The Impacts of the Affordable Care Act on Preparedness Resources and Programs: Workshop Summary (2014)

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7 Leveraging the Affordable Care Act and Information Technology to Innovate Highlights of Main Points Made by Individual Speakers1 • “Social-health” information exchange also includes community-based service organizations and can enable providers to focus on the whole person during a disaster response, addressing acute medical needs as well as housing, shelter, and other needs that impact health. • Many hospitals are looking for help with how to meet the Affordable Care Act community benefit requirement, and engaging the comm- unity in a health information exchange could be one approach. • Communication technologies such as telemedicine enable the sharing of information and expertise remotely, in real-time, extending workforce capacity and increasing quality of care. • Specialists can help manage patients at local hospitals through telemedicine. This could be an important asset when hospitals are surged and could benefit from additional workforce from unaffected areas. • Education is only a small part of getting people to embrace health information technology. A major component is making it very user friendly so that it is easy to learn and use. Technologies such as telehealth and health information exchanges (HIEs) are enabling the mobilization of health information across systems and geographies and are building opportunities to broaden the reach of specialist practitioners as well as allowing public health and clinical care to connect and care for the patient at a more holistic and 1 This list is the rapporteurs’ summary of the main points made by individual speakers and participants and does not reflect any consensus among workshop participants. 75 

76 IMPACTS OF THE ACA ON PREPAREDNESS fundamental level. Again, as more health systems shift toward technology use and integrated care with the Affordable Care Act (ACA) at the national level, more opportunities arise for innovations at the patient care level to build connections and expand partnerships that can come into play during disasters. This chapter explores some of these opportunities that are beginning to grow. PCCI: LAYERING TECHNOLOGIES FOR INFORMATION EXCHANGE, ANALYTICS, AND CONTINUITY OF CARE Connie Chan, project director at PCCI, a nonprofit organization specializing in the development of real-time predictive and surveillance analytics for health care, described three parallel tracks of technology that PCCI is developing to make health care “safer, simpler, and less stressful.” In the context of the ACA, its program fits within the “triple aim” of health care, striving for higher quality care, lower cost, and better population health. In addition, PCCI’s model can add the unspoken fourth aim of making the country more resilient in disasters by connecting social and clinical services. The first technology is the Dallas Information Exchange Portal (IEP), which is the underlying infrastructure for several other PCCI technologies. Chan noted that there are approximately 10 large health systems and 134 hospitals in Dallas. About 23 percent of the Dallas population lives below the federal poverty line. About 20,000 individuals were relocated to Dallas/Fort Worth after Hurricane Katrina, and many of them remain there today. Social Health The Dallas IEP is a “social-health” information exchange. The concept is very similar to an HIE, Chan explained, but reaches a broader provider community. The vision is to include more than 400 community- based service organizations (e.g., those that provide shelter, housing assistance, food and nutrition assistance, transportation assistance, and financial assistance), as well as health care organizations via the regional HIE, the mental health and behavioral health community, and the Dallas County Detention Facility. In the context of disaster preparedness, responders could also be included within the Dallas IEP. 

LEVERAGING THE ACA AND INFORMATION TECHNOLOGY 77 The initiative was developed out of the Parkland Health and Hospital System, which is a safety net hospital (more than 30 percent of the care provided is for patients without insurance). It became very apparent, Chan said, that the patients regularly going to Parkland were also regular users of the Salvation Army, Catholic Charities, Visiting Nurse Association, and other community organizations and that there was a serious lack of coordination of care for these patients moving across these different sectors. A flexible, standards-based, social-health information exchange would enable care providers to share information about medications, appointments, housing and transportation needs, and other needs that are critical for patients to achieve positive health outcomes. This will not only help in everyday care and reduce readmission rates, but also can help focus on the “whole person” during recovery. Identifying High-Risk Patients The second technology is predictive analytics software called Pieces™ that accesses the electronic health record (EHR) system and uses clinical and social risk factors to identify patients that are at high risk for an adverse event (e.g., congestive heart failure). Similar to Dean’s and Hupert’s earlier comments on predictive modeling to alert health departments to adverse events, this system can then alert the care providers, allowing them to mobilize interventions to prevent the adverse event from happening. Pieces is currently in place at Parkland and has been used in clinical and operational decisions for more than 100,000 patients across Dallas/Fort Worth. Chan said there has been a relative reduction in readmission of 30 percent across all patients and 20 percent relative reduction among Medicare patients. Getting Patients Involved The third technology PCCI is developing is the Intelligent Continuity of Care Document (iCCD), a multiuser interface for the Dallas IEP. Through technology such as natural language processing, artificial intel- ligence, and machine learning, the iCCD condenses patient information from multiple sources to provide a summary of the information most relevant to the point of care. The iCCD is also being developed for mobile interfaces so that providers and patients can interact with the information on tablets or smartphones, enabling services to be delivered directly in the community. These are great examples of coordinated, 

