Utah Digital Health Commission Meeting Minutes
Thursday November 6, 2008
10:00 a.m. -12:00 p.m.
Utah Department of Health
288 North 1460 West Salt Lake City, Utah
Members Present: Joseph Cramer (Chair), Brad LeBaron (Vice Chair), Scott Barlow, Rulon Barlow, Chet Loftis, Jan Root, Nancy Staggers and Mark Probst
Members Absent: Deb LaMarche, Mark Munger, Dennis Moser and Natalie Gochnour
Staff Members: Wu Xu and Humaira Shah (UDOH, Office of Public Health Informatics)
Guests: Blaine Goff (UDOH), Jeffrey Duncan (UDOH), William Stockdale (UDOH), Jeff Hawley (Utah Insurance Department),Christie North (HealthInsight), Henry W. Gardner (Vice President, Zion’s Bank) and Mark Fotheringham (UMA Vice President of Communication), Via Telephone: Stephen Clyde (Utah State University)
Introduction and Update:
Joe Cramer welcomed all the commission members. He then introduced Dr. Stephen Clyde and made a comment on how he was really excited on what they were doing in Logan.
Cache Valley e-Health Community Initiative:
Stephen Clyde updated the Commission that creating a functioning and useful digital health community requires a lot of collaboration. It involves a broad range of stakeholders and organization of various technologies. The initiative’s strategic plan had four parallel tracks: planning, concept analysis and feasibility studies, funding, and community building. They have made progress in the first three areas and have chosen to delay activities in community building until they are further along with the first three. They have restructured the strategic plan by breaking up concept analysis into four areas: Technology review, concept analysis, vision building, feasibility study and prototype. They are getting ready to begin marketing surveys so they can test the use of systems and their growth. Most of the current systems are web based. They have been working on some funding activities, specifically from AHRQ, and it deals with demonstrating the potential benefit of integrated systems. They were looking for the right collection of collaborators, particularly in the Utah State University, needing people from sociology and economics to join the team.
Mr. Cramer commented that he is overwhelmed with the amount of work that Steve had put into this. He asked how reproducible this is in other communities and is it too early to begin to identify not only people locally but also others around the state to see if there are other communities that begin to parallel or shadow some of the things that Steve is doing. Mr. Cramer thought what Steve was doing is important in the personal health record systems, as well as bringing in other various specializations such as the sociologist and psychologist.
Mr. Clyde answered that this can be reproduced in other communities. They want to approach this by taking it by little pieces so each little project has a reproducible result. Mr. Cramer asked whether they had someone from the media who could be a part of this conversation and would be invaluable as a communicator of the events to the community. Mr. Clyde agreed and would first start with some of the public relations people at the university. Christie North invited a representative from the Cache Valley Initiative to come to one of their Value-Exchange steering committee meetings to talk about this project, which would be a good opportunity to educate a broader group. Mr. Clyde accepted the invitation.
Mr. Barlow needed a clarification on how Mr. Clyde used the term “personal health record (PHR) system.” PHR or a PHR system, according to Mr. Barlow, could have delivery components tied as a part of it, or where PHR only has the documentation or tracking mechanisms. Mr. Clyde explained that at this point they have seen a range of these things and most of them appear to be document-tracking tools at the moment. He envisioned them becoming more personal health care management systems where they can truly be used for patients to interact with their physicians.
Nancy Staggers shared some feedback on developing PHR. She said as you develop this concept, put a twist on it that’s different than the current documentation and tracking systems then you would have more of an advantage. Mr. Clyde thanked her for the feedback. Mr. Cramer explained that it’s a deciding rule of the commission to support these sorts of initiatives, as resources that are around this table. He said he’s very excited for both what we are doing and the resources and opportunity that this commission displays. Mr. Clyde appreciated Mr. Cramer’s invitation to return in January.
Public Comments on the New Rule for Standards:
Wu Xu reported that the new rule for adopting standards for clinical information exchange was published in October 15. UDOH did not receive any negative comments on the rule.
