evolvent magazine vol1_2011

TRANSFORMING HEALTH CARE

Better Data for Better Care

Volume I, 2011

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Volume I, 2011 | 3

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In This Issue:

VOLUME I, 2011

EDITOR-IN-CHIEFPaul Ramsaroop

EDITORSJennifer CupkaBrittany Palmer

CONTRIBUTING WRITERSBill Oldham Bill Sorrells

David Parker, MDGeoff HowardJ.D. Whitlock

Stephen Gantz

ART DIRECTORBridget Skelly

PUBLISHEREvolvent Press

•Statements contained herein may

constitute forward-looking statements that involve risks and uncertainties.

Due to such uncertainties and risks, readers are cautioned not to place undue reliance on such statements.

Copyright © Evolvent,2011 All rights reserved.

A Tale of Two FuturesJ.D. Whitlock, Vice President, Research and Development, Evolvent

Page 1515

Sustainable Health Information ExchangeStephen Gantz, Chief Security Officer, Evolvent

Page 1919

Accelerating Clinical ResearchJ.D. Whitlock, Vice President, Research and Development, Evolvent

424

Patient-Centered Medical Home (PCMH)Bill Sorrells, Executive Director, Alaska eHealth Network

Page 2828

Health 2.0J.D. Whitlock, Vice President, Research and Development, Evolvent

Page 3232

TelehealthBill Sorrells, Executive Director, Alaska eHealth Network

Page 3636

MAGAZINE

ARMY MRMS IDIQ

AF NETCENTS

ARMY ITES-2s

CIOSP2

GSA Alliant Small Business

Transforming Health Care: Better Data for Better CareBill Oldham, CEO, Evolvent

Page 1212

4 | Evolvent Magazine

Our new tag line at Evolvent is purposefully bold and sets a high bar for all our work. In Health IT, we seek nothing less than making a transformative difference in the delivery of care through better use of technology.

Whether it be for wounded warriors suffering from traumatic brain injury, or an active duty soldier’s spouse seeking services for their children – much more can, and is being done to improve care with technology.

Health care and information technology are seemingly always in the news, and for a few years now have also been at the forefront of health care reform. Many stories or news items bemoan the low rates of adoption and provider satisfac-tion, while other stories claim how wonderful the world is – once the right IT solution is in place.

In this issue of the Evolvent magazine, we are trying to focus the lens a bit and bring just a little more clarity of thought to the myriad problems of health care, and how IT is trying bit by bit to help. We have provided overviews of our new book on a variety of issues, as well as some more time-sensitive articles on current work.

Just a few highlights:

» Taken from our book chapter on the “Future of Health Care”, our lead executive for Research and Development, J.D. Whitlock, examines possible futures and the uses of technologies across the health care continuum.

» Featuring one of the more intriguing concepts at issue in health care delivery today, one of our lead specialists in health administration and technology, Bill Sorrells, examines the nature of Patient-Centered Medical Home programs.

» One of our lead architects and experts on data exchange, Steve Gantz, provides highlights of his book chapter on Health Information Exchange and the challenges, use cases, and opportunities of this domain.

» A synthesis of the thinking of a number of clinical and technical contributors highlights the technology opportunities and challenges in Behavioral Health applications.

» Our chief technologist and chief clinical experts collaborate to discuss the state of the union for Interoperability in Health IT.

I hope you find this edition informative and useful in your daily work and we welcome your feedback. IT can do so much to transform health care and we need all the thoughtful professional collaboration we can get. So, if you would like to share your thoughts, please join me and comment on my blog postings at www.evolvent.com. ♦

Transforming Health CareWELCOME TO THE 2011 EDITION OF EVOLVENT MAGAZINE!

Bill OldhamCHAiRmAN & [email protected]

Our service members take an oath to serve, protect and defend this country. In return they ask for nothing from us. And yet, many of us feel a great sense of duty to say, “Thank You” whenever we come across someone in uniform. We take tremendous pride attaching a troop-supporting ribbon on our vehicles. And we’re grateful to the young men and women who bravely go into battle for the freedoms we enjoy.

For the more than 31,000 service men and women wounded or injured in Iraq or Afghanistan, “Thank you for your service” is no longer enough. Give thanks — then get involved.

To help these wounded service members and their families, we’re asking you to become part of something more meaningful, something truly rewarding. A donation to the Fisher House Foundation or a Fisher House in your area helps our heroes at a time when they need it the most. Fisher Houses, built through generous public donations, offer our service members and their families a comfortable living situation during treatment for traumatic, war-related medical crises. In most cases, these service members are being treated at medical facilities far from home — and their stays are lengthy due to the severity of their injuries.

Go above and beyond for those who give their all. Make a donation to the Fisher House program at www.fisherhouse.org or call (888) 294-8560 toll free.

“Thanks for your service” is no longer enough.

©2011 Fisher House Foundation | Creative services donated by ds+f, Washington, DC www.dsfriends.com | Photos compliments of Brendan Mattingly www.brendanmattingly.com

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Volume I, 2011 | 98 | Evolvent Magazine

david Parker, mdCHiEf mEDiCAl OffiCER AND ExECutiVE [email protected]

It has almost been a year now that I have been the Chief Medical Officer for Evolvent Technologies. It really has been a great year – for a whole bunch of reasons. Some might wonder why the now-former CMO of the second largest public sec-tor health IT company would leave to join a relatively small company like Evol-vent. I could say “I wonder sometimes too”, but I really don’t. My year here with Evolvent has been fantastic, and I could not be happier with this transition – for a bunch of reasons. These reasons are the sorts of things I tell people that ask me how it has been, and I’ll share them with you. Evolvent is a great company.

One the main reasons I have enjoyed this transition is that I have really appreci-ated Evolvent’s focus of the work. I’m a clinician. Evolvent’s work is clinically rel-evant. We build systems that are focused on clinicians, providing them important functionality and capabilities that bring critical information to the point of care and decision. We work on health care images and document management, clinical repositories, clinical research, health care interoperability and more. All of these areas are directly relevant to clinical care. They are all about improving the quality of care and satisfaction of clinicians – goals near and dear to my heart. I’m just not nearly as interested in finance, billing and personnel-type systems, which are so much the focus of the “Health IT” work of most of the large public sector Health IT companies. There may be good money in that stuff, and there are im-portant things to accomplish there, but it’s just not my interest.

I have to be honest with you at this point, however. A project being clinically focused does not, in and of itself, make it all that interesting to me. There are thousands of clinically focused projects being done all over the country. Very few of them, though, will have broad impact – they are just intended to help a few clinicians locally. It’s not that these aren’t useful and important in some way. It’s just that Evolvent’s work is large scale. There are tens of thousands of clinicians that benefit from our good work. An obvious example is that we get to work on one of the largest scale Electronic Health Record (EHR) implementations in the world! With around 140,000 encounters documented in the system every day, millions of clinical messages every day, all contributing to a non-image clinical database of over 80 terabytes…in the health care space, that’s “Big Data.” That by itself is cool!

However, we’re not just peripherally involved in this EHR effort (the Military Health System’s AHLTA EHR). We are in the thick of it – overhauling the per-formance and reliability of the AHLTA clinical data repository (CDR), provid-

ing broad integration services for it and other main-tenance and upgrade tasks. The very large scale and technical complexity, and in some areas, sophistica-tion of this system keep my technology interests peeked as well.

Beyond the core EHR system, Evolvent is leading the charge on much of the new capabilities for the MHS. For example, we are building the data services for use in the new web portal for physicians, providing a much needed fresh face to the AHLTA data. It is also quite exciting to watch the rollout of the Health Artifacts and Image Management Solution (HAIMS) that we have developed. This will be one of the larg-est health care image and document management im-plementations anywhere, and is filling a longstanding critical gap for MHS clinicians and medical staff. Very cool. Further, HAIMS is a very important part of the MHS’s interoperability efforts.

Indeed, Evolvent is at the center of nearly all of the MHS’s interoperability upgrades and new capabilities. Health care interoperability, along with general EHR adoption, has finally made it front and center of the nation’s health care agenda. Health Information Ex-changes are starting up all over the country, backed by significant federal and state funding. All of the major federal agencies that have significant respon-sibilities in health care are jumping into the fray, in-cluding CMS, SSA, CDC, NIH, VA, DoD and others. As the MHS’s technology partner for the overhaul of the Bidirectional Health Information Exchange (BHIE) and the Virtual Lifetime Electronic Record (VLER), we are in the midst of much of this activity. I have been fortunate to be very personally involved in these interoperability efforts, and to get to interact with several of these agencies and commercial HIEs and health care providers, discovering and working through the shortcomings of the latest and emerging standards. It appears that I’ve become one of the key Health care standards subject matter experts for the DoD and VA in these efforts. I’ve been able to di-

rectly contribute to the knowledge and resolution of some of these challenges, and hope that many of the lofty goals for interoperability will be able to be met.

These are big projects with big impact. So, now I think you can see why I have found it hard to get too excited about the average local health IT project.

Coming to Evolvent has also meant that I have been able to get back to my roots, if you will. The MHS and VA is my personal heritage. This is a familiar cus-tomer base that matter to me personally. The clini-cians in and out of uniform taking care of our service members, retirees and family members have had to sacrifice quite a lot as of late to perform this impor-tant mission. They deserve the best tools to perform this mission, and we at Evolvent are privileged to help bring these tools to these great people.

