Apple kicked the door open in terms of Patient Engagement and patient control of their own information with the Apple Health Records. What they did, by using emerging and new standards, they made it so that the patient has control of all their information that they get through the portals, which is independent or agnostic of the platform, it is being used in the care setting, so if you are being seen at dignity at ucsf and stanford and sutter and kaiser and you are enrolled in all their portals, as well as independent practitioners who may be using a variety of other systems, and you have their portal, and their systems are subscribed or have an a. P. I. Enabled, this gets pushed to Apple Health Records and on your phone, on your smart device in an encrypted manner and secure manner, the patient has control over their information. Im spending a lot of time on this, but the reason that this is important is his Large Tech Companies have engaged in the healthcare business or tried to get into the 48 many times over the last 25 years, in particular , with the bend on patient records. The reason they failed is because they say it is the patient record, we will put it in our system, on our servers. This is not on apple servers, this is the patient controlling their own information. I heard a great comment about navigating through kaisers site and going through questionnaire, having to answer your own data, but this does is not unlike if you have had Google Photos or any other app in which you can take the information that is on your device and actually have it interact with an application of your choice. If im tracking, you know, Blood Pressure or heart failure, diabetes or copd or any other myriad of chronic disease conditions, you can control that data, have it interact with an up in a secure and seamless, without special effort on part of the user, who is the patient, direct that through your care settings. I will get into later, just at the very end, some of the legislation that has come down the pipe with this. So the onc, which is the office of National Coordinator for health i. T. , which is part of hhs, ten years ago, in 2015, they set a tenure interoperability roadmap. The first phase was really just the start of exchanging data across domains, having these different systems exchange data, and then the ultimate goal is really improved efficiency, higherquality, lower cost, and improved outcomes, as well as enabling knowledge and Public Health. So there was a comment when i sent the draft out about what we call the Interoperable Health i. T. Ecosystem. It is a biologic term that is making its way into the healthcare space. That is really all the participants, and that is including patients, payers, pharmacies, labs, clinics, physicians, nurses, everybody who is involved in the whole environment of healthcare, and all the technology that comprises of it is what they call so you will hear health ecosystem, or health i. T. Ecosystem. And then, the end goal is nationwide interoperability that is patient centred, and that it is enabled from individual patient scaled up to how we manage and care and improve the health of our communities and populations, and really use that data to go from data to knowledge and knowledge to wisdom, insight insight and real , true predictors. So it is just a map of where we are in terms of nationwide Health Information exchange. In 2004, the onc was formed and set up a National Network, and that was really meant to give people access to the v. A. , and Social Security administration. Over time, is a Technology Got more advanced, and the user became more advance, through standard based exchange, which make it possible for information to really be portable across the continuum electronically, that has morphed into a National Network called the health exchange. At the time that the e. Health exchange was stood up and really what is happening with the majority of Healthcare Organizations across the country , they Exchange Information, care summaries, and other Clinical Data. Some other networks popped up. One is the common well alliance which is a gender participation alliance, which they created their own network to Exchange Information with each other. Then i will get into the care quality which is our network, but also a framework. The sequoia project became is a private Public Partnership that oversees and manages the National Network, it is really important the work that the sequoia project is doing because they are joint hip and hip with o. N. C. Just blowing through some of the data that we have, it really is our current capability from our hospitals, exchanging care summaries at about 80 now. Finding data is about 60 now. The ambulatory providers, sharing data outside of the organizations, is probably at 40 or 50 now. When we talk about the methods of health exchange, theres multiple methods, and i went through that, and this many more , those are the highlevel methods. The mooring more methods of Electronic Health exchange that you use, the more robust your activity in terms of determining how to best care for your patience and population. This is just some data about those who were using multiple methods across the continuum. A breakdown on the hospital side about the availability and use. We have a lot of distance to travel, even though the technology is there. As you see, it is not surprising in the larger urban and suburban areas. It is more widely used in critical acts active hospitals and rural hospitals. When we talk about the domains of the building, that is to find , send, receive, and integrate. The integration is really the end game, and you need to use all four domains. There has been some advancement, but not tremendous. And the ambulatory setting, conducting off for domains is not really improved that much over the last few years. In terms of sharing information outside, and the different settings, it has not advanced that much. When you look at those who are conducting all four domains of interoperability, it is still heartening to see that the response is often the way that they are using the information. If you look at the barriers to adoption, it really has to do with the five rights which are the right information at the right place, at the right time. The integration of this information into intuitive, native workflow, with a platform that the provider is using is key with the Successful Use and integration of this data. So just to point out, i believe at dignity, this is a passion of mine and one of my responsibilities as the system from a clinical and, across dignity health, which is now called Spirit HealthSpirit Health, but within our markets