Washington hospitals and some emergency physicians and Medicaid health plans have reported positive experiences with EDIE and working with CMT. The following is a comparison between the two major options the OHLC considered when deciding the best technology for implementation. This research and comparison remained focused on the OHLC’s main objectives and goals for the project: Objectives Quick Implementation Ability to work across multiple IT systems

Functionality outside of Oregon Reduction of ED visits

Cost Notifications

EDIE CMT was able to go live with 59 hospitals within a nine-month time period. CMT has successfully implemented in hospitals of different sizes and varying technological capacities. Their product’s platform allows for flexibility in implementation. EDIE is available statewide in Washington and is present in other states as well. In 2012, the Washington State Hospital Association had seen a 23% reduction in ED visits over a six month period for high-needs patients , while some individual hospitals experienced a 58% reduction of ED visits with patients who had care guidelines in place. 6 An affordable, low-cost solution. Real-time notifications about patients as soon as they register are available for the ED, primary care, and even specialty care.

Epic Care Everywhere

Care Everywhere would require all hospitals to integrate with Epic.

Care Everywhere has been successfully used and implemented nationwide.

This option could be relatively expensive for smaller facilities. There are notifications for primary care.

6

Carol Wagner, Implementing Emergency Room Best Practices: Improves Care, Reduces Costs, Washington State Hospital Association, IHI Summit, March 11, 2014.

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

9

Objectives Reporting

EDIE EDIE will have a reporting platform that will allow hospitals as well as the state progress in ED utilization rates.

Epic Care Everywhere

Because of the urgency to try and achieve a quick implementation in order to support CCOs and primary care homes mitigate the impact of adding 200-300k new Medicaid members, OHLC and EBBP agreed that moving forward with a proven vendor who was reasonably priced made sense. The Washington State Hospital and Health System Association gave CMT very high ratings for their capability and noted that CMT worked quickly and proactively to implement the EDIE system. OCHIN also reviewed their capability and reinforced EDIE as a good solution. Thus, OHLC decided to go with CMT and its EDIE product.

Financial Plan EDIE Plus As mentioned earlier, OHA and OHLC and the OHLC member health plans sponsored the first year costs of EDIE. After thorough review by the EDIE Governance Committee and its operation and finance subcommittees, and input from OHLC members, its partners, CCOs and a variety of stakeholders (including a stakeholder retreat in March 2014), the EDIE Governance Committee recommended that EDIE Plus be funded as a foundational utility service. In April of 2014, the OHLC and CCO agreed that a business plan should be developed for review and consideration in July 2014 before moving forward. Under the EDIE Plus Utility model, funding partners would commit for three years to allow for sufficient time to demonstrate the value of the utility. The total cost for funding EDIE and EDIE Plus for the entire state is $750,000/year. The following table outlines the annual operating expenses for the EDIE Plus Utility. Note that this budget does not include the following incurred costs: OHLC, OHA and other stakeholder donated staff time, analytics, and training costs. Expense Collective Medical Technologies EDIE (live emergency department data)1 EDIE Plus (live inpatient and discharge data)1 Subtotal Implementation Subsidies2 Administrative/Contingency Costs3 TOTAL

Cost $383,690 $250,000

$633,690 $30,000 $86,310 $750,000

1

CMT costs include onboarding costs, standard support costs (reflected in the EDIE Licensing Agreement) and interface costs for CMT. CMT startup fees are amortized and built into ongoing EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

10

costs. 2 Subsidies are tied to one-time implementation costs for eligible hospitals (see below). As such, the budget allocation for subsidies will be reduced in years 2-3 of the utility. 3 Administrative/Contingency Costs include: legal fees, business planning and consulting fees, some operational support, and a contingency fund in the event that users do not pay their allocated fees. Funding will begin in 2015 based on a tiered structure of financing partners, 50% funded by the hospitals, tiered based on revenue, and 50% by the health plans and CCOs, tiered based on membership size. Principles for financing: Given the utility nature of EDIE Plus, the following principles are proposed: • Financing should be as broad as possible. • Administration of financing mechanism should be as simple as possible. • Investment by as many stakeholders as possible assures greater adoption. • Federal and State investment to stimulate implementation of statewide technology should be leveraged. • Return on investment will take several years requiring financing commitment of that same time period. • Tiering of financing partners based on revenue. o Sources for revenue size should be as current as possible and consistently applied. o No hospital should pay more for utility than it would if purchased directly. Application of the Principles • Data representing size should be as current as possible and consistently applied. • Hospital revenue will be based on annual revenue report prepared on annual basis by Apprise of OAHHS. • Health plan and CCO data will be provided by OHA using OHA enrollment data for CCOs and DCBS membership data for plans based on first quarter/March membership reporting. • Self-insured plans will pay base fixed rate in separate tier due to reporting outside of DCBS. • Hospital systems with owned health plans will receive a discount on total billing to reflect "double counting" of internal payment from health plan to owned hospitals (proposed discount discussed below). • Invoices will be sent by OHLC in fourth quarter of each year prior to operating year. The following tables represent the tiers. See Appendix B for hospital and plan/CCO specific numbers. Kaiser and Providence are discounted 25% for both Hospital and Health Plan due to fact that they are counted in both health plan membership and hospital. Overall they will both pay higher total rates. EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14) 11