Finally, the team I get to work with here has been one of the most rewarding reasons for enjoying this tran-sition to Evolvent. I cannot say enough how much I appreciate the corporate ethos and mindset. The Evolvent executive team just doesn’t spend all of its time on the financial issues. We don’t have to worry about “briefing up” the chain of some big corpo-rate hierarchy. Quite frankly, the executive team here spends most of its time working to understand our customers’ challenges, developing solutions for those challenges, and simply trying to do the right thing. Further, as I strive hard personally to be a person of integrity, the fact that in my experience the ethics here at Evolvent have been impeccable is very satisfying.

These aspects of the corporate ethos, have been very important and rewarding. However, truth be known, I have to admit that I probably most value the fact that it has actually been fun to work with this team! Smart and funny people are hard to come by. I’ve found some great ones here!

Thanks for a great year, Evolvent! I’m looking for-ward to another one! ♦

CMO Message


GeOff hOwardCHiEf tECHNOlOGy OffiCER & ExECutiVE [email protected]

CTO Message1010100110100010110101001101000101101010011010001010100010110101001101000101001010010

Evolvent is preparing for continued growth, and for the changes we anticipate in the marketplace and in the needs of our customers. As a result, a major theme for Evolvent’s technical practice has been investment – investment in areas such as, people, research, facilities, tools and process improvement.

Evolvent has a consistent history of investment in talented people. For example, we have been working to address a new focus that analysts foresee in Federal health care organizations in the coming years: Health care data warehousing and analytics. Accordingly, we have been adding to our existing database adminis-tration and warehousing staff, new talent familiar with data warehousing in the health care space, but also those who can bring experience from more mature data warehousing segments of the market, such as the financial and insurance world. At Evolvent, we have also been adding those with the analytical, statistical and mathematics backgrounds to draw careful conclusions from the data. We are also investing, through hiring and training, to keep our staff current in emerging tech-nologies for handling the large amounts of data our federal customers have al-ready, and will continue to, collect. In some cases, the disciplines and technologies necessary to achieve meaningful analytics at large data volumes require a break from the traditional, and we are ensuring that we have the skills and knowledge to succeed in this arena. We are also training and certifying our staff in disciplines relevant to new and existing customers, such as, Scrum Master and Scrum Prod-uct Owner certifications.

At Evolvent, we have been making significant investments in Research and De-velopment. Our Research frequently takes the form of market and technology research, which enables us to offer solutions that keep pace with the constant evolution of technology. We pay special attention to assessing when emerging technologies have matured sufficiently to make them appropriate for our large federal customers where experimental early adoption is usually undesirable. We have also been increasingly prototyping innovative solutions for known customer problems in our labs, both on our own and through partnerships, with both large vendors and small innovative inventors. We have worked hard to achieve a cor-porate atmosphere that enables our employees’ good ideas to win a hearing and, where warranted, to be tested and possibly proposed to our customers.

Evolvent has made many lab investments this year – most significantly a build out and transition to a new primary lab facility collocated in our new pri-mary Northern Virginia office in Herndon. This new facility provides some additional space, but more importantly, additional cooling capacity for the ever-denser loads presented by modern equipment. Even as efficiency of equipment increases, virtualization and blades technology drive heat loads to more con-centrated levels, and our new facility is engineered to handle these changes into the future. On top of this, we have been increasing our storage and virtualiza-tion capacity, and we are preparing to install a new research-focused computing cluster.

Over the years, Evolvent has been working to expand our integrated set of tools to facilitate our develop-ment work. These tools are focused on making our work more efficient and to make it easier to achieve excellence in quality. Most recently, we have been adding to, or upgrading our, tools for Test Manage-ment, Requirements Management and Code Quality in particular. These tools give us a cost advantage as we continually identify opportunities to streamline manual or error-prone processes, which enable us to spend a greater percentage of effort on core design, development and testing activities and less on inci-dental tasks.

This dovetails into our investments this year in pro-cess improvement and standardization. We recognize that in order to scale our success, we need to cap-ture key elements of the approaches that have made us successful, which enables us to “franchise” as we grow. One component of this is automation through our tools, but this is only possible for some aspects of our work. For the remaining, we need to capture and standardize through documentation and training. We also recognize the need to apply lessons-learned

for continual improvement of these processes to en-sure that we repeat only successful approaches. We are aligning this effort with the CMMI best practices and are achieving certification as a by-product.

All of these investments flow from our passion to server our customers’ needs with excellence. At Evol-vent, we look forward to serving you with the fruit of these investments in the years ahead. If there are any new directions in which you see federal technology needs moving, we would love to hear from you to see if we are already investing in alignment with these needs, or if we need to look to new directions in the coming months. ♦


What follows in the next several articles are snapshots of the research, content and perspective compiled for Evolvent’s latest book, Transforming Health Care: Better Data for Better Care. Our senior leaders, tech-nical experts, clinicians and consultants have teamed up again to revisit the topics in last year’s Better Data for Better Care with new information and the les-sons learned from our ongoing work. I hope you will find a lot of new ideas, creative insights and thought-provoking content as you work your way through the next several articles, and be intrigued enough to read the full effort in the book version.

A Word About Why We Write Books at Evolvent

This is my fifth effort as writer, compiler, editor, com-mentator and producer, and the rationale crystallizes more with each book. The reason we write books is simple – our complex problems in health care and technology demand thoughtful, careful, considered application of creative thought, and writing books helps us deliver that creative thinking for our clients – plain and simple.

Have you ever asked a tough question of a colleague or vendor and received a pat, trite, or flip answer in response? Of course the answer is yes, we have all been there. These responses are precisely what we

seek to avoid in our work at Evolvent. The legacy issues we find in health IT did not occur through malfeasance or ignorance, but in many cases they did arise out of shoddy thinking, a “patch” mental-ity, or an abundance of haste that led to unexpected poor performance.

Another perspective that informs our writing is that developing solutions takes a lot more thinking and a lot less preaching – there is no nirvana to a better sys-tem, there is no better off-the-shelf (read COTS) tool that will magically deliver better care and a complete picture of the information needed for a patient or provider. Every time our technologists and clinicians get a chance to work thoughtfully with our clients – a good solution emerges and it is usually at a fraction of the cost of what the old-fashioned “build-deploy-rebuild-throw away and start over” cycle does.

We are also not writing in a vacuum, or from an ivory tower. Each of our writers works closely with real customers, many of whom are leaders themselves in health IT. So our thoughts, research, and daily work are informed by today’s real-world problems and the current limitations of both medicine and technol-ogy. And, in writing books we lift our eyes from the “art of the possible” to “what do we wish we could know.” Often the difference between these two no-tions is just taking the time to think.

A Further Word About Our Writers

I am richly blessed and tremendously grateful to work with such a talented, caring group of professionals. Our team at Evolvent truly does aspire to do more for health care through better technology every single day. They are pragmatic and creative, thoughtful and exacting. It is truly a pleasure to spar and joust and together deliver for our clients. They are also a fairly humorous lot, too.So, I hope you enjoy this window into our labors and learn from it, take it back to your organiza-tion and do some good. Health care needs us all to collaborate, and to think. Enjoy. And, feel free to let us know what you think – just drop us a line at [email protected]. ♦

Transforming Health Care:Better Data for Better Care

By Bill Oldham, EvOlvEnt CEO


Two FuturesA Tale of

n 2011, we are at a critical junction in the future of Health care Information Technology (HIT). Billions of dollars in grants and incentive payments are al-ready, or will soon, significantly influencing both the short-term and long-term future of HIT. Will all this investment and effort come together into a coher-ent framework that permits the secure but seam-less exchange of your clinical data? Or, will various technical, political and economic factors result in a patchwork of clinical data stovepipes that do not ef-fectively communicate?

Let us look at a hypothetical health care scenario ten years from now and describe two possible futures: One in which your clinical data is available at a criti-cal time, and one in which it is not. In both scenar-ios, it is 2021 and you are traveling out-of-state on business. While driving, you are hit head-on by an-other vehicle and sustain life-threatening injuries. You are unconscious.

Now our two scenarios diverge. Let us consider the “what-good-looks-like” future first.

In the ambulance on the way to the local trauma cen-ter, the paramedic opens your wallet/pocketbook and pulls out a card that uniquely identifies your clinical record. This might be part of the Voluntary Universal Health care Identification (VUHID) project, or per-haps it is simply a website that points to your clini-cal record on the Personal Health care Record (PHR) of your choosing. It is not a “Big Brother” assigned

number, and it is not available to the public. It is a universal identification system that you elected to participate in, and your clinical data may only be ac-cessed by appropriately credentialed clinicians. The paramedic slides the card into a scanner that sends your universal identifier to staff at the ER. The ER staff immediately query the Nationwide Health In-formation Network, via a local EHR (Electronic Health Record) or HIE (Health Information Ex-change) interface, which is able to pull your clini-cal record from the EHR or HIE attached to your Primary Care Medical Home (PCMH) and/or pull from your PHR. A C32 Summary of Care document details your problem list, medications, allergies, in-surance and other information.

In your case, the allergy list is particularly useful in-formation, because you are allergic to the contrast agent commonly used during CT scans in trauma situations to diagnose internal bleeding. This criti-cal information enables your ER physician to order steroids as prophylaxis prior to the contrast agent, thereby minimizing your allergic reaction. The CT scan reveals internal bleeding, and you are rushed into surgery to open you up, stop the bleeding and save your life.

