AHRQ Innovations Exchange | Instant Access to Clinical Information From Other Providers Leads to Reports of Higher Quality and Lower Costs for Medicaid Beneficiaries

Instant Access to Clinical Information From Other Providers Leads to Reports of Higher Quality and Lower Costs for Medicaid Beneficiaries


Snapshot
Summary
The Arizona Medical Information Exchange (AMIE) enables clinicians to immediately access hospital discharge, laboratory test, and medication data on specific patients from other providers, thereby allowing them to make more fully informed clinical decisions, avoid test duplication, ensure safe medication prescribing, and provide continuity of care. Survey data and anecdotal feedback show that users of AMIE report that it has led to greater efficiency and safety and a reduction in costs associated with unnecessary procedures and laboratory tests.
begin doxml
Developing Organizations
Arizona Health Care Cost Containment System

The Arizona Medical Information Exchange was developed by the Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, located in Phoenix. end do
Date First Implemented
2008
The AMIE project began in 2007; the system went live in September 2008. begin pp
Patient Population
Vulnerable Populations > Impoverished; Medically or socially complex


What They Did
Problem Addressed
Inadequate or delayed communication about patient care and clinical information exchange among clinicians working in different care settings is associated with suboptimal quality, inefficient care provision, and resource waste. However, many providers, particularly those involved in caring for Medicaid patients, do not have access to technologies that facilitate information sharing.

A major cause of inappropriate care: A landmark 2003 study found that Americans receive appropriate care only about 55 percent of the time.1 The failure to provide appropriate care is often the result of clinicians not having full information when a decision needs to be made.2
Lack of technology to facilitate information exchange: A 2007 Commonwealth Fund survey of 214 health care opinion leaders revealed that 66 percent believe that accelerating the adoption of information technology would be an effective or very effective strategy for improving the quality and safety of health care.2 Experts believe that health information technology “can be instrumental in providing evidence of effectiveness—just-in-time—through decision support; avoiding duplication and waste . . . and achieving better coordination of care by transfer of appropriate information among providers.”3
Especially among Medicaid providers: In many states, Medicaid providers do not have a quick and easy way to share clinical information about patients and often rely on faxed information, which can be incomplete and/or result in delays in care.4
Description of the Innovative Activity
Arizona clinicians providing services to Medicaid patients use an electronic web-based health information exchange, called the Arizona Medical Information Exchange (AMIE), to instantly access patient health information from other participating facilities at the point of care. Using AMIE, clinicians can collect information about a patient prior to treatment to ensure fully informed, efficient, and safe clinical decisionmaking and to prevent duplicative care.

Key elements of the program include the following:

Provider login: A clinician who has been trained to use the system logs in with a name and password. The clinician searches for a particular patient by entering the patient’s name and other identifiers. Currently during the pilot project 100 clinicians at 70 sites (including hospitals, clinics, and private practices) are using AMIE, which includes 4.1 million records on 2.26 million unique patients.
Relationship validation: Only clinicians actively involved in the patient’s treatment may access the record. Clinicians sign a contract guaranteeing that they will only access information needed to treat a patient. Furthermore, an “attestation screen” presented after login requires the provider to record his/her relationship with and involvement in the treatment of the patient.
Immediate access to clinical data from numerous sources: AMIE accesses clinical (rather than claims or administrative) health care data from numerous sources, including hospitals, laboratories, and managed care pharmacy administrators. Information is not collected or stored; rather, AMIE connects providers to these sources via a Web-based browser and converts the data into a standardized format so that it can be easily indexed and shared. The provider checks the type(s) of information he/she would like to receive, and the information appears on the screen within one second. Three types of data can be accessed:
Hospital discharge summaries and related documents: Discharge summaries (the clinical notes written by a physician when an inpatient is discharged from the hospital) include information such as diagnosis, treatment provided, health status at discharge, and post-discharge expectations and instructions. Consultations, operative notes, cardiac studies, and other reports are also available.
Laboratory test results: All laboratory test results can be accessed through AMIE.
Medication history: The medication history includes all medications prescribed to the patient. Since February 2009, behavioral health medication histories have also been accessible through AMIE.
Individualized workflow: Use of AMIE will vary depending on an individual clinician’s preferences. For example, in a clinic or private practice, the clinician may access the information prior to, during, or after a visit, and may either review it on line or print it. In the emergency department, the secretary may search AMIE for information about a presenting patient and then print the information for the clinicians providing treatment. Sites that have their own electronic medical record (EMR) can use the information gathered via AMIE to inform automated alerts and clinical decision support tools.