Mr. Cramer made a motion to approve the September meeting minutes and recognized comments. Mr. LeBaron made a comment on the section of public comments on the DEA proposal, explaining that he doesn’t sense any of the feeling of the commission members being expressed, just mainly the recording of the actual facts. A general concern he had is that as a commission we should be trying to establish some sense of how we feel about things. The minutes need to capture not just what was talked about, but more importantly the sense or feel of the commission.
Mr. Cramer moved to approve the minutes with the recommendations as a stipulation. Mr. Barlow seconded that motion. The motion was passed.
Medicaid e-Health Efforts:
Blaine Goff introduced himself as one of the assistant directors in the Utah Medicaid program. He reported on some E-Health efforts and explained that in order for a service to be delivered or paid for under Medicaid, it has to be listed in the State Medicaid Plan. Tele-Health or Tele-Medicine is listed in the state plan in three areas: Diabetes monitoring under health services, specifically in the diabetes education area; special need children, and mental health. The use is limiting and has to be in a rural area for the service to be acceptable for payment.
Mr. Cramer asked whether the law supersede the department rule. Mr. Goff answered that the law doesn’t always supersede the rule, but the State Plan is what Medicaid is able to do that. The State Plan is actually our contract with the federal government and they have to approve the state plan. Mr. Cramer asked why Tele-Health is a separate item vs. just a different way of providing the same care, perhaps at more convenience and accreditation for the practitioner? Mr. Goff said there is some question about it being equivalent to the same care. He talked to the program people regarding special need for children for example, and it’s available very sparingly because the physicians want face-to-face consultation with these children.
Mr. LeBaron explained the way it is dealt within radiology. In most of the remote areas there are contracts with providers who read the results after hours and on weekends and the contract for payment for them to do that is not with the third party payer, it’s with the hospital and the provider, so we’re going to bill Medicaid as our institution, but the service for this interpretation is done by the doctor in Provo. Mr. LeBaron wondered if more of the actual practice of medicine through Tele-Health resources can be done in that way where a physician is at the rural location and is hands on, seeing and describing medical terms to another physician who’s in another place. Mr. Cramer suggested that they could illuminate some of the concerns and opportunities that are not necessarily standard but will fit within reasonable interpretation of the law.
Mark Probst asked if it’s true that Tele-Health is a threat to rural facilities and one could be doing children based business out of Primary Children’s where rural facilities don’t have all the pediatric specialists. Mr. LeBaron said it’s a threat to a degree, but if used mainly for an extender of capability, then it’s really a benefit. There’s a credibility thing as well.
Mr. Loftis mentioned that in radiology they are potentially going to be able to bill. Mr. LeBaron explained that when billing globally for radiology exams, the hospital sends their bill on behalf of the facility and the radiology, whoever that radiologist may be. That makes it easier if a contracted physician says I want to do my own billing. Mr. Loftis asked if there is anything unique about radiology in terms of global billing, or can it be done in other areas as well? Mr. LeBaron answered that they do it in several areas and that he isn’t sure if there is anything unique about it and that would be the test case for a provider in a rural area. Mr. Loftis added that most physicians billing requires a face-to-face interaction but radiologists don’t have that.
Mr. Cramer pointed out that to make a physician’s payment is very expensive, so if you had nurse practitioners who would consult with physicians, then that would become the package. He asked if that would work. Mr. LeBaron answered that without the physician’s supervision the nurse practioners can bill on his or her own.
Mr. Goff continued to explain other e-health activities with Medicaid. They are a funding source for the project with HealthInsight to get electronic medical records set up in clinics. They got money from the legislature and matched it through Medicaid. Mr. Cramer recognized Mark Fotheringham from the Utah Medical Association, and Christie North from the Utah Value Exchange, who worked to get physicians to get EMR. Mr. Cramer then asked what the next step was and about other types of electronic communication, and also if there were evaluations of any change in practice patterns or anything else after using the EMR? Mr. Goff had to refer the questions to Christie North. Christie North said that it was in the best interest of development of EMR’s to adopt and to make sure utilization is maximized. She pointed out that HeathInsight does make every effort to get them in and help clinicians figure out the best way to use them. Mr. Cramer suggested that Medicaid could electronically communicate with the doctors as opposed to by mail.