After a couple weeks in the hospital, you are dis-charged and return home to the care of your Pri-mary Care Provider (PCP). During your slow and painful recovery, you use your tablet device or smart phone at home to keep in touch with your PCP, who practices using a Primary Care Medical Home (PCMH) model. This PCMH structure reimburses your PCP for providing patient centered care in an environment that leverages all widely available health care information technology. Because of this, secure

“What-Good-Looks-Like” Future


messaging with your provider (via your mobile device – and possibly also your PCP’s mobile device) is built seamlessly into your PCP’s workflow.

You have a follow up appointment with your PCP in a few days, but you are feeling fatigued and won-der if it is anything to worry about. You type out a

message to your PCP while eating lunch that says, “Just wanted to let you know I have felt a

little winded the last day or so. OK to wait for my appointment Friday to discuss this?”

Your PCP responds with a phone call. After answering some of her

questions, she sends you directly to the ER, where you are diagnosed with

pulmonary emboli (blood clots in the lungs) and given anticoagulants immediate-

ly. After careful management and follow up, these blood clots are dissolved and you are able to safely complete your recovery.

Now let us consider an alternate future: A future in which EHR meaningful use only gets halfway to-wards projected goals because HIE business models are not financially sustainable. A future in which state and “county option” legal barriers prevent wide-spread connection to the Nationwide Health Infor-mation Network. A future in which well-meaning but short-sighted privacy advocates push the legislative landscape far enough towards “privacy” that efficient sharing of clinical data is crippled. A future in which Accountable Care Organization (ACO) and PCMH based funding reform proves to be a “bridge too far” away from the entrenched status quo.

In short, a future in which the technology was ready, but our health care system was not.

In this future, after your accident, the ER does not know your allergy to the contrast because there is no Nationwide Health Information Network con-

nection between the ER in one state and your PCP in another state. Or maybe there is, but you have a common name, and because there is no voluntary universal health care identifier in common use, the matching algorithms used on the Nationwide Health Information Network returns multiple potential pa-tient matches, which are too hard for the ER staff to sort through quickly.Due to this, you are not ad-ministered prophylactic steroids prior to the contrast agent, and therefore go into anaphylactic shock while in the CT scanner. The CT scan is not completed, and you are rushed back into the ER to deal with your allergic reaction. This delay means that your internal bleeding is not recognized until it is too late, and you die on the OR table.

Or, perhaps you survive your trauma despite these misadventures because of heroic efforts on the part of the ER and OR staffs. Now you are back home, feeling a little winded. You wonder if you need to call your PCP, or if it is safe to wait a few days until your next appointment. You decide you can wait for your appointment, especially since you know your PCP is very busy and generally does not return phone calls right away. Later that night you collapse on the floor and your spouse dials 911. You have thrown a large clot which has completely blocked a pulmonary ar-tery. You are dead before the ambulance reaches your local ER.

In our hypothetical 2021 health care scenario, well connected health care that permits efficient transfer of your clinical data enables your full recovery from life threatening injuries. Without this “Better Data for Better Care,” you are dead (twice over). Of course this is an extreme example created to illustrate a point. But there is a point, and it is an important one.

Evolvent’s “Transforming Health Care: Better Data for Better Care” book explores the benefits of well connected health care, and the enablers required to achieve the optimistic version of this 2021 vision. You can get a copy at www.evolvent.com. ♦

J.d. whitlOckVP, RESEARCH & DEVElOPmENt

[email protected]

Alternate Future


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By STEPHEN GANTZ

Sustainable Health Information Exchange

The majority of current HIE initiatives are still in the process of planning, development, or implementa-tion (fewer than one-third of the HIE’s identified by the eHealth Initiative were operational in 2010). And, in many cases the effort to launch HIEs is supported, at least in part, by federal or state government fund-ing. A key consideration for any of these HIE initia-tives – if they hope to survive and remain operational beyond the time period in which their funding is pro-vided largely through federal grants or other one-time sources – is to develop and implement an operational model that allows a health information exchange to become self-supporting in a way that is sustainable into the future. The term sustainable when applied to an HIE means the exchange is economically viable on an ongoing basis and, most importantly, that the HIE generates enough revenue to offset its opera-tional costs and provide sufficient incentive for the owners or operators of the HIE to maintain it. This article describes some of the challenges associated with sustaining HIEs at all levels, and highlights some of the approaches and business models adopted by HIE initiatives in an effort to ensure sustainability.

Seeking a Business Model for Health Information Exchange

The Health Information Technology for Economic and Clinical Health (HITECH) Act contained within the American Recovery and Reinvestment Act of 2009 included a variety of provisions offering fi-nancial incentives to health care providers to adopt and “meaningfully” use health information technol-

ogy such as electronic health record systems. It also directed the Office of the National Coordinator for Health Information Technology (ONC) to perform a variety of activities “consistent with the development of a nationwide health information technology infra-structure that allows for the electronic use and ex-change of information.” (P.L. 111-5, §3001[b]). What is not explicit in the HITECH Act is what funding, if any, should be specifically allocated to establishing or operating such an infrastructure. The primary fed-eral government health information exchange initia-tive is the Nationwide Health Information Network, managed by the ONC. Nationwide Health Informa-tion Network provides no physical infrastructure for health information exchange, but does establish a set of data and technical standards, service specifica-tions, and policies that are intended to enable secure information exchange among public and private sec-tor health care organizations. While several programs established under HITECH have provided grants to regional and state HIE initiatives, the emphasis at the federal level has been on identifying and specify-ing sufficient health IT standards and interoperabil-ity mechanisms to try to ensure that the many ex-changes across the country will be able to share data across HIEs. ONC awarded no fewer than a dozen contracts in 2010 to help further the development and recommended implementation of standards for health information exchange.

ONC has long envisioned a mature Nationwide Health Information Network that is no longer gov-ernment-run, but operated by one or more private sec-

To realize some of the many benefits anticipated from health information technology, such as, electronic health

records (EHRs) and health information exchanges (HIEs), the use of such technology needs to pervasive. Despite the

promise of lower costs, better quality of care, reduced medical errors and other health information technology (IT)

outcomes – health IT adoption among health care providers and organizations is not yet widespread; it is inhibited

by a variety of factors including the relative immaturity of local, state, and federal health IT infrastructure to sup-

port heath data sharing and the integration of health IT systems. In an attempt to overcome some of the barriers to

health IT adoption, the federal government has made significant financial incentives available to state and regional

health information exchanges, which along with state-level efforts to launch health information exchanges, has

resulted in more than 230 such initiatives nationwide, according to the eHealth Initiative’s 2010 Annual National

Survey on Health Information Exchange. Current major HIE initiatives exist at the local, state, regional and national

level, and in many cases there are multiple HIEs that may serve the same community of health organizations.


tor organizations to provide infra-structure services used for health information exchange and manage the information flow among HIE participants. To expect a commer-cial or non-profit entity to step in and provide HIE services for the Nationwide Health Information Network, even using the Internet for technical infrastructure, there needs to be a revenue source or other business opportunity to at-tract service providers. The lack of incentives for non-government entities to provide infrastructure, security, monitoring and other necessary services for the Nation-wide Health Information Net-work, will likely require the federal government to continue signifi-cantly supporting the Nationwide Health Information Network to avoid slowing health IT adoption. In the absence of federal-level co-ordination of infrastructure devel-opment efforts and corresponding funding dedicated to those efforts, HIE capabilities may be provided

separately and incompatibly at re-gional or state levels, frustrating the widespread interoperability goals the Nationwide Health In-formation Network is intended to achieve.

One possible way to provide in-centives for running regional or national exchanges would be to es-tablish a service-or record–based transactional system in which HIE participants would be paid for pro-viding the data requested by other exchange participants. If the wide-spread adoption of health IT ac-tually results in producing the sort of cost savings so often projected, some portion of any savings to be realized could be allocated to paying the owners or stewards of data made available for exchange in HIEs. In theory, the amount of money involved could be quite small and still provide the neces-sary financial incentive to po-tential service providers – such a system would be analogous to the

per-transaction interchange fees (typically under 50 cents) associ-ated with the completion of au-tomated teller transactions, where the fee is paid by the ATM card issuing bank and received by the acquiring institution and the in-terchange provider. Having a fi-nancial incentive built into HIE could simultaneously foster great-er adoption and help participat-ing entities maintain compliance with various privacy and security requirements. If, for instance, the holder of a health record was entitled to a payment each time the record was accessed or in-formation from it was sent to a

requester, not only would record holders have an incentive to make the data available for exchange, but by logging each transaction in or-der to generate billing records, the record holder would also produce an accounting of disclosures as re-quired under HIPAA.

Laws governing HIE, particularly including HITECH and HIPAA, impose constraints on health care organizations in terms of how much they can charge for data in EHRs when providing that data to others, for a variety of differ-ent purposes. The HITECH Act strengthened regulatory prohibi-tions on the sale of electronic personal health information, gen-erally requiring that covered enti-ties and business associates are not allowed to receive remuneration in exchange for protected health information about an individual, unless they have been authorized by the individual to do so (P.L. 111-5, §13405[d]). The law al-

lows for several exceptions when remuneration is permitted, such as, when the purpose of the ex-change is for public health activi-ties, research, treatment, or health care operations; but the language used in the law strongly implies that the amount of any remunera-tion should be limited to the costs associated with preparing and transmitting the data. The result is a regulatory scheme that allows little room to establish a market for health data, potentially limit-ing the return on investment for entities that might establish infra-structure or services to support health information exchange.