Hospital Tiers: Based on Revenue $1.5 BB and above $1 BB to $1.5 BB $500 MM to $1 BB $200 MM to $500 MM $100 MM to $200 MM $50MM to $100 MM $20 to $50 MM $0 to $20 MM

$60,000 $45,000 $27,000 $12,000 $5,900 $2,750 $1,250 $500

Health Plan/CCO Tiers: Based on Enrollment Over 300,000 members $55,000 Over 250,000 members $43,000 Over 150,000 members $31,000 Over 100,000 members $19,000 Over 75,000 members $14,000 Self-Insured Plans $11,000 Over 30,000 members $8,250 Over 15,000 members $3,000 Under 15,000 members $1,000 Implementation Subsidy for Independent Critical Access Hospitals The EDIE governance committee has proposed eligibility criteria for hospitals to received partial subsidies for their EHR implementation costs for implementing EDIE Plus: 1) The hospital must be a critical access hospital (CAH); and 2) The hospital must use a third-party vendor for IT; and 3) The hospital must be independent. In 2014, OAHHS identified the hospitals that would qualify for this one-time subsidy: Blue Mountain Hospital Pioneer Memorial Hospital (H) Curry General Hospital Wallowa Memorial Hospital Good Shepherd Medical Center Columbia Memorial Hospital Grande Ronde Hospital Coquille Valley Hospital Harney District Hospital Lower Umpqua Hospital Lake District Hospital Southern Coos Hospital & Health Center PreManage Financing Each organization and community will determine if PreManage has value for them. Participating organizations will develop a contractual and financing arrangement for a PreManage subscription directly with CMT. There is nothing that restricts parties from sharing financing arrangements to achieve economies of scale for a common population of patients or notice requirements. CMT has set a price for the most basic functionality for each use package. EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

12

All health plans and CCOs that contribute to the EDIE Plus Utility will be eligible for discounted PreManage package pricing. The Provider Direct package pricing is available to any medical group or clinic. Pricing will vary based upon the needs of the individual organization. HIE Connect: includes the basic EDIE feed and direct integration into HIE, at a cost of $0.04 PMPM. Provider Direct: includes the feed, optional direct integration into EHR and access to web portal reporting to view visit history detail, at a cost of $0.05-0.06 PMPM. Health Plan/CCO Direct: includes the feed, ED/inpatient census reports, optional direct integration into EHR and access to web portal reporting to view visit history detail, at a cost of $0.05-0.06 PMPM. Changes in Financing or Project Scope The process for addressing significant changes in financing levels or structure, or for authorizing changes to the scope of the EDIE Plus/PreManage project, will be developed by the EDIE Governance Board moving forward.

Risks and Mitigation

The following table outlines the primary risks for EDIE Plus/PreManage and methods for mitigating those risks: Risk “Scope creep” arising from moving to EDIE Plus before full implementation of EDIE

Risk Description There is a risk of moving toward implementation of EDIE Plus before EDIE is fully implemented or demonstrating value, either through reduced ED visits or cost savings.

Mitigation 1) OHLC and partners closely monitor statewide EDIE implementation progress and intervene if not on track. 2) Clarifying that 100% statewide participation in EDIE is the first priority. 3) Providing performance data and success metrics to hospitals to demonstrate return on investment for EDIE as soon as possible. 4) Evidence Based Best Practice Committee advocates the value proposition for statewide EDIE Plus utility.

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

13

Risk Less than 100% of hospitals or OHLC member health plans in the state participate in EDIE/EDIE Plus

Risk Description While all 59 hospitals have agreed to participate in EDIE, implementation may prove challenging for certain facilities and failure to participate would lead to gaps in the EDIE database. In some regions these gaps may have considerable consequences to the value of EDIE/EDIE Plus. Further, hospitals, OHLC member health plans or CCOs that do not contribute to the utility could compromise the sustainability of the utility over time.