Mr. Goff also explained the Medicaid Transformation Grant’s project. One purpose of the project is to improve quality and safety of medication use.
HIT Transformation: One of the Three Value Strategies for Utah Chartered Value Exchange (CVE):
Christie North, the director of the Utah’s Chartered Value Exchange (CVE), explained that there are four cornerstones to the CVE. The first two are transparency of quality and cost information, and merged together it’s called transparency of value. The third is aligning incentives, primarily pay for performance. Aligned incentives in the CVE vernacular also refer to all stakeholders including consumers, which is a key piece that needs to change. Consumers right now have an incentive to consume a lot of health care and providers have incentives to do a lot of things. Part of what’s being looked at are medical homes. Christie then talked about the Prometheus Program, which is a payment reform structure; it would like to use Utah as a pilot state. She then discussed the last cornerstone being about health information technology. HealthInsight supports adopting EMR’s and help providers use EMR in the best possible way. She asked for feedback from the commission about how they might take a look at other areas to help in the transformation. She thought the partnership with the Cache Valley Initiative would be very helpful and she would like to pursue that.
The CVE has been asked to be the host sponsor for the fifth annual health science research conference and the CVE agreed. Wu Xu asked if the commissioners could have a panel so people know what the commissioners are doing and Christie North support the idea.
Christie then talked more about Prometheus and said it’s a different way of looking at payment for healthcare. Mr. Cramer then thanked Christie. Christie asked for any suggestions on how the Chartered Value Exchange can blend better with digital health benefits on source of those issues.
Comments on the 1st Legislative Report on Clinical Health Informatics Exchange (cHIE):
Mr. LeBaron complimented Wu Xu, her staff, Dr. Sundwall, Barry Nangle, and others on what he thought was an excellent report. He reviewed the report in line with the recommendations from the first annual report done by the State Alliance on E-Health. He said that David Sundwall is on the Alliance. In the executive summary, the Alliance’s report made six suggestions for states to implement to make things effective. Number one is providing leadership and support for E-Health efforts in each state. He explained that the commission is a good indication of Utah’s commitments to the progress of E-Health initiatives in our states, addressing privacy and security, which is always in the forefront of UHIN and cHIE. The second point is promoting the use of standard based interoperability technology, and that’s what we are talking about when we talk about cHIE. The next is streamlining the license process to enable cross-state E-Health. The next is engaging customers to use Health Information Technology (HIT) in managing their health care. He said that the State Alliance did an excellent job in the report.
House Bill 47 and 133 empowered and gave resources to this function and the process of clinical health information exchange. He mentioned that he loves how the cHIE is set up open; providers open whether you participate, and patient’s permission is needed. He also said that the architecture being established sounds exactly where it needs to be. There are two types of users: one the data supplier, another the data user. Mr. LeBaron said he likes the implementation plan; it is a lot of getting people involved and people using it. He also said that marketing it and getting some implementation are vital. The cHIE has estimated the cost at approximately $3 million annually to operate. Each stakeholder will determine the pricing mechanism that contributes that amount. The project needs to be as self-sustaining as possible. He also thought that it would be helpful to break it down and say what would be in it for payer, what would they pay, what would be in it for the clinics or hospitals, what will each of them pay for. Make it clear, price accordingly, so hopefully at the end of that there’s somewhere close to 3 million dollars.
Mr. Cramer mentioned that this has need for ratification by the commission, and everyone’s input is critical and he asked for thought or comments that specifically stated something about the commission. Mark Probst asked who is going to use this report and for what? Wu Xu answered that it is required by legislature and we have submitted it to the Health and Human Services Interim committee and also the appropriation committee. The legislature uses this report to monitor the funding they put in cHIE. Mr. LeBaron asked how much money was put in? Ms Xu answered that the State put in $500,000 and Medicaid matched $500,000.