There are few legal restraints, however, on the ability of ex-change providers to charge health care entities (such as providers, hospitals, insurance plans, or in-tegrated delivery networks) for access to an exchange and the ser-vices it provides, whether or not the exchange enters into a formal business associate arrangement with the health care entities. This presents an alternative business model for sustaining HIEs that may not be available for health IT initiatives of the health care organizations that participate in the exchanges. Transaction or subscription fees charged to pro-viders, payers, and other HIE participants, are sources of rev-enue employed by some of the largest and most financially stable operational exchanges, including the New England Health care Ex-change Network (NEHEN), Indi-ana Health Information Exchange (IHIE), and HealthBridge. These,

and some of the other most prominent operational exchanges, often held up as examples of sustainability, all operate as non-profit organiza-tions; and all were initiated well before the recent government emphasis on funding health IT. The vast majority of current HIE initiatives were driven, at least in part, by new legislation and associated federal funding opportunities. Through the provisions of the HITECH Act alone, bil-lions of dollars in federal grants were awarded to state and regional initia-tives, including 56 state-designated entities (SDEs) receiving grant awards through the State Health Information Exchange Cooperative Agreement Program; 62 Regional Extension Centers (RECs) funded through the Health Information Technology Extension Program; and 17 established HIEs receiving additional funding and recognition as model exchanges under the Beacon Communities Program.

Challenges to Making HIEs Sustainable

There are a number of obstacles currently faced by HIE initiatives that threaten their ability to achieve sustainability. These include practical chal-lenges such as a lack of understanding of the potential value of health IT, a concern exacerbated by the relative immaturity of so many HIE initia-tives and the need to achieve widespread use of health IT before evidence of significant cost savings or service improvements can be demonstrated.

In this respect, the expanded use of HIEs reflects a classic conundrum: HIEs need greater levels of participation in order to produce intended benefits, but potential participants want to see evidence of benefits be-fore agreeing to participate. Health IT adoption, like any technology-enabled transformation, involves significant and potentially disruptive changes to current health care practices; in many cases, requiring new or unfamiliar skill sets among health care practitioners or the resources that support them. Federal funding programs like the EHR incentives available to health care providers who demonstrate “meaningful use”

To the extent that HIEs can offer participants enabling

services like data encryption, messaging, and technical

support for health IT systems, the HIEs may be able to

facilitate participation and thereby augment the value of

their exchanges and enhance prospects for sustainability.

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of EHR technology are intended to mitigate some or all of the fi-nancial burden of adopting health IT, but many organizations still face significant cost and effort in order to assimilate and adapt to new technologies. For all of these reasons, HIE initiatives need to provide training and outreach to participants, along with technical capabilities and services, and also need to ensure that the services they provide are easy enough to use and produce the expected re-sults when employed, to avoid dis-couraging new users.

Many would-be HIE participants also lack the technical capacity or staff-knowledge to implement and manage some of the technolo-gies needed for successful data exchange, or experience working with the many health IT data and service standards. For instance, federal, as well as many state HIE initiatives, rely on digital certificates within a public key infrastructure (PKI) model in order to provide security for data exchanges such as authentication. While large health

care organizations like hospitals and health insurance plans would likely be able to install, configure and use certificates to support data exchange, such abilities are less of-ten found among the small provid-ers that deliver roughly half of the health care services in the United States. To the extent that HIEs can offer participants enabling services like data encryption, messaging, and technical support for health IT systems, the HIEs may be able to facilitate participation and thereby augment the value of their exchanges and enhance prospects for sustainability.

A further challenge to interoper-ability – and by extension, utility and sustainability – among differ-ent HIEs, is the tendency by many state and intra-state regional HIEs to focus on exchange capabilities and services only within the user community defined by the HIE, and not on inter-state, regional, or nationwide operations. There are reasons that help justify deci-sions to limit the scope of HIE initiatives at the state level, includ-

ing the way federal grant funding has been allocated, and the desire by some state-designated entities to provide capabilities to resident health care providers to help sat-isfy meaningful use requirements for data exchange. Federal initia-tives like the Nationwide Health Information Network offer a pos-sible resolution to this problem as state-level HIEs could potentially achieve integration with other HIEs simply by becoming par-ticipants in the Nationwide Health Information Network. In Septem-ber 2010, Indiana became the first state participant in the Nationwide Health Information Network, with the Regenstrief Institute using the Nationwide Health Information Network to send public health on behalf of the state to the Centers for Disease Control and Preven-tion (CDC). As the number of op-erational HIEs continues to grow, achieving inter-HIE integration via the Nationwide Health Infor-mation Network may become an increasingly attractive option for state and regional HIEs, especially compared to the effort required to establish multiple HIE-to- HIE connections.

Current Approaches to Sustainability

Regardless of the business model in place or availability of public funding support, the nature and amount of use of HIEs are con-tributing factors to sustainability. Active use of a HIE is important not only to demonstrate viability of the operation, but also to pro-vide a basis for determining the appropriate mix of data, services and purposes for the HIE that will produce value to participat-

ing organizations, therefore making the HIE a useful resource. In this sense, the idea of sustainability is often characterized in terms of establishing a “criti-cal mass” of HIE usage, after which point the con-tinued realization of benefits serves to retain current users and attract new ones. Much of the federal grant funding awarded to state and regional HIE initiatives is intended to provide sufficient financial support to enable the HIEs to reach this point. The level of par-ticipation is also an important factor in making an HIE initiative sustainable, both in terms of securing participation of health care entities in newly estab-lished HIEs, and for maintaining active participation among entities who may be served by an HIE over time. Exchange initiatives sometimes focus on tech-nical infrastructure, and data exchange mechanisms and standards without giving sufficient attention to ensuring that entities are willing and able to partici-pate, and that the HIE provides sufficient data to de-liver value to its users. Several early-phase state initia-tives have encountered the “empty HIE” problem, in which HIE services are made available to participants – but only limited health data is available for shar-ing through the HIE. “Empty HIE” causes providers and other potential HIE users, who attempted to use HIEs and did not find the information they need, to not try again.

When it comes to funding operations, there are sev-eral different approaches HIE initiatives use to pro-duce revenue, many of which are used together. The funding model used by a given HIE is driven by a number of factors, particularly including its organi-zational structure and characteristics such as whether HIE participants are members or partners in the HIE, or non-member users of the services offered by the HIE.

No single “best” operational model has emerged among current HIE initiatives, and many HIEs use a combination of funding sources to generate oper-ating income. While some of the more established HIEs are notable for their structure as non-profit or-ganizations, other alternative structures also appear viable, including for-profit, public utility, and public-private partnership models. The collective experience of many state and regional HIEs suggests that sus-tainability can be achieved using different approach-es, as long as effective governance structures and a suitable business model is put in place. ♦

SOURCES OF HIE FUNDING IN USE TODAY INCLUDE:

» user fees paid by HIE participants such as hospitals, health care systems and

integrated delivery networks, physicians, laboratories, and public and private

sector payers, including health insurance plans and accountable care organi-

zations. These fees can take the form of ongoing subscription or membership

dues, initial participation fees paid at the time an entity signs on to participate

in the HIE, or incremental charges associated with particular services offered

by the HIE (for example, different fees for participating in public health report-

ing versus participating in health data sharing in support of treatment).

» transaction fees charged to participants as they use the services provided

by the HIE. Transaction-based funding requires a mechanism that allows the

HIE to track actions performed by participants, and in many cases to distin-

guish among requests or communications that do not incur charges, (such

as a participant lookup) and those that do (such as retrieval of health records

by a requester from a respondent).

» Fees assessed by the state (or with the approval of the state) to support

HIE services offered as a sort of public utility. This model considers HIE as a

type of public good, and funding for HIEs under this model may be provided

through assessments paid by health care industry participants, business li-

censees, or individual citizens and organizational through taxes collected by

the state and allocated to fund HIE operations.

» Fees charged for the sale of data, including data used for research or

public health activities and for advertising and marketing purposes (subject

to regulatory limitations). Many states already generate revenue from the sale

of data in records, such as those maintained by motor vehicle departments,

and active markets exist for both personally identifiable and de-identified

data contained in health records. Any decision to try to generate revenue

through the sale of personal health data must consider federal and state

legal constraints and conditions placed on remunerated health information

disclosures, including how much HIEs can charge, allowable purposes for

which data can be sold, and the need to obtain consent from individuals

prior to sale.

» Federal or state grants available to HIEs to enhance or expand services. In

contrast to federal funding initiatives that are intended to support the initial

establishment of HIEs, such as the State Health Information Exchange Coop-

erative Agreement Program, opportunities exist for HIE initiatives to receive

additional funding to augment health IT infrastructure and HIE capabilities.

Several grant programs also exist to help HIEs provide technical and practical

assistance to health care providers and other organizations to implement

health IT, and become active participants in HIEs. To date, high visibility ini-

tiatives like the Beacon Community Cooperative Agreement Program have

rewarded HIE initiatives that have already established core infrastructure

and services.

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he traditional model of clinical research involves a clinician, armed with a research hypothesis, writ-

ing up a proposal and submitting it to an Institutional Review Board (IRB). After approval and fund-ing, an often very laborious pro-cess is involved in identifying re-

search subjects. Then depending on the study, a very laborious

(and therefore costly) process

is involved in acquir-ing data, often in-cluding an extensive

manual review of paper medical records. Months or even years can be eaten up by writing a research proposal, getting it approved and funded, and searching for research subjects – only to find out that not enough research subjects can be found that meet the research criteria. The worst part is the re-search that is not completed, and the medical breakthroughs that are not discovered, and the lives that are not saved, because this process is so hard and so expensive that many good research hypotheses never get off the ground.