78 IMPACTS OF THE ACA ON PREPAREDNESS streamlined care with an emphasis on technology that American Reinvestment and Recovery Act (ARRA) and the ACA are encouraging through Meaningful Use Requirements and the Patient Centered Medical Home model (POCP, 2012). Chan noted that PCCI is cognizant of the privacy and security concerns associated with cross-sector information exchange, and a detailed assessment of federal and state regulations has concluded that this is a feasible and permissible approach to information exchange with the right provisions and agreements. Applications to Disaster Preparedness These three layers of technologies are being developed for daily clinical and social workflows, but there are clearly opportunities for application to disaster preparedness. As an example, Chan described how the Dallas IEP could be of value in a tornado throughout all phases (see Box 7-1). BOX 7-1 Potential Applications of the Dallas Information Exchange Portal in a Tornado Disaster Before • Build collaborative relationships to strengthen community resilience. • Build redundancy into technology systems. • Collect baseline data on community health. • Require clinical and social providers to document needs in case of disaster. • Provide data to inform disaster resource planning. During • Identify individuals or populations at highest risk to target and deliver scarce resources. • Assist on-the-ground workforce and resource management, coord- ination, and communication. • Use real-time surveillance of emergent health issues and community trends. • Mitigate impact if there is any loss of public health infrastructure. • Employ mobile tools to enable response efforts in the field. • Document needs with first responders or response coordinators. • Marshall the primary care network to support hospitals and the Red Cross. • Prevent exacerbation of disaster effects. 

LEVERAGING THE ACA AND INFORMATION TECHNOLOGY 79 After • Communicate back to primary care providers after disaster. • Help relocated individuals to thrive in new settings. • Enhance community recovery efforts, particularly for vulnerable populations. • Provide data to improve disaster response planning for future disaster events. • Use long-term surveillance of populations affected by disasters. SOURCE: Chan presentation, November 19, 2013. Chan highlighted three areas of focus of the Dallas IEP that support the ACA: chronic disease management, population health surveillance and health disparities research, and optimizing transitions of care. The Dallas IEP also supports the ACA relative to public health preparedness in the areas of community resilience, surveillance, and managing scarce resources in the community. In developing information exchange portals and predictive analytics and technologies, Chan said that technologies being developed for non- catastrophic events could be very useful in disaster situations. It is important to harness the strength of smaller players, the community- based organizations that are not traditionally part of the health sector, to build a layer of redundancy during and after disasters. By having a social-health information exchange, providers will be able to focus on the whole person during the disaster response, acute medical needs as well as housing, shelter, and other needs. This would complement the Patient Centered Medical Home model that the ACA encourages, and would help to focus on value, decrease readmission rates, and increase patient satisfaction. Finally, predictive analytics, artificial intelligence, and natural language processing technologies could help to better direct resources intelligently during disaster situations. During the discussion, various participants expanded on the idea of community-based organizations as part of the HIE, in particular, what they would need to participate (e.g., finances and technology). Chan said that PCCI has designed integration solutions and technology options for high-, medium-, and low-tech organizations, noting that most of the organizations fall into the low- to medium-tech level. In terms of finances, sustainability is a challenge for HIEs in general. The current PCCI approach is grant funded, and the pilot program is completely cost neutral to community organizations. The intent is to be able to measure 

80 IMPACTS OF THE ACA ON PREPAREDNESS and demonstrate the economic impact or potential cost-savings, Chan explained, and then potentially move into a shared-savings model2 or a gain-sharing model in the community. PCCI is also exploring alternate means of funding information exchange, such as licensing, because the technology for social HIEs can be applied to other applications. Another opportunity for funding such efforts mentioned earlier by Larsen could be the State Innovation Models Initiative through the Centers for Medicare & Medicaid Services3 that seeks to pilot new and innovative mixtures of payment and service delivery models. Larsen pointed out that many hospitals are looking for help with how to meet the ACA community benefit requirement, and perhaps engaging the community in an HIE could be one approach. INTEGRATING TELEMEDICINE INTO DISASTER PLANS Regionalization of care improves efficiency and quality but can create disparities in access for those who do not live near regional centers. Telemedicine and similar conferencing technologies allow clinical expertise to be everywhere, said James Marcin, director of the pediatric telemedicine program at the University of California (UC), Davis. Telemedicine has a myriad of clinical applications and has been used in various scenarios already for several years, especially in rural areas (IOM, 2011). The most common uses are for outpatient specialty consultations, inpatient intensive care specialty consultations, operative and procedural consultations, interpretation of images, and remote patient monitoring. Although the concept of telemedicine is not entirely new, provisions in the ACA, many of which are tied to the Center for Medicare & Medicaid Innovation, contain several advances for telemedicine. The legislation also encourages new opportunities in home health services and remote monitoring (ATA, 2010). Marcin gave an example of some of these potential opportunities through his experience at UC Davis. 2 When health care facilities spend less on care, they can be rewarded with a portion of the savings from the payer, so both entities share in the savings. This is often promoted through participation in accountable care organizations. For more information see http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram /index.html?redirect= (accessed May 2, 2014). 3 See http://innovation.cms.gov/initiatives/state-innovations (accessed May 2, 2014). 