Mr. Probst asked if they were looking for any in accounting, and what that money was being used for? Ms. Xu said that needs to be reported through the contract process. UDOH currently has a contact with UHIN on this funding. Jan Root said in terms of the funding for cHIE, the major funding for 2009 is $1 million from the state, $1 million from the AHRQ federal contract, and the committee has agreed to increase the UHIN membership prices a little bit in this year and that will bring in about $500,000. Pricing is based on value, the value to, for example the three stakeholder groups. For example, value to the payers is looking at them being able to access information they now have to ask providers for, they can have appropriate access to the authorized information.
Mr. Cramer stated a personal note thanking Mr. Probst and his organization for sharing health information. He mentioned that two days ago he treated a 21-year-old lady who gave birth to a baby. She’s a former drug addict and has Hepatitis C and there is no treatment currently. Dr. Cramer got on to the Health Tube program, went to their resources, looked up Hepatitis C information, and became at that moment the most current knowledgeable individual about Hepatitis C and nursing for this patient. He said it was exhilarating. It allowed her to say should she or should she not nurse, what are the treatment standards for both American pediatrics and American College of Obstetrician and Gynecologist. It was profound in his mind that even though it was a simple question, it did make a difference in this child’s life.
Ms. Xu asked how to implement Mr. Cramer’s suggestion that the commission should be included in this report. Mr. LeBaron said after reading this his assumption was that it was being written to fill the need that cHIE has to fill relative to reporting. Our need was to be informed to be a critical reviewer of the document but there’s not a legislative mandate that we as a commission do anything. Mr. Cramer responded by saying that they do play a role in the standard process. Also they talked with Mr. Clyde about what they’re doing to try to connect on the ground level up to the ceiling, which is where UHIN and CHIE is. Mr. Henry Gardner commented that there are apparent economic objections that the commission has. He said the best place to turn to when you are looking for results is Medicaid. There’s such a huge amount of information coming through Medicaid and they have the ability to control. They could be able to see if too few doctors are seeing people, or giving too many prescriptions and things. Wouldn’t Medicaid be a great place to start and save money? If you can save the state money it’s obvious they are going to be on board and happy to help.
Mr. Cramer then welcomed a motion of acceptance of the report for the legislature, with the additions of the commission as a standards accepting body. He asked if they had a motion on this item on the body. Mr. Loftis moved the motion and Jan Root seconded it. Mr. Cramer stated that everyone is in favor of the motion.
Utah Electronic Death Entry Network: Outreach to Physicians and Connect to cHIE and the Intermountain Healthcare’s Clinical Information System:
Jeffrey Duncan, Director of the Vital Records, presented a newly funded grant to the commission. Utah, along with other 30-35 states, has developed an internet death certificate system EDEN (electronic death entry network), to replace the traditional paper certificates about 2 years ago. You can log in from home and register on weekends and print out a transit permit. Right now 60% of all deaths in Utah are electronic. Funeral directors in Utah all use EDEN right now, but it’s not that easy for doctors because the nature of their work is different from funeral directors.
The traditional work flow was typically started by a funeral director who would take possession of the dead body and filled out demographic information and he or she would drive this paper to the physicians’ office. After that the paper would go to the local health department where they would check to see if everything was done correctly and then register that record. Funeral directors spend a lot of time driving the piece of paper out.
The new grant will enable the whole thing to be done electronically. They don’t have to go to the local health department to get those papers. The grant proposes to make death registration a part of the electronic medical record in Intermountain Healthcare; and to develop a web interface through UHINet to provide a single login for physicians to access the UHINet, then a link to EDEN.
Mr. Cramer asked if there could be access through health for those who are not employed? Mr. Duncan answered that Intermountain project would be sort of a prototype and we would develop maybe a standard the way this message would be transmitted. Mr. Cramer said that instead of having a standardized medical record necessarily, it would be through a portal concept.
Dr. Cramer expressed his appreciation to all who attended and the meeting was adjourned at noon.