There is a better way. Now that large health care orga-nizations like the Department of Defense (DoD), Veterans Affairs

(VA), Kaiser, and many Academic Medical Centers (AMCs) have had Electronic Health Records (EHRs) in place for a few years, there ex-ists a steadily growing mountain of clinical data on tens of millions of patients. There are many holes the in the data, and depending on the research need, some required data is still on paper or stove-piped away in difficult to access specialty systems. Also, the EHR data must be exported to a data warehouse to permit mining the data without shutting down the EHR, and data warehouse projects are expensive. Nevertheless, these clinical data warehouses now exist, or are soon coming online at large innovative health care organizations, and the answer to thousands of unasked

research questions are now orders of magnitude easier to discover.

Gartner Research health care analyst Vi Shaffer has coined the term Advanced Clinical Re-search Information System (ACRIS) to describe the kind of system that will be required to manage clinical research in this new world order.

An ACRIS is: ... a complex constellation of

capabilities that can rapidly assemble

data assets for research questions,

and provide data mining and research

processes support to meet the needs

of clinical and translational research

and related biostatistics and biocom-

putation ... The Enterprise Data Ware-

house ... may be shared between the

ACRIS and an enterprise business

intelligence system that assembles

data from some of the same sources

but for the purposes of performance

management. However, the require-

ments for clinical research are very

different from—and even more

complex than—the requirements for

business intelligence.

Shaffer points out that the need for ACRIS capabilities are being accel-erated by the rapidly advancing in-terest in genomics and translation-al research, as well as the fact that the funders of research are coming to expect the research process ve-locity and discipline that an ACRIS can deliver.

One important enabler of ACRIS functionality is the capabili-ty to leverage advanced and emerg-ing data warehousing technolo-gies to efficiently query massive amounts of clinical data. These in-clude Massively Parallel Processing (MPP), MapReduce technology, column-oriented analytic databas-es, and in-memory analytics. These technologies are further discussed in the CTO message on page 10.

This all closely mirrors the goal of the National Institutes of Health (NIH) in funding the Clinical and Translational Science Awards (CTSA) program. This consor-tium includes 55 medical research institutions located across the na-tion. When fully implemented in 2012, 60 institutions will be linked together with the goal of col-laborating on and energizing the discipline of clinical and transla-tional science. Drawing from the NIH Roadmap for Medical Re-search and extensive community

input, the CTSA program creates an academic home for clinical and translational research. The CTSA program vision statement is to: “Improve human health by trans-forming the research and training environment to enhance the effi-ciency and quality of clinical and translational research.”

Let us briefly examine the experi-ence of one of the CTSA facilities, The Ohio State University Center for Clinical and Translational Sci-ence. Vi Shaffer at Gartner feels that OSU is a leader in understand-ing the critical link between op-erational medicine and clinical re-search. They ensure epidemiology expertise is imbedded throughout the entire clinical research process. They are focused on developing translational research information architects, to ensure that the data collected during research can be efficiently and effectively “trans-lated” into operational medicine as soon as it is clinically responsible to do so.

OSU had an early start with clini-cal data warehousing, and the les-sons they have learned in the last ten years from the blood, sweat and tears associated with pioneering this work are now incorporated into their clinical data warehouse data

Accelerating Clinical Researchby J.D. Whitlock

T – Mining of patient data, including

that contained in transcribed and other unstructured reports

– Automatic correlation of data with medical knowledge in published research, providing more effective/ efficient secondary research

– Use of external data and open-source tools, including assistance in translating between ACRIS data models and vocabu-laries, and those of other institutions, for collaborative research

– Creation of research study data marts from enterprise and other clinical trial data

– Cohort identification

– Facilitation of researcher workflows, including support of the scientific method, grant preparation, internal/ external collaboration and documentation

An ACRIS includes tools that enable:


organizations worldwide. A cous-in to i2b2, also being developed at Harvard, is SHRINE (Shared Health Research Information Network). SHRINE helps clini-cal researchers overcome one of their greatest problems – compil-ing large groups of patients across different health care organizations that meet criteria for a clinical trial. Qualified investigators may use the SHRINE web-based query tool to determine the aggregate total number of patients at participat-ing hospitals who meet a given set of inclusion and exclusion criteria (currently: demographics, diag-noses, medications, and selected laboratory values). Because counts are aggregate, patient privacy is protected. SHRINE is still in beta testing at Harvard, but could soon enable a significant leap forward in the federated discovery of patients for clinical trials.

The Archimedes ModelAnother aspect of the future of clinical research is the ability to conduct computer simulations of health care interventions. The Archimedes Model is a full-scale simulation model of human physi-ology, diseases, behaviors, inter-ventions and health care systems. By using advanced methods of mathematics, computing, and data systems, the model enables man-agers, administrators, and policy makers to be better informed and to make smarter decisions than has previously been possible. The core of the model is hundreds of equa-tions that represent human physi-ology and the effects of diseases. Attached to these are hundreds

more equations and algorithms that realistically simulate the health care system including processes such as tests, treatments, admissions and physician behaviors. Together with population data, the equations are integrated into a single, large-scale simulation model that accurately represents what happens to real people in real health care systems.

Proponents of Archimedes point out that the model would never be used independently to recommend a new intervention. If the model pointed to a particular treatment or intervention as more efficacious than the status quo, then clinical trials would always be performed to confirm the treatment worked on carbon based human beings instead of software model based human beings. The key point is that Archimedes could be used as an accelerator to pinpoint treat-ment modalities that could then be confirmed with clinical trials – as opposed to “fishing” with clinical trials that can drag on for years, or even decades.

Unlike clinical trials, Archimedes can easily run a wide variety of modifications to the experimental hypothesis. Unlike clinical trials, Archimedes can conduct experi-ments that could not be done on humans for ethical reasons. It can model factors like arterial plaque that cannot easily be measured with diagnostic devices. Because it can run 16,500 person-years of simu-lation per minute, it can conduct large-scale studies with so many re-quired variables that it would be astronomically

model. The data model and as-sociated business logic surround-ing the clinical research process is a goldmine for other health care organizations wanting to copy their success. And, copying their success is critical if we want to expand translational research and empower thousands of researchers with all the clinical data that EHRs will produce in the next 5-10 years. Vi Shaffer feels it is important to replicate the success of larger Aca-demic Medical Centers (AMCs) like OSU at second tier AMCs. She states that to do this the market desperately needs accelerators, and the acceleration required is part technical, part change manage-ment, and part research operations.

Another pioneering CTSA facility is the Harvard Clinical and Trans-lational Science Center. Among their many accomplishments is the development of a scalable infor-matics framework that is enabling clinical researchers to use existing clinical data for discovery research and, when combined with Insti-tutional Review Board (IRB)-ap-proved genomic data, facilitate the design of targeted therapies for individual patients with diseases having genetic origins. Dubbed i2b2 (Informatics for Integrat-

ing Biology and the Bedside), this platform

enjoys wide adoption by the C T S A consor-

tium, and is now used

by more than 40 health care

expensive (and take decades) to complete them with clinical trials.

Last but not least, the Archime-des team is currently working on ARCHeS, an online interface that will allow physicians and research-ers to access Archimedes and de-sign their own trials.

Putting it All TogetherPutting this all together, hope-fully the future of clinical research looks something like this: physi-cians, epidemiologists, and other researchers at AMCs across the country are able to access ma-ture ACRIS-type systems to mine mountains of clinical data, dis-cover new relationships among the data and propose new hypotheses on better treatments and interven-tions. They log on to ARCHeS and run these studies on a massive Archimedes platform built to sup-port a large volume of analysis. If confirmed on Archimedes, they use i2b2, SHRINE, or similar plat-forms to streamline the process of identifying patients that qualify for a clinical trial. Additionally, pa-tients can use tools like TrialX.com and researchmatch.org to discover and volunteer themselves for clini-cal trials they are eligible for, even if their clinical data is not acces-sible to the AMC conducting the study. Clinical trials are conducted and repeated to the extent required to satisfy the medical community that the proposed new treatment or intervention is in fact an im-provement. An improved clinical research process along these lines

would greatly acceler-ate the advancement of medical science. ♦

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Patient-Centered Medical Home (PCMH)By Bill SOrrellS

What if health care consumers could go to a place where

their doctor does not keep them waiting, actively keeps

them healthy, and works with a whole team of other health

care professionals. Further, imagine if that place makes

the doctor’s life easier and health care cheaper.

Health care nirvana?

In a nutshell, this is the idea behind what is called the “patient-centered medical home,” and it is an idea that is spreading across the country. The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth and adults. The PCMH is a health care setting that facili-tates partnerships between individual patients and their personal physicians, and when appropriate, the pa-tient’s family.

The American Academy of Pediatrics (AAP) intro-duced the medical home concept in 1967, initially re-ferring to a central location for archiving a child’s medi-cal record. In its 2002 policy statement, they expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate and cul-turally effective care.

The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have since developed their own models for improving pa-tient care called the “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006).

In January 2008, the National Committee for Qual-ity Assurance (NCQA) released standards for Physi-cian Practice Connections/Patient-Centered Medical Home. PCMH is a model for health care providers that’s seeks to replace episodic care based on patient complaints and illnesses with coordinated care and a long-term healing relationship between the patient and their primary care team.

One important feature of the medical home is doc-tors are also supposed to be able to hand-off some of the less specialized, and often time-consuming, tasks to others. The idea of having all care team mem-bers practicing at the “top of their license,” or doing what they are most trained to do,should best serve the patients and the health professionals in terms of satisfaction.