CMT is either acquired by an unknown company, or hits financial hardship

Vendor for EDIE/EDIE Plus, CMT is a small innovative and rapidly growing company. Their product has demonstrated success in Washington and they are in conversations with other states for use of the EDIE system. This makes CMT a ripe target for acquisition by a larger IT company or venture capital firm. In the alternative, there is a risk that CMT’s revenues do not keep up with their rapid growth and they are unable to meet contractual obligations or file for bankruptcy. Under either scenario, this would result in disruptions to EDIE/EDIE Plus contracts, data, support, relationships, and pricing.

Mitigation 1) OHLC and partners will proactively work to identify facilities in jeopardy of meeting EDIE implementation commitments. 2) OHLC and partners will provide resources and support to facilities in need of assistance. 3) OHLC and partners will provide a subsidy to independent (non-system affiliated) cost based, critical access hospitals if necessary. 4) Hospitals or OHLC member health plans that contribute to the utility will be eligible for preferred pricing for PreManage. 5) The budget for the Utility includes a contingency fund in the event that hospitals or OHLC member health plans do not pay their dues. 1) All contracts with CMT should include an assignment clause that protects the licensee and ensures integrity of contract terms in the event that CMT goes under new ownership. 2) All hospital License agreements with CMT clearly define hospitals are the owners of the data. OHLC could be defined as the intermediary to coordinate transfer of data if an acquisition event occurred. 3) OHLC could extend the contracted period with CMT to enforce the same terms regardless of acquisition status. This would not obligate hospitals to automatically renew annually, but if they did, the same terms and pricing would apply based on the OHLC contract period agreement. 4) OHLC and its partners could ask CMT for contractual obligation for first right of refusal in the event of an acquisition.

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

14

Risk EDIE Plus will include inpatient and ED data and will thus be a richer source of data to be potentially misused and/or at greater risk for security and privacy issues

Stakeholder perception that EDIE Plus/ PreManage is a comprehensive health information exchange service Stakeholder perception that the EDIE Plus utility will escalate in costs over time

Public perception that EDIE will be an invasion of privacy or weaken the security of their PHI

Risk Description A database of statewide ED and inpatient visit information can provide great value in care coordination, but also great value for marketing or research purposes. Thus, there is potential pressure to use the data for purposes beyond the original scope of patient care. Given that the database will expand with EDIE Plus, there are also additional security and privacy concerns. There may also be concerns moving forward as to ownership of the data (particularly should a hospital terminate their participation in the program). In engaging with stakeholders around EDIE Plus/PreManage and its value proposition, there has been some confusion as to the scope of the database and the limitation that it is really for notification of ED/inpatient visits and does not have the capacity to serve as a comprehensive HIE. The proposed utility financing structure of EDIE Plus has led to concern among some stakeholders that once they have committed to paying for it, there will be rapid increases in the cost or scope of the service.

A significant benefit of EDIE Plus and PreManage are that they include data from all hospitals in the State and thus cover virtually all hospital patients in the state. The public may have concern about privacy and security of their personal health information.

Mitigation 1) Explicit data usage agreement between CMT and each hospital specifies data ownership as belonging to the hospital or originating organization. 2) The hospital must approve, in writing, any use of their data for purposes other than sharing with other hospitals or care providers for treatment. 3) CMT is responsible to protect the privacy and security of the data they receive and comply with all state and federal PHI regulations. 1) OHLC and its partners will create a communication plan that clarifies the fixed scope of EDIE Plus/PreManage and emphasize ease of integration of these services with other HIE and EHR systems. 1) While there is some chance that costs will increase slightly over time in providing EDIE Plus/PreManage services, the EDIE Governance Board will oversee any major changes in financing. 2) The EDIE Plus/PreManage service is a relatively low-cost service and is fixed in scope so it is unlikely to lead to significant cost increases over time. 3) Contracts currently allow CMT to increase subscription prices annually by no more than CPI. Historically, CMT has not taken advantage of this clause and has had no annual increases as verified by WA counterparts. 4) OHLC could establish a fixed pricing agreement for the contracted period to ensure no price increases over 3 year term. 1) EDIE Plus/PreManage falls within the TPO exemption of HIPAA and thus complies with federal and state law. 2) Patients can opt out of PreManage. 3) Each hospital will need to design a process to ensure that patients have the opportunity to opt out of PreManage according to new HIPAA guidelines.

