NHII Educational Seminar Series Hubert H. Humphrey Building August 5, 2004 John Walton

1. Mendocino SHARE NHII Educational Seminar Series Hubert H. Humphrey Building August 5, 2004 John Walton Project Director jwalton@ruralcommunityhealth.org Will Ross Chief Technology Officer wross@ruralcommunityhealth.org

2. Mendocino County, California Northwest coast of California Two hours north of San Francisco Population 87,000 3,500 square miles Low population density (24 / sq. mi.) Long distances between rural communities over mountain roads Economically depressed

3. ARCH Consortium ClinicTypeEncounters Anderson Valley Health Center RHC 7,000 Potter Valley Community Health Center FQHC Look Alike 14,000 Long Valley Health Center FQHC 20,000 Redwood Coast Medical Services FQHC 22,000 Mendocino Coast Clinics FQHC 25,000 Mendocino Community Health Clinics FQHC 135,000

4. Mendocino SHARE Project Securing Health Access and Records Exchange Modeled after Santa Barbara County Care Data Exchange Target Population 32,000 + Under 200% of poverty level 48% uninsured

5. SHARE Objectives • Health Records Exchange • Coordinated chronic disease case management • Patient enrollment

6. SHARE Collaborative All six ARCH Community Health Centers Consolidated Tribal Health Project, an IHS clinic All three local hospitals Ukiah Valley Medical Center Howard Memorial Hospital Mendocino Coast District Hospital Mendocino County Department of Public Health Mendocino County Department of Social Services

7. Governance and Participation • Administrative Committee • Program Committee • Technical Committee • Solutions Workgroup

8. SHARE Staff John Walton, Project Director 30 years clinical and administrative experience in community and hospital settings Will Ross, CTO 12 years in production agriculture and horticulture 15 years in technology project management Greg Wenneson, Technical Project Manager 25 years in software development and software project management at NASA Ames, Autodesk and other commercial settings

9. HCAP All Grantee Meeting Sustainability highly valued Doing well valued over rapidly making mistakes Met other communities with MPI projects Most MPIs were Enterprise, not Federated Most HCAP projects featured a large, well funded partner Open source software development is acceptable Other projects were interested in collaboration

10. Community Clinics Initiative CCI Grant from the Tides Foundation in 1999 to build an enterprise ASP model Practice Management System Phase One Anderson Valley Health Center (AVHC) Mendocino Coast Clinics (MCC) Mendocino Community Health Centers (MCHC) Phase Two Long Valley Health Center (LVHC) Potter Valley Community Health Center (PVCHC) Redwood Coast Medical Services (RCMS)

11. Enterprise ASP Plan Host enterprise servers at MCHC Data Center PMS on Windows NT Thin client via a Citrix Server 56K fractional T1 circuits Internet access to remote sites through Citrix desktop

12. Enterprise ASP Result Good News Phase One enterprise ASP live in 2000 Patient scheduling, registration and billing But there's trouble in paradise Bad News T1 lines intermittent Disagreements on ASP priorities ARCH Executive Director and CIO quit

13. New Decentralized Direction • Site level servers for each clinic • No ASP model • No enterprise WAN • Every site made whole, no dependence on another site

14. Lessons Learned Enterprise ASP failed for social not technical reasons • Remote sites uncomfortable with distant support • Governance model unable to avoid frustrating all participants • Collaboration across separate institutions is possible • Decentralised solutions are optimal

15. Santa Barbara County Care Data Exchange July 2003 SBCCDE Interim Report Loosely coupled p2p decentralised solution to PHI data sharing Functionally consistent with decentralised IT collaboration model in ARCH consortium

16. No HRE without EHR R = “Records” EHR is not just automation, it is workflow redesign EHR requires • Secure Internet Access • Redundant journaling file system • Not just email, but secure clinical messaging • Facile presentation, clinical interaction and decision support

17. Making EHR Possible Clinical Records Regular Email Simple File System Regular Internet Access Common Knowledge Paper records feel secure Email not secure Drives crash Access intermittent

18. Preconditions for MPI & HRE All four layers above a PMS must be present before content can be made available to an MPI & HRE * EHR Clinical Messaging Document Management Secure Internet Access Practice Management System * Potential for MPI, HRE and other NHII goals Mendocino SHARE will help deliver all three upper layers ARCH clinics have accomplished Secure Internet Access and PMS