While doctors and patients may be happier and health-ier in the PCMH model, what will really determine the success or failure in the long run is whether it actu-ally saves money. That is a big concern, and unless it can demonstrate that the model not only improves quality and patient experience but also controls costs, early successes will diminish. One key silver lining is the hope of actually reducing the overall cost to deliver health care. One key element of success is the effective use of and leveraging information technology.

1. Build content-rich, easy to use EMR/EHR/PHRs that create high levels of consumer satisfaction from both the provider and patient perspective. Give them information they want in a form they want to see and give them tools to use that information to make better decisions. Information to deliver better health care; information to help shape behaviors for sustaining better health.

2. Offer information services that both the providers and patients want to come back to. There is no doubt there has been an explosion is social networking in the last two years because of the social networking services such as MySpace, Facebook, Twitter, etc. So much so that thousands of businesses and both federal and state government organizations have a social networking presence…even the Pentagon! Even more so is the power and ubiquity of mobile devices that serve as both cell phone and computer allowing people to connect in many ways and receive very content rich information services at their fingertips. The consumer demand for mobile-form information services is enormous and health care related tools are no exception. From fitness planners to nutritional guides for patients, and pharmacy drug interaction guides to a mobile version of UpToDate for providers, and everything else in between, it is an information resource that must be leveraged.

3. Secure it all where necessary. Once privacy and trust is lost, it is lost.

4. Create health related push/pull information services for patient education. Better data; better self-care.

5. Stay ahead of the “frequent flyers.” Often the patients with more complex conditions tap the health care resources the most. Home telemonitoring solutions have proven very helpful to the Veteran Affairs patients and other large health care organizations where case or nurse managers and often providers actively “coach” their patients when their health care metrics are not improving or “out of bounds;” and “cheerlead” them when they improve or sustain good health.

6. Participate and advocate to other local communities and state officials to get on the health information exchange (HIE) bandwagon. There is no doubt that patients will get health care at other service providers. Having complete visibility to shared health data gives the primary care providers and other health care participants more, as well as timely information when rendering future care. Better data for better care.

7. Build quality throughout the health care chain. Measure, measure, measure... continu-ous improvement. Leveraging IT will greatly help via near real-time electronic dash-boards, decision support tools, etc.

8. Share your best practices and worst practices with everyone.

9. Create streamlined channels of communication where there is no fear of new ideas.

10. Use proven, systematic and repeatable processes to improve. Six Sigma, COBIT, TQM, etc. A lot to choose from and each have their best use... learn organizationally how to use them though. Otherwise it is just another buzzword from 30,000 feet.

11. Let your patients be part of all the above. Active participation can lead to better buy-in.

12. Learn from others. It doesn’t make much sense to reinvent the medical home “wheel”.

13. Reshape the culture. Change is tough for many and leaders need to be out front, otherwise it will be viewed as another “drive-by” program. A clear vision is essential and probably the most important criteria for success.

14. Stay the course. Look for quick wins to gain enthusiasm, but keep preaching the long-term goals.

Let us walk this IT-based PCMH with a recipe to consider: Although this is not a complete list, it does highlight some of the major points.


In a 2010 study of seven PCMH pilot programs, there were numerous positive results when examining hospi-talization frequency, emergency department visits and savings to patients:

Pc-Mh Pilothospitalization reduction %

er visit reduction %

total savings/Patient

Colorado Medical Homes for Children 18% N/A $169-$530

Community Care of North Carolina 40% 16% $516

Geisinger 15% N/A N/A

Group Health Cooperative 11% 29% $71

Intermountain Health Care 4.8%-19.2% 0-7.3% $640

MeritCare Health System and BCBS North Dakota 6% 24% $530

Vermont BluePrint for Health 11% 12% $215

Adapted from Fields D, Leshen E, and Patel K. “Driving quality gains and cost savings through adoption of medical homes,” Health Affairs, May 2010; 29(5): 819-826. Appendix Exhibit 1.7

Considering the costs associated with emergency department visits alone, the reduction in emergency department visits for the seven PCMH health care organizations is astonishing. While the level IT ma-turity was not the same for each organization exam-ined, certainly those that had EMRs were in better position for early PCMH successes. The key ingre-dient for success in implementing new IT solutions to help PCMH projects is making sure the workflow and change management is well defined, agreed, and codified as a major part of the implementation.

How Important is IT? The US Air Force is rolling out their version of the PCMH and refers to it as the Family Health Initiative. Started in early 2009, the idea to have mili-tary and retiree beneficiaries primarily see their pri-mary care provider was a crucial success factor as was appropriate staffing. One key foundation cornerstone for the Air Force medial home is leveraging and mak-ing effective use of IT.

To date, the performance metrics for the Air Force medical home are positive especially provider conti-nuity and all 75 Air Force military treatment facili-ties will be under the PCMH by the end of 2011. Looking at the model to the right you can easily see the key ingredients for success including the use of IT.

Although leveraging IT to support PCMH implemen-tations like the US Air Force can lead to successful outcomes, it is not a “magic box.” Often times health care organizations field some of the newest and best

and exploitation of best practices along with a strong commitment from executive leadership with a clear vision on the way forward. Of all things that are im-portant, leadership is above all.

The Patient-centered medical home only works if pa-tients take active roles in their care. Health care teams see patients for just a few minutes at a time. The re-mainder of the time, it is up to patients to self-man-age their health. Empowering patients with education and online self-management tools is critical to their success. The medical home structure calls for each individual patient to be treated by a team of medical professionals under the direction of a primary care physician. This is the ultimate collaborative approach which, in order to reach optimum effectiveness, will require each care team member to have access to complete and up-to-date patient data. The PCP will need to know when the cardiologist has discontinued a beta-blocker. The pulmonologist will need to know when the PCP ordered a chest x-ray. All of the pa-tient’s physicians will need to know when the patient has been hospitalized or visited and emergency de-partment, and so on.

Reporting and tracking outcomes for quality perfor-mance measures is essential for the medical home to succeed. Often these tasks are performed manually with paper-based medical records that are labor-in-tensive, time consuming and terribly costly. Infor-mation technology can expedite these processes by giving each care team member consistent, real-time access to clinical data. Of course this will require open, standards-based systems that can transmit and receive data across networks and delivery mecha-nisms, essentially giving health care teams access to information where and when they want it and in a form they need. ♦

IT available to stay on the cutting edge, but unfor-tunately, they fail in the change management aspect that often leads to poor satisfaction, ineffective workarounds, and in some cases, significant patient safety issues. Those organizations that do not have the organic change management expertise can easily get help. Organizations that do not have necessary organic resources for effective change management and try to grow it on the fly often struggle and even-tually seek outside assistance anyway. Shifting from a physician-centered model to a PCMH patient-cen-

tered model is no doubt a tough transition. This

requires careful thinking, re-

search

Sources

1. Allred NJ, Wooten KG, Kong Y (February 2007). “The association of health insurance and continuous primary care in the medical home on vaccination coverage for 19- to 35-month-old children”. Pediatrics119 Suppl 1: S4–11.

2. Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N (2007). “Toward higher-per-formance health systems: adults’ health care experiences in seven countries, 2007”. Health Affairs26 (6): w717–34.

3. Homer CJ, Klatka K, Romm D, et al. (October 2008). “A review of the evidence for the medical home for children with special health care needs”. Pediatrics122 (4): e922–37.

4. Rosenthal T., (2008) The Western Journal of Medicine155 (1): 43–6.

5. Strickland BB, Singh GK, Kogan MD, Mann MY, van Dyck PC, Newacheck PW (June 2009). “Ac-cess to the medical home: new findings from the 2005-2006 National Survey of Children with Special Health Care Needs”. Pediatrics123 (6): e996–1004.

6. Reid RJ, Coleman K, Johnson EA, et al. (May 2010). “The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers”. Health Affairs29 (5): 835–43.

7. Fields D, Leshen E, and Patel K. “Driving quality gains and cost savings through adoption of medi-cal homes,” Health Affairs, May 2010; 29(5): 819-826. Appendix Exhibit 1.

Health ResearchTx (HRTX) is a health

research organization that has a multi-year

contract with the U.S. Department of Defense

(DoD) to leverage the DoD health care system

to improve health outcomes, lower costs, and

increase force readiness.

HRTX is working with the DoD on programs such as:

» health Outcomes Research Center of Excellence (hORCE)

» “medical home” Program and Publishing Facilitation

» dod - hhS health Research Collaboration

healthresearchtx.com

Evolvent introduces a new strategic partner...

Evolvent is proud to be the IT partner for HRTX.


Health 2.0 is participatory healthcare.

Enabled by information, software, and

community that we collect or create, we

the patients can be effective partners in

our own healthcare, and we the people

can participate in reshaping the health

system itself.

— Dr. Ted Eytan

Patient focused internet tools have matured signifi-cantly in the last couple years, mirroring and building on the recent explosion in the adoption of social net-working tools, and on the slow growth of Electronic Health Records (EHRs) and Personal Health Records (PHRs). EHRs enable the electronic documentation of a patient’s clinical data, and PHRs that are teth-ered to EHRs enable patients to view this data, report additional relevant information to their providers, and communicate more effectively with their provid-ers. When combined with emerging health care deliv-ery models like Primary Care Medical Home (PCMH)

and Accountable Care Organizations (ACOs) that financially incent providers to communicate more effectively with their patients via these online tools, the Health 2.0 phenomenon will truly blossom. Many patients, particularly the elderly, have little desire to use these tools to change anything about how they manage their health. However, the sizable and grow-ing percentage that does will soon have a chance, as Dr. Ted Eytan puts it, “to participate in reshaping the health system itself.” Let us take a brief look at some of the different ways Health 2.0 is starting to enable participatory health care.