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

15

Implementation Plan

EDIE Plus is an expansion of EDIE and will require additional data sources and filtering to the IT interfaces established for EDIE. IT resource requirement estimates to accomplish the additional requirements for EDIE Plus are approximately 40-60 hours of interface development and 20-40 hours of testing. OHLC and its partners will facilitate implementation efforts, including hospital participation across Oregon working with CMT to develop a schedule to expand their existing EDIE interfaces to accommodate EDIE Plus. The new EDIE Governance Board will ask for a three-year commitment from all hospitals in the state for EDIE Plus—in order to see a return on investment. This commitment will be captured in a Memorandum of Understanding (MOU) committing to the parameters of this business plan. MOU should be completed by October 1, 2014.

Rollout and Billing The first year’s costs for implementing EDIE have been covered by an OHA grant and OHLC and its member plans contribution. The original plan for the billing cycle for EDIE was to initiate one-year EDIE licenses for each participating hospital when they are both contributing and receiving data to EDIE (“go live”). To ensure administrative simplification moving forward, it is proposed that billing for EDIE Plus for all participants in the second year will be pushed to December 1, 2014, with payment due by January 31, 2015. This billing cycle will continue for years 3-4. Hospital licenses for EDIE (EDIE Plus going forward) will be renewed annually based on the go-live date for that hospital, but billing for participation in the EDIE Plus Utility will remain on the calendar year schedule. OHLC, as administrative support to the EDIE Plus Utility Board, will invoice participants and will receive payments, and pay CMT. Each entity participating in the utility will sign an MOU with the EDIE Plus Utility Governing Board/OHLC, committing to the parameters of this business plan, including delegating governing decisions to the Governance Board, and committing to financial participation for the full three years.

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

16

Timeline Implementation Year Year 1 - EDIE (2014) Year 2-4 – EDIE Plus Utility (2015-2017)

Billing Cycle Deadline EDIE costs are covered by OHA grant, OHLC and its member plans contribution, hospitals incur technical integration/interface costs December 1 invoice date, Payment due by January 31

For CCOs, OHA is currently seeking approval from the Centers for Medicare & Medicaid Services to use federal and state funds to cover the CCO’s EDIE Plus Utility contribution, thus covering their dues. Implementation Deadlines Currently, CMT is actively working to implement EDIE individually with all 59 Oregon hospitals with a goal to be finished with the implementation by November 2014. EDIE Plus would be implemented beginning in 2015 with a goal to be fully implemented statewide no later than end of 2015. Other logistical decisions, (i.e., revision of agreements to accommodate for EDIE Plus data, etc.) will be made and overseen by the EDIE Governance Board moving forward.

Governance and Management

Several alternatives exist to initiate and ultimately govern the EDIE Plus Utility. That said, several principles were adopted early on for financing which can also serve as guideposts for oversight and management of EDIE Plus in early stages. Principles Given the assumption of the utility value of EDIE Plus, the following principles adjusted for governance are proposed: • • • • • •

Governance should represent broad stakeholder interests. Administration should be simple. Engagement by as many stakeholders as possible and practical fosters greater adoption. Commitment to governance responsibilities over several years provides continuity. Data sharing among parties shall be of aggregated nature only unless specifically noted. Individual data use by contracting parties with CMT shall be restricted to respective patients or members of contracting parties.

Governance Structure Membership EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

17

• •

Transition current EDIE governance committee to more permanent governance board for EDIE Plus Utility. Current governance committee accept nominations from each of following stakeholder groups / participants to serve staggered three year terms, with the following distribution of nominated positions: o Hospitals / Health Systems: 4 positions, all voting o Health Plans 2 positions, all voting o CCOs 2 positions, all voting o OHLC physician member 1 position, voting o OCEP physician member 1 position, voting o CCO physician member 1 position, voting o OAHHS (ex-officio) 1 position, voting o OHA (ex-officio) 1 position, non-voting o At-large community member 1 position, voting

Responsibilities • Provide oversight to management of EDIE Plus contractual relationships among stakeholders, CMT, and management, including oversight/coordination of data analysis. • Accountable for Financial, Operations, Data Use and Communication policies and procedures among stakeholders.