References/Related Articles
More information about AMIE is available at http://www.azamie.gov/.
Contact the Innovator
Marc Leib, MD, JD
Chief Medical Officer
Office of the Director
Arizona Health Care Cost Containment System
801 E Jefferson Street
Phoenix, AZ 85034
Phone: 602-417-4466
Fax: 602-252-6536
E-mail: marc.leib@azahcccs.gov

Anita Murcko MD, FACP
Medical Director, Clinical Informatics & Provider Adoption
Arizona Health Care Cost Containment System (AHCCCS)
701 East Jefferson Street
Phoenix, AZ 85034
Phone: 602-417-6969
Fax: 602-417-6999
E-mail: anita.murcko@azahcccs.gov

Perry Yastrov
Project Director, EHR Systems and Services
Arizona Health Care Cost Containment System (AHCCCS)
701 East Jefferson Street
Phoenix, AZ 85034
Phone: 602-417-6970
Fax: 602-417-6999
E-mail: perry.yastrov@azahcccs.gov

Did It Work?
Results
A 3-month proof-of-concept study involving convenience sampling methods and questionnaires, focus groups, and personal interviews found that users of AMIE strongly believe it has led to greater efficiency and safety and a reduction in costs associated with unnecessary procedures and laboratory tests. (To read specific anecdotes that demonstrate the benefits of AMIE, see the Story section.)

Greater efficiency: Seventy-one percent of the 29 respondents believed that AMIE saved time. Nearly 70 percent said that they “agreed” or “strongly agreed” that AMIE made the medication reconciliation process more efficient.
Improved safety and quality: Ninety-eight percent of respondents agreed or strongly agreed that AMIE reduces the probability of medication errors. Anecdotal responses suggest significant benefits in terms of avoiding narcotic abuse and drug-drug and drug-food interactions. In addition, clinicians report being happier with the quality of care they can provide when using AMIE.
Lower costs: Seventy-one percent of respondents agreed or strongly agreed that obtaining clinical information using AMIE reduces costs and duplication of health care services. For example, some providers noted that the ability to access discharge summaries and information about procedures associated with prior cardiac evaluations (including computed tomography scans and magnetic resonance imaging) reduced unnecessary procedures (and hence saved money). Anecdotal feedback suggests significant savings through reductions in duplicative laboratory testing; estimates from project developers suggest that 4 percent of laboratory tests have historically been duplicative, and that the majority of these tests have been eliminated because of AMIE. According to project developers, the cost savings generated through reductions in duplicative testing alone would more than pay for the costs of adopting the system.
Evidence Rating (What is this?)
Suggestive: The evidence consists of post-implementation survey results regarding the efficiency, safety, and cost implications of using AMIE.

How They Did It
Context of the Innovation
The Arizona Health Care Cost Containment System, Arizona’s Medicaid agency, serves over a million Medicaid recipients in the state. Because the agency contracts patient care out to several managed care organizations (which in turn contract with many providers), and because behavioral health is a carve-out service administered separately, Medicaid recipients typically receive treatment at many different locations, including clinics, hospitals, and private physician offices. The impetus for the program came when Arizona Medicaid executives realized that there was no way for all of these different locations to share clinical information easily and quickly to ensure appropriate coordination of care, patient safety, and efficient resource use. With these goals in mind, they sought and won a Medicaid Transformation Grant in 2007 to fund the development of a health information exchange.
Planning and Development Process
Key elements of the planning and development process included the following:

Focus groups to identify needed data: The agency held focus groups with clinicians around the state to identify the types of clinical information that would be most useful in providing clinical care. The groups identified three categories of data—hospital discharge summaries, laboratory test results, and medication histories.
Clinicians advisors and surveys: A group of 40 clinicians served as an initial advisory group to the project. (These clinicians also served as the initial users/testers of AMIE.) The agency surveyed these clinicians to understand what features and information were important to them, and how they could use and interact with a health information exchange.
Provider selection: The 100 providers who participated in the pilot study were selected based on their willingness to commit the time involved to evaluate AMIE and provide feedback regarding its use and expansion.
User feedback: Electronic surveys of users were gathered weekly during the pilot project to inform project enhancements and expansion.
Data partner identification: The agency talked with executive leadership at each hospital, laboratory, and pharmacy benefit company to ask them to be data partners (i.e., to share information) as part of the new venture. Data partners engaged their clinical, legal, and public relations staff to ensure their understanding of the venture.
Data-sharing agreement: Data-sharing agreements were developed to permit and define the sharing of clinical data. The agency began with templates for agreements developed nationally by the Markle Foundation and then adapted these model agreements to the local context. Each data partner had a unique approach based on their specific data requirements.
Laboratory data accommodation: The Clinical Laboratory Improvement Amendments (CLIA) is a Federal law that regulates the operations of clinical labs. Among other things, CLIA limits to whom a clinical lab may release the results of tests. An "authorized person" is one permitted recipient of those results. CLIA defines an authorized person as an "individual authorized under State law to order tests or receive test results, or both." Therefore, sharing laboratory test results through AMIE required the agency to request a policy interpretation and approval from the Arizona Department of Health Services to allow clinicians who did not order the tests to access the data. This process led to the agency's initially excluding certain tests from AMIE, including those related to behavioral health and some genetic and reproductive health tests. Many of these tests have since been added to AMIE (in February 2009), while others require additional policy development.
Software development: The agency identified open-source software for the project, developed by the Massachusetts—Simplifying Healthcare Among Regional Entities (MA-SHARE) initiative and funded by the U.S. Department of Health and Human Services as part of its first Nationwide Health Information Network pilot project (a project to provide a secure, nationwide, interoperable health information infrastructure). The agency significantly enhanced this software using an internal software development team.
Training: The agency developed a 2-hour, in-person structured training program, led by agency staff, to introduce users to the technology, describe the available information, present the risks associated with breach, and cultivate an understanding of the limits of the information. The agency has since developed online video tutorials and training for new users.
Formal evaluation: A formal evaluation was performed as part of the three month proof of concept (October-December 2008). The evaluation and evaluation report were subcontracted to the University of Arizona; the report was filed with CMS as part of the Medicaid Transformation Grant project deliverables. AMIE has expanded with the addition of two pilots. One is the behavioral health pilot, in which pharmacy claims from Arizona's Regional Behavioral Health Authorities were included in AMIE and behavioral health care providers were added as users of AMIE; a formal evaluation report is due to be completed in August 2009. The second pilot is the inclusion of care providers who are part of the Children's Rehabilitative Services program in Arizona; this pilot was initiated in June 2009 and is gradually increasing the number of users.
Planned expansion: The developers of AMIE are planning to increase the number of clinician participants. The plan includes the creation of a non-profit organization governed by the facilities that are sharing data. Once the non-profit organization is formed (scheduled for Fall 2009), the plan for expansion will be created to specify the timing and number of clinicians to be added.
Resources Used and Skills Needed
Staffing: The program involves 13.5 full-time staff, half directly involved in technology development and half managing business operations, provider training, auditing, data partner and user relationships, and other administrative functions.
Costs: AMIE cost $11.7 million to develop and implement. Major cost categories include background analysis, program development (including contracting, legal, and policy issues, which collectively represent roughly half of total costs), and technology development.
begin fsxml
Funding Sources
Centers for Medicare and Medicaid Services