Health 2.0by J.D. Whitlock

Secure Patient-Provider Communication:

According to an August 2009 survey by Lightspeed Research, 1 in 2 Americans would like to be able to email their provider to ask questions and request prescription refills. Although many providers are at first resistant to the idea of opening up their practice to email, after they try it, most find that re-sponding to an email is easier than responding to a phone consult, because it is easier to budget their time. For example, if a provider has five minutes available before a scheduled office visit, they may well be able to respond to an email consult, but they would not pick up the phone and respond to a phone consult because they have no idea how long that phone call would take.

In order to comply with HIPAA requirements, it is much easier to enable email/online patient-provider communication in the context of a PHR or patient por-tal specifically designed to accom-modate HIPAA. A provider that permits online communication with their patients armed only with an email account is opening themselves up to significant legal liability, because HIPAA requires that the clinical information used for diagnosis in emails be pro-tected like any other clinical data. This is part of the reason Kaiser Permanente has been so success-ful with their secure messaging so-lution – it is well integrated with their PHR and EHR; therefore, it is easy for providers to appropri-ately document the care they rec-ommend via secure messaging. In

the absence of a PHR tethered to an EHR, vendors like RelayHealth offer secure patient-provider com-munication solutions, to include e-prescribing and other features.

Trusted Health Education Resources:

Patients want information on their (and their loved ones’) health con-cerns. They want to stay up to date as medical science evolves and new treatments or medications are released related to their chronic conditions. Providers want their patients to get trusted health in-formation, so they do not have to waste valuable time in the exam room debunking fad treatments.

Additionally, thanks to Facebook, most patients are familiar with the concept of “subscribing” to top-ics/groups/organizations of inter-est to them and receiving updates in one centralized location. So, it is not surprising that PHRs and third party websites are copying this model. To cite one example of many, MyDailyApple.com is a Google Health integrated service that de-livers news and search results tai-lored to specific health concerns.

Putting this concept together with secure messaging, the following sce-nario is certainly not far off: A patient subscribes to health topics/disease conditions of interest to them, and

is delivered updated content in one centralized location (and notified via email or Facebook if desired). If they have a question, e.g. “Is this new medication for my chronic disease appropriate in my case?” then with one mouse click they initiate a secure message to their provider that refer-ences the content they just read. This streamlines the business process not only for the patient but also for the provider, because the provider can more quickly understand the clinical context of the request (as opposed to a query in the exam room based on, “my brother told me he heard about some new drug on CNN”).

This subject ties directly to, and builds on, the previous two topic ar-eas. There is enormous potential in bringing social networking capabili-ties into the communication equation between patients and their provid-ers, between patients and their family members, and between patients with similar health concerns.

Social Networking Functionality:

“Our profession, at its core, is fundamentally flawed rela-

tive to how today’s world communicates and functions.

The infrastructure of health care needs a total repair from

the ground up. It needs to be Facebook-ed and Wiki-ed”

— Dr. Jay Parkinson, Hello Health


HelloHealth.com is a new model of health care de-livery that has been described as “part EHR, part practice-management system, and part social-net-working site, complete with profiles and photos of doctors and patients, all in a secure environment that complies with federal privacy standards.” Patients pick a provider via their Facebook-like profile, and pay a monthly enrollment fee (usually on the order of $30-$35) that covers quick questions via email or IM, prescription refills, and viewing their medical re-cords online. Some practices include simple lab tests and generic medications for acute conditions in the enrollment fee. Office visits are guaranteed within 24 hours if necessary, and patients can schedule an ap-pointment themselves online by viewing open slots

on their provider’s calendar. Five different modalities of outpatient visit are offered (with different prices set by each practice): house calls, office visit, video visit, phone visit and IM visit. The Hello Health model does not include accepting insurance, but patients can of course submit office visit invoices for reimbursement if they have out of network coverage. Hello Health’s parent company, Myca, sells the Hello Health software platform for use at other practices that want to adopt its model.

Another innovative example of social networking in health care is Emota.net. A startup funded by the Na-tional Science Foundation, Emota is working on an “emotional networking” solution to help busy families and care professionals stay aware, in touch and support-

Specialized Health & Wellness ApplicationsAll types of Health 2.0 web and mobile applications are being developed to help patients manage chronic diseases, assist the healing/recovery process, manage fitness/diet, etc. Here is a small sampling:

ive of the elderly. The interface for the elderly is a touch screen, always on a dedicated hardware device connected to the internet. The presentation is like a “two-way interactive picture frame” that allow the elderly to communicate through touch-based video, voice and text tools (without any technical skills). The interface for family members and friends is a smart phone application or web site that helps them stay aware of their elderly loved ones’ condition and provide timely emotional and physical support when required. The interface for caregivers is a dashboard that lets them monitor multiple patients and provide support as needed. The Emota technical architecture is built to allow rapid integration with PHRs, remote patient monitoring, and telehealth applications.

An example of social networking among patients is PatientsLikeMe.com. Their goal is to “enable peo-ple to share information that can improve the lives of patients diagnosed with life-changing diseases.” Patients with one of 19 serious conditions can cre-ate a profile, track their symptoms, find patients like

According to an August ‘09 survey by

Lightspeed Research, 1 in 2 Americans

would like to be able to email their

provider to ask questions and request

prescription refills.

themselves and com-municate via forum discussions or pri-vate messages. Profile charts let patients see how their treatment is affecting their health over time, and anony-mized patient outcome data is used by providers, pharmaceutical companies and research organizations to drive treatment research and improve medical care.

As innovative Health 2.0 tools proliferate on the web and on mobile devices, and as providers ask patients to use tools tailored to their chronic diseases that as-sist the provider in monitoring and improving patient care, Health 2.0 will have an important impact on medicine. This is just one more way that better data will result in better care. ♦

Health 2.0 will have an important impact on medicine.

scanavert.com rememberitnow.com 411fit.com trialx.com

Delivers instant personalized decision support in the supermarket. Patients register and establish a profile at the ScanAvert website, identifying any allergies, dietary preferences/avoidances, illnesses/conditions, prescriptions, etc. Then they use the camera on their mobile phone to scan bar codes on food items they are considering for purchase. The item’s ingredients are compared to the consumer’s profile. If a product’s composition is incompatible with a customer’s profile, an alert is generated identifying the substance(s), accompanied by proposed compatible substitutes.

Enables patients to input their medication regimen and then receive text or email updates to remind them when to take their pills. Additionally, it charts and trends their progress with weight, blood pressure, or other goals, and permits patients to include family members and caregivers into a private community that can assist/encourage them in inputting their data or reaching their goals.

Allows users to set weight loss and exercise goals, enter diet and exercise data and receive daily feedback on their progress. What separates 411fit from most other diet and fitness websites is a very rich user interface and social networking features, which allow friends (or personal trainers) to monitor and encourage progress.

Matches patients to relevant clinical trials based on their health conditions. It is available as a plug-in to both HealthVault and Google Health PHRs, so that it can monitor a patient’s existing health data in their PHR (as opposed to the patient needing to enter clinical data directly in the TrialX.com website).


The way we communicate certainly has come a long way, especially in recent years. Many people remain unaware as to the extreme changes to the capabilities that exist. To illustrate this, let me share a story. Recently, I was on my way back home to Alaska from a business trip. There I was at 37,000 feet taking advantage of the Wi-Fi access on the plane. The quality of service was bet-ter than I thought. I was invited to Skype with a good friend taking care of her sick mother in Greece, and then started instant messaging with a friend on his cell phone in Alaska…while I was somewhere over west Arkansas. And, by the way, I was also watching live the Arkansas vs. Georgia football game on the plane’s Direct TV. With all this capability, one has to wonder how information tech-nology (IT) can equally be leveraged for health care. The good news is, it is. Maybe not widely used or adopted as it should be, but there is hope that IT is bringing patients and medical personnel together in new ways regardless of distance, time, and terrain. There is no doubt that tele-medicine today is greatly expanding the reach and range capability of health care professionals and positively impacting lives.

New telehealth initiatives across the country are starting to address critical shortages of medical specialists and primary care providers, helping supply care to patients who previously did not have access. Widespread adoption of electronic health records (EHRs) is expected to boost telehealth adoption even further. That is because in addi-tion to videoconferencing capabilities that let clinicians remotely communicate with each other and patients, digi-tized health records will provide remote specialists with more complete information about those patients. Much of this is done with growing participation of health in-formation exchanges (HIEs) and the maturing of the Nationwide Health Information Network. Meanwhile, the use of digital medical images from picture-archiving systems and digital cameras are making a wide range of information available to doctors regardless of distance, time or environment.

Health care organizations are deploying telehealth to pa-tients where there are shortages of specialists such as der-matologists, neurologists, radiologists, critical care doctors and mental health specialists. Telehealth is also helping to

close the care gap for patients who live in rural areas, as well as patients with debilitating illnesses for whom travel is difficult or impossible. In some instances, telehealth is helping to link patients with medical expertise even while the patient is in transit.

A great example is how Alaska’s wide and rough ter-rain prompted the creation of a statewide health care net work1. Many Alaskan communities are located hun-dreds of miles from large regional medical centers and are designated as “medically underserved.” Physicians and mid-level providers are scarce in Alaska’s rural and re-mote locations. By far, most of the providers are located in the Anchorage area, and to a lesser degree, Fairbanks and Juneau.