LEVERAGING THE ACA AND INFORMATION TECHNOLOGY 81 The UC Davis telemedicine network interacts with more than 100 sites across the state every year, Marcin noted, resulting in more than 40,000 live interactive adult consultations and 6,000 pediatric consultations since its inception in 1996. Marcin shared the case of a comatose child who, because of his immediate needs, was transported to a local level II trauma center instead of the pediatric trauma center 150 miles away. Through a videoconference with the adult critical care physician, Marcin was able to help manage the care of the child in the adult intensive care unit. This remote patient management avoided the need to transfer the child and displace the family. Surveys of parents have shown that they are overwhelmingly more satisfied with the care they receive via telemedicine versus the standard of care, which is telephone consultation (Dharmar et al., 2013a). Similarly, physicians rated the quality of care higher when the consultation was via telemedicine versus telephone. Medication errors were also reduced when telemedicine was used (Dharmar et al., 2013b). Telemedicine also offers significant cost savings. There is a 31 percent lower transfer rate among ill children receiving telemedicine compared to telephone consults. Assuming 10 seriously ill children per year, receiving care via telemedicine results in a cost savings of $38,366 per year, Marcin said. Another way to look at it, he said, is that for every dollar that UC Davis has invested in the telemedicine program, society (or typically the payer) has saved $12. Telemedicine is used every day in the UC Davis emergency depart- ment, and it has now been integrated into the existing disaster preparedness framework at every step of the process (see Figure 7-1). Marcin said there are videoconferencing units in the ambulances and satellite videoconferencing units that fit into a suitcase and can be dropped at a scene. In the pre-hospital setting, telemedicine can lead to improved triage decisions, improved transport decisions, access to rural sites, and decreased exposure of providers to toxins or infectious agents. From a workforce perspective, telemedicine offers the potential to increase capacity by extending expertise beyond regional centers. Specialists can help manage patients at local hospitals. This could be an important asset when hospitals are surged and could benefit from additional workforce from unaffected areas. 

82 IMPACTS OF F THE ACA ON N PREPAREDNE ESS FIGUR RE 7-1 Integraation of telemed dicine in disastter preparedness. SOURC CE: Marcin presentation, November 19, 20013. Deespite the success of telemedicinee, there arre barriers to implemmentation. Medicare M has very restrictiive reimburseement policiees, and on nly about hallf of states reimburse forr telemedicinee for Medicaaid populaations, Marciin explained. There are aalso issues w with cross-staate licensu ure because thet consulting g specialist ccould be in a different staate and miight not be liccensed in the state where tthe patient is. A related isssue is hosppital credentiialing and priivileging of tthe specialistss at the remoote hospitaals before they are able to act as a consuultant via videeoconferencinng. There is also conccern about in ncreased liabbility. While some of theese barrierrs will remaiin at the locaal level, the ACA legislaation’s relevaant teleheaalth provisioons, and thee Health Innformation T Technology ffor Econoomic and Clin nical Health (HITECH) ( A Act through thhe ARRA haave an oppportunity to asssist in movin ng this forwarrd and augmeenting everydday care annd disaster response. INCORP PORATING G HEALTH IINFORMATTION HNOLOGY INTO EVER TECH RYDAY USE E Many particip pants discusssed the impportance of educating and engagiing health proofessionals in the use of heealth informattion technology (IT). Barnes B said thhat with regaard to the upttake of EHRss, about half of providders are adop pting this techhnology simpply to receivve the incentiive funds, and the oth her half understand what the technoloogy can enable. Larsen t understandd why they aree implementing n said that gettting people to EHRs is very impo ortant. Educattion is only a small part off getting peopple to embbrace health IT. I A major component c is making it verry user frienddly so thaat it is easy y to learn an nd use. Thee challenge ffor technology develoopers is to try y and minimizze the amountt of educationn needed to uuse the syystem. Durin ng his remaarks, Gamachhe added thhat conducting exercisses like theyy do in the military m woul d not be susstainable in tthe 

LEVERAGING THE ACA AND INFORMATION TECHNOLOGY 83 community. What is needed for this effort to succeed are systems that are used every day that can continue to be used in a disaster. What is done with the information may change in a disaster, he said, but how the information is reported or retrieved should stay as similar as possible to routine use. Terry Adirim, special consultant on maternal and child health at the Health Resources and Services Administration (HRSA), noted that Meaningful Use,4 the financial incentives created to support optimal use of EHRs, requires that there be functionality in EHRs for public health. However, it was suggested that only about 10 percent of physicians and 15 percent of hospitals are using their EHRs for public health purposes. As Dawkins noted, the ACA brings a lot of great opportunities to share data. If this is the case, then there is opportunity for public health to capitalize on the ACA and include themselves in the conversations to not only meet their own objectives of data sharing and providing needed services to the population in disasters, but also to help hospitals meet the community benefit requirement spelled out in the legislation regarding 501(c)(3) status (referenced on p. 15). As more health care facilities switch to electronic data records, more information will be available to inform models and support decision making, whether at the local, state, or hospital catchment level. 4 The Medicare and Medicaid EHR Incentive Programs provide financial incentives for the “meaningful use” of certified EHR technology to improve patient care. See http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ Meaningful_Use.html (accessed June 9, 2014).