Management Structure • OHLC Board accepts management responsibility for providing management services to EDIE Plus project through contractual agreement with OHA, CCOs represented by OHA and other OHLC stakeholders for three year implementation period or until EDIE Plus Governance Board recommends alternative structure. • OHLC Management staff will continue management support for EDIE Plus utility project as directed by OHLC Board • Specific management functions of the management agreement will include Financing, Operations, Data Use and Communications and others as specified by the EDIE Plus Board. Committees EDIE Operations Workgroup The purpose of this committee is to identify common statewide goals, measures and best practices that have evidence of improved quality and more appropriate ED utilization within a focused population through effective use of notifications and other tools available within EDIE. This workgroup makes policy recommendations to the OHLC board and other stakeholder organizations regarding EDIE operational implementation across healthcare boundaries for the purpose of achieving the triple aim (see Appendix). EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

18

The EDIE Governance Board may opt to create additional committees in the future.

Measurement

The EDIE Plus Utility provides the technology for providers across systems and organizations to improve care coordination on behalf of their patients. The workflows and communication required to coordinate patient care, once the patient has been identified by EDIE, will necessitate collaboration among hospitals, health plans, CCOs and providers within communities. These community collaboratives will require common metrics across ED’s to assess areas of opportunity and progress toward improvement. The CMT agreement with hospitals, that determines the use of the data, will need a revision to allow CMT to report patient de-identified and aggregated data to the EDIE Governance Board for the purpose of reporting aggregate measures and hospital de-identified data. A basic data set has been identified which CMT will obtain permission to share with the EDIE Governance Board monthly. Basic Reporting Apprise, a subsidiary of the OAHHS, will compile complementary “basic” monthly reports including the number of ED visits, number of high utilizers, and the number of patients who have been treated 3 or more times in an ED in 60 days. These include Hospital level reports and aggregate statewide stakeholder reports showing these basic de-identified metrics. Data Analytics and Advanced/Custom Reporting The EDIE Governance Board will determine any additional analytics or reporting of the aggregated de-identified EDIE data set provided by CMT, subject to the CMT-hospital data use agreement, beyond the “basic” reporting provided by Apprise. The purpose of aggregating and analyzing de-identified data is to enable cross organizational quality improvement initiatives and to evaluate the impact of the investment in the Utility on utilization outcomes and cost.

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

19

APPENDIX A: Data Flow and Relationships/Governance

EDIE Plus/PreManage Provider

Provider

HOSPITAL (ED/Inpatient)

EDIE Plus

PreManage ED Data1

PreManage Subscribers4

Notification

Inpatient Data Discharge Notes

HIEs

EDIE (Plus) 2

(CMT)

Member or Patient Panel Notification

Aggregate Patient-Identified Data3

EDIE Governance Board

Providers

Health Plans/ CCOs

Basic Reporting Aggregate Hospital De-identified Data

Apprise (OAHHS)

Basic Reporting Aggregate De-identified Data 1

The use of hospital data is specified by agreements between CMT and hospital CMT is Collective Medical Technologies, the EDIE Vendor 3 Existing agreements between CMT and hospitals require amendment to give Apprise authority to aggregate data. 4 Subscription agreements are between CMT and the subscribing entity. PreManage subscriptions are subject to CMT-hospital data use agreements. 2

Relationships/Governance HOSPITAL (ED/Inpatient) PreManage Subscribers4

Data Usage Agreement

HIEs

EDIE (Plus)

Subscription Contract

(CMT)2

Providers

Health Plans/ CCOs

OHLC Management Support

EDIE Governance Committee

Contract for Analytics

Apprise (OAHHS)

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

21

APPENDIX B: EDIE and EDIE Plus Utility Financing Model Health Plan Contribution

Health Plan Commercial Health Plans Regence Kaiser* Moda Providence* PacificSource HealthNet Lifewise

Membership

Tier

EDIE Plus Dues

358,663 334,445 279,229 266,157 108,632 53,503 44,098

1 1 2 2 4 7 7

$55,000 $41,250 $43,000 $32,250 $19,000 $8,250 $8,250

OHLC Self-Insured Plans (Used 70,000 as proxy for membership) Aetna 70,000 6 Cigna 70,000 6 First Choice 70,000 6 United 70,000 6 CCOs** Health Share Family Care Willamette Valley Community Health Trillium PacificSource Community Intercommunity Health Network Allcare Eastern Oregon CCO Jackson Care Connect Umpqua Health Alliance

194,498 87,709 82,961 76,209 54,084 45,882 41,152 39,398 24,206 22,641

3 5 5 5 7 7 7 7 8 8

EDIE Plus/PreManage Business Plan Final Version - minor modifications have been made (08/08/14)

$11,000 $11,000 $11,000 $11,000

Tier 1 2 3 4 5 6 7 8 9

Membership >300k >250k >150k >100k >75k self ins. >30k >15k