19. Federated Master Patient Index Others Mendocino SBCCDE

20. Health Records Exchange

21. A Modest Technology Proposal August 2003 Innocent Proposal Scaled down clone of SBCCDE as a technology component in a $2 million HCAP grant application Is This Wise? ARCH has no idea that this proposal is way larger than HCAP funds Funded, October 2003

22. Primary Care Coalition Primary Care Coalition of Montgomery County • Third year HCAP grantee • Open Source PMS & EHR (“CHLCare”) • Needs a federated MPI Mendocino SHARE • First year HCAP grantee • Building Open Source federated MPI • Need a PMS & EHR solution

23. Seeking an MPI Vendor HCAP List of MPIs MPIs built by previous HCAP grantees 77 MPIs listed None free or open source Almost all are Enterprise, not Federated

24. Browsersoft RFP Published, February 2004 12 vendors submitted bids Extensive negotiations Viewed 5 full demos Browsersoft, April 2004 Overland Park, Kansas An IBM Development Partner

25. Browsersoft Builds SHARE Prototype Dave Forslund's OpenEMed used during first prototype phase Try loading PIDS files totaling over 50,000 patients from multiple domains, in some cases multiple files from a single domain Has trouble scaling past 10,000 records Due to HIPAA constraints our files have simulated data, false name pairs and false birthdates

26. SHARE Prototype Patient Lookup Three value limit during prototyping phase August 2004

27. SHARE Prototype Correlating Multiple Patient Listings “Show Grouped” August 2004

28. SHARE Prototype Viewing a Patient August 2004

29. SHARE Prototype Graphing a Result August 2004

30. Discovery Process We Learned • Vision > Funding • Not yet scalable • Productizing needed • Not ready for production • Needs architecture

31. System Level Architecture Meeting July 14 & 15, 2004 System Level Architecture Meeting (SLAM) • Two day brainstorming session • Review lessons learned in iterative Year One discovery process • Include Open Source experts from outside Mendocino SHARE • Imagine an optimal technology road map for Year Two • Meeting funded by the BPHC

32. SLAM #1 Participants Invitees David Forslund, LANL Jie Wang, Stanford University Guy Fisher, Primary Care Coalition of Montgomery County David Uhlman, Pennington Firm Tom Passim, Mitretek Systems ARCH Will Ross John Walton Greg Wenneson Browsersoft Don Grodecki Paul Misner

33. Mendocino SLAM #1 Outcomes Technology to Test in Next Iterations (August - November) Run PIDS index as OpenLDAP Run PIDS with POJO (can do WS when needed) Use MySQL to manage PIDS updates UCLA DataServer for population data de-identification Test lexicon transformer based on Mayo Clinic LQS Launch portal for virtual SLAM

34. Mendocino SLAM #1 Use Case Schematic Illustration Greg Wenneson

35. NHII July 2004 Mendocino SHARE network design matches proposed designs from major national studies

36. NHII

37. NHII Strategic Framework Before Conference Mendocino SHARE is an LHII Mendocino SHARE is developing free LHII software At Conference Mendocino SHARE is less than a full LHII Free LHII software projects • Mendocino SHARE • Massachusetts SHARE • Indiana Patient Care Network

38. NHII Strategic Framework Personalize Care Encourage use of Personal Health Records Enhance informed consumer choice Promote telehealth systems Improve Population Health Unify public health surveillance architectures Streamline health status monitoring Accelerate dissemination of evidence Inform Clinical Practice Incentivize EHR adoption Reduce risk of EHR investment Promote EHR diffusion Interconnect Clinicians Foster regional collaborations Develop a national health information network (Mendocino SHARE fits here) Coordinate federal health information systems

39. NHII in the Public Domain Why Open Source? Because there are enough collaborators to succeed

40. OpenHRE.org Portal Place development content on portal Launch in August 2004 OpenHRE.org available to host access to any free or open source (FOSS) software solutions contributing to LHII solutions OpenHRE.org will use the NHII technology framework to identify FOSS projects

42. Mendocino SHARE Challenges • Technology • Collaboration • Funding < Vision • EHR

43. Mendocino SHARE Vision • Federated solution • Feature complete LHII components • Using Open Standards • Free

44. Mendocino SHARE thank you! to contribute to our enterprise software project www.openhre.org questions or comments Will Ross, Chief Technology Officer Alliance for Rural Community Health wross@ruralcommunityhealth.org