Fortunately, IT improvements surged in the mid-90s al-lowing a telehealth strategy to be envisioned. The Alaska Federal Health Care Partnership formed the Alaska Fed-eral Healthcare Access Network (AFHCAN) to address the health care needs of the 315,000 federal beneficiaries in a statewide telehealth project. Specialties were added beyond primary care, including dermatology, otolaryngol-ogy and cardiology.

Between 2001-2007 there were over 50,000 telehealth patient encounters with over 1,300 different providers participating. Most of the cases involved primary care (38,000); in which the telehealth system prevented un-necessary patient travel in 1 of 5 cases. Of the remain-ing, 11,000 cases were referred to participating specialty providers where 3 of 4 cases resulted in travel savings. Over $14 million was saved in unnecessary travel alone and today, the state saves $3.5 million each year.

The Alaska telehealth project also illustrates the reliance on partnerships from caregivers in the field, participating provider consultants, health care IT vendors and leader-ship from stakeholder organizations. Without a clear vi-sion, effective partnerships and appropriately leveraging IT, Alaska could not have realized the positive outcomes for the health care beneficiaries they serve.

California launched the California Telehealth Network (CTN) to connect patients and physicians using broad-

band technology2. By 2011, CTN is expected to link al-most 900 health care facilities across the state. Currently, it is set up across 50 sites where UC-Davis Medical Cen-ter serves as the network’s control center. CTN visually links small hospitals and health clinics with a system of physicians, surgeons and specialists as far as hundreds of miles away.

The connection will allow health care professionals to:

» Check on patients in real-time using home telemoni-toring solutions

» Review X-rays and diagnostic tests

» Advise on procedures, prescription drugs and emer-gency treatment

The primary goal for using broadband as a telehealth means, is the hope for reduction in medical costs and im-provement of clinical outcomes overall.

One big hurdle for telemedicine is that its capabilities for improving care are advancing faster than many health insurers’ willingness to cover these services. While gov-ernment programs like Medicare cover some telehealth services, coverage is usually tied to services provided to patients living in regions where there are shortages of primary care doctors, not specialists like stroke experts, who are even scarcer. Perhaps coverage of telemedicine services by health insurers and other payers will expand in the years to come as more is learned about how telehealth can not only improve patient care and save lives, but also help to cut costs.

Such research is under way at Mayo Clinic, which, with Intel and GE Healthcare, launched a program to study how home telemonitoring can help sick, elderly patients avoid hospitalization 7. During a year-long study, 200 Mayo Clinic high-risk patients over the age of 60 who suffer chronic conditions including heart failure, diabetes, and lung disease will use telemonitoring devices to take their vital signs, such as blood pressure, peak air flow and weight or blood sugar readings every day.

The medical devices transmit the readings to a remote patient-monitoring system located in the patient’s home.

T E L E H E A LT H

Telehealth is helping to close the care gap for patients who live

in rural areas, as well as patients with debilitating illnesses

for whom travel is difficult or impossible.

By Bill SOrrellS


The health insurance industry as well as the gov-ernment is finally ready to accept a nontraditional delivery system and help invest to get telemedicine initiatives matured. But believe that telemonitoring technology is an excellent solution to increase the degree of medical services, while at the same time decreasing the cost. Newer systems will use high-defi-nition cameras and monitors in a telepresence format that will create an experience between the doctor and patient that will be much like that of a visual confer-ence call. A trained medical professional, along with an IT technician, will be the onsite presence at the patient’s residence along with the monitoring and telecommunications equipment that will be set up to connect with the same type of equipment back at the doctor’s office.

There are various telemedicine systems being used in test modes throughout the country, by various health insurance groups and technology companies, with the ongoing monitoring of the new technology ef-ficiency, cost effectiveness and how the test group of patients perceives this new method of delivering health care. The majority of the testing is being done in areas with limited access to adequate health care, or rural areas where the travel distance in receiving health-care services can be problematic. However, telehealth initiatives can and are being used in other opportunities where it makes sense. The telehealth space is marginally being exploited however.

One of the most valuable direct benefits of IT’s emergence on a global scale is the impact it is having on health care. As medical technologies and use cases emerge in conjunction with computer networks, med-ical information systems and decision-support ser-vices, ITers and clinicians in close harmony will pro-

vide, support and extend health care delivery in ways that bring the provider and patient together virtually. Not so many years ago, ubiquitous health care would have been unthinkable; however, improvements in IT have allowed health care to take a great leap forward providing a bright outlook for the future. When an IT-driven culture shifts, health-related information and services can be readily available anytime and any-where. Medical researchers will be better equipped to synthesize data into meaningful e-Discoveries while collaborating across cultural and organizational lines, which will lead to beneficial treatments. ♦

Sources:

1. “Improving Efficiency through Telemedicine: The Alaska Experi-ence”, A. Stuart Ferguson, HIMSS 2007 Presentation.

2. California Telehealth Network (CTN), http://www.caltelehealth.org/

3. “Telemedicine may help individuals with type 2 diabetes improve their dient”, http://www.endocrineweb.com/news/type-2-diabetes/2929-telemedicine-may-help-individuals-type-2-diabetes-improve-their-diet

4. Connected Pediatric Critical Care, http://www.connected-health.org/programs/remote-consultations/center-for-connected-health-models-of-care/connected-pediatric-critical-care.aspx

5. “Advances in Technology Increase Telestroke’s Viability”, American Academy of Neurology, November 25, 2008, http://www.aan.com/news/?event=read&article_id=6811

6. Telemedicine and e-Health. May 2010, 16(4): 385-392. doi:10.1089/tmj.2010.9974.

7. “Today’s Health Information Exchanges”, Information Week Health-care, http://www.informationweek.com/news/healthcare/EMR/

8. “Cisco Launches Telemedicine Platform”, Information Week Health-care, http://www.informationweek.com/news/healthcare/patient/showArticle.jhtml?articleID=223101422

9. “Creating Telemedicine-Based Medical Networks for Rural and Fron-tier Areas”, Leonard R Graziplene, PhD, IBM Center for the Busi-ness of Government, http://www.businessofgovernment.org/report/creating-telemedicine-based-medical-networks-rural-and-frontier-areas

deliver health care can be reduced significantly. This, and/or other similar care models are exploited for other communities and not necessarily only rural. Economically challenged urban communities suffer similar constraints in term of access to affordable health care.

Advances in sensor technology, wireless networks, mobile monitoring devices, and telecommunications have all made it possible to address the increasingly dire shortage of health care professionals in rural ar-eas. There are approximately 60 million Americans living in rural or frontier areas, and the average age of physicians practicing in these areas is over 55 years. In fact, in over one-quarter of the counties in the United States, there are no practicing physicians10.

The recently passed American Recovery and Rein-vestment Act provides funding to support a telemed-icine infrastructure for rural areas. It also provides funding to support wellness initiatives, which are im-portant ways to reduce the demand for emergency medical treatment. This article offers a three-part ap-proach that can leverage these Recovery Act initia-tives to respond to the health care crisis in rural and frontier areas10.

This approach includes:

» Expanding the use of telemedicine

» Better managing care for chronic disease patients via the use of the medical home concept

» Investing in Ka band satellites to ensure afford-able, pervasive and dependable network connec-tivity for both telemedicine devices and a medical home network

In spite of the fact that the United States is spend-ing more on health care than any other country in the world, the nation ranks poorly on many health indictors when compared to those of other advanced countries. There are actions that need to be taken to correct these problems. Rural and frontier America are the areas facing the most growing disparities in the provision of health care. There is a big push, however, governmentally and health insurance indus-try wide, to reduce the cost of delivering health care while expanding the level of service.

As medical technologies and use cases emerge in conjunction

with computer networks, medical information systems and

decision-support services, ITers and clinicians in close harmony

will provide, support and extend health care delivery in ways that

bring the provider and patient together virtually.

Depending on the medical device, data is transmitted to the system by wired or wireless connections, such as Bluetooth. From there, data is transmitted to a Mayo Clinic health information system, and accessed by clinicians who watch an application dashboard for early signs of patients who could be developing a medical problem such as weight or blood pressure out of normal range. Using the videoconferencing capabilities, clinicians can observe and “cheerlead” with the patient and offer up intervention that pre-vents a condition from worsening to the point where the individual needs hospitalization. Considering the high costs of ER visit, this strategy bodes well for reducing medical insurance costs, and relieves some pressure and wait times in participating ERs.

In rural Louisiana, telemedicine is helping to diag-nose breast cancer in patients who might otherwise not get screened8. A mobile van equipped with digi-tal mammography allows women in rural locations to quickly have their mammograms performed and read by remote radiologists. Mobile digital mam-mography is one of the telemedicine services of-fered via the Louisiana Rural Health Information Ex-change, which was launched in 2007 to serve central northern Louisiana.

A highlight of the exchange is its support of tele-medicine services that help link rural patients with medical experts at LSU Medical Center in Shreve-port. Without those telemedicine services, patients often would need to wait three months or more for an in-person appointment with specialists like cardi-ologists and pulmonologists, not to mention a long road to the facility. Compounding the problem is the number of low-income patients who are with-out personal transportation and cannot afford the price of a cab or other transportation to get to the medical center.

A key service of the exchange is mobile digital mam-mography; women in rural Louisiana communities can get the screening, whether or not they have insur-ance coverage. Remote radiologists can often detect a possibly cancerous or suspicious spot immediately after the patient has her digitized mammogram. Con-sidering the impacts of early detection of improved morbidity and quality of life, the long-term costs to

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