The project was funded through a Centers for Medicare & Medicaid Services Medicaid Transformation Grant. end fs
Tools and Other Resources
The Markle Foundaton has developed programs and tools related to communication and information technologies that are available at: www.markle.org.

Adoption Considerations
Getting Started with This InnovationAssemble a forward-thinking clinician group: Begin with a focus group of clinicians who are amenable to incorporating technology into their work and who recognize the potential quality and safety benefits of sharing clinical data.
Use clinical (rather than claims or administrative) data: Medicaid agencies have a significant amount of claims and administrative data available, but, according to program developers, these data often have little value to clinicians making real-time care decisions.
Set appropriate expectations: Not all data will be available for all patients immediately, particularly if historical information is not pre-loaded into the system. Prepare clinicians for the likelihood that the usefulness of the technology will grow over time as information and data elements are added.
Accommodate clinicians who lack EMRs: Realizing that many Arizona doctors did not have EMR systems, the Arizona Health Care Cost Containment System created a simple Web-based application that clinicians could use to search and locate information on their patients.
Do not limit data to Medicaid patients: Clinicians will find the system much more helpful if data are available for all patients, not just Medicaid enrollees. In Arizona, clinician focus groups noted that using AMIE for a broader patient base would simplify their work processes.
Sustaining This Innovation
Expect success to spur interest: As information is shared and benefits are realized, clinician enthusiasm and excitement about having information at their fingertips will ensure continued use and interest in expansion to additional sites. For example, different groups of specialists, such as optometry providers, are now interested in using AMIE.
Expect clinicians to want more data: Once clinicians become used to data sharing, they are likely to want access to additional types of clinical data. Consider how to expand the system over time (both technically and with revised data-sharing agreements) to make it even more useful for clinicians.

Comment on this innovation/Read other comments.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.
--------------
1 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 June;348(26):2635-45. [PubMed]
2 Shea KK, Shih A, Davis K. Health Care Opinion Leaders’ Views on the Quality and Safety of Health Care in the United States. The Commonwealth Fund. July 2007. Available at: http://www.commonwealthfund.org. Accessed July 1, 2009.
3 Schoenbaum SC. Vision of Health and Health Care Transformed. The Commonwealth Fund. July 2007. Available at: http://www.commonwealthfund.org. Accessed July 1, 2009.
4 Interview with Marc Leib, MD, JD, Anita Murcko, MD, FACP, and Perry Yastrov.


Innovation Profile Classification Patient Population: Vulnerable Populations > Impoverished; Medically or socially complex
Stage of Care: Primary care
Setting of Care: Ambulatory Setting > Physician office (individual), Physician office (group practice); Health plans and managed care organizations
Patient Care Process: Active Care Processes: Diagnosis and Treatment > Laboratory tests; Medication: ordering, transcription, administration, dispensing; Patient safety; After Care Processes > Transitions between settings; Care Management Processes > Coordination of care; Provider-provider communication
IOM Domains of Quality: Efficiency; Patient-centeredness; Safety
Organizational Processes: Medical record keeping; Process improvement; Staffing; Technology - HIT
Developer: Arizona Health Care Cost Containment System
Funding Sources: Centers for Medicare and Medicaid Services

Original publication: August 05, 2009.
Last updated: August 05, 2009.


abrir aquí para acceder al documento AHRQ INNOVATIONS completo:
AHRQ Innovations Exchange | Instant Access to Clinical Information From Other Providers Leads to Reports of Higher Quality and Lower Costs for Medicaid Beneficiaries