that were predominantly california and Southern Nevada and arizona, we have 87,000 users, and Community View is our main platform. We deployed the solution, and i will show you a screenshot of it , of an integrated view of all data sources for the patients that we see and data coming from external Exchange Partners or other system such as centre and kaiser and the v. A. We have 40,000 active users in the system across the system. We are connected to the community, 320 connections. We are doing about a million queries a month. So if a patient, each time a patient has a scheduled appointment and is being seen in any encounter, it triggers a . To go out to our Exchange Partners, and if there is a positive match, then it returns information to the patient. We have 9 million patients, what we call those are 9 million covered lives, basically. This is expanding rapidly. This is primarily through a National Network called the e. Health exchange. This is what it looks like. This screenshot, i know it is very busy, but it gives usm his of, so i am their provider and this is a patient that im looking at within context, and this is a page that i click on that actually brings in data like medications, encounters a bad, notes, diagnostic reports, labs, meds, pathology reports, all the data i would generally be looking for, including and probably most importantly, care summaries and care coordination. And this is a logo of all the different organizations that we are at the care with. When i look at these pages, these are all the organizations that i will be seeing. Some of them are nationwide. The v. A. Is a national connection. Im also proud to say locally that we just connected with the San Francisco department of Public Health, which i will get to in a little bit about why that kind of data is still important. Other efforts that we did the healthcare continuum is really in the community. So there are four walls of our care settings. The clinics, the centres, the diagnostic centres, the procedural centres, and you look at things like e. M. S. Or ambulances. How do we effectively connect what is happening in the field, and the prehospital or precare setting where patients are actually seen a lot, and is the primary mode of transit or entry into our system. So not surprisingly, the ambulances and what we call the e. M. S. Services, they brought their own version of electronic Health Records and they have a whole different electronic standard. We were able to map those standards together so that if a patient is seen by an ambulance in the field, they are able to connect and do the same kind of korey about patient formation and transmit that to the hospital or anywhere they want and pilots that we have done that came out of some initial successful pilots out of southern california, we did one in sacramento with the county fire to reduce unnecessary transfers for high utilizers who generally are not, because they are not connected to community providers, or they have had Behavioral Health needs, and this is where we actually put an advanced practice practitioner in the van or in the ambulance, and it they were to respond to a call and add it and get the patient coordinated right in the field without a transfer to the Emergency Department, saving millions of dollars per year. Another thing that we have activated that i am proud to say really helped with some of the devastating fires that we have had, is an emergency disaster response. Were trying to figure out, is there a way we can effectively connect First Responders in the setting of a Natural Disaster or a major epidemic outbreak, and this is just how it works that if you are a designated First Responder or have that kind of access in these settings, you will be able to access and identify patients and really get them the care they need. Other cases about interoperability, there is an Opioid Crisis in this country. All of the states have their own version of a registry of controlled substances that the patients are getting, and this is a way so right within the platform you are using, you can send out a . To the state registry and see they the history for the control substances for the controlled substances. Youre exchanging all this data, we see it as being underutilized , and we are really still not at the point where it is truly seamless, liquid data interchanged with the patient at the centre. So theres a couple ways how we get there. One is, how do we scale this up . Im going to use the cell phone analogy. I dont know if you remember back in the early days of cell phones, i had to pay a lot of money. And so these were separate networks that connected to each other. That is where we are now in terms of Health Information exchange. Theres a framework of networks now that basically connect those networks together so lets say from a pointtopoint connection youre on a network and you get six clinics, you get a few dozen visit few dozen physicians and a couple hundred patients, if you connect six networks, that exponentially increases and you get thousands of physicians and tens of thousands of patients. Getting that data and managing populations is really the only way you will be able to get to that kind of scale. As an example, if you look at just our e. Health, our internal , our local facilities, testing california, and then what we call federated sources, there was another question about federated sources. If we federated things and the information is not centrally controlled, so there is one method called a centralized hie where, for instance, your dignity, you are set or, you argue c. S. F. Data, all those with a central repository, and then it is requested that way, that is not the standard space model that exist today. Federated means that the information is that dignity, and they respond to incoming . That is managed or federated through those networks. Were on the e. Health exchange. If you look at the map here, if we just go to that framework of care quality, we start to really extend expands the connections in the community that we have. If you look at adding the common well alliance there, then we see just in california how much that expands our capabilities. I am going to actually skip over a lot of this stuff. I think im really passionate about this, but im taking a lot of time, but this is really about communitybased population care which is what were talking about with care coordination, which we have heard about. The other aspect of how we get true interoperability that is meaningful from a clinical standpoint that is really transforming care. We need to talk about what the meaningful data is. Yes, there are data points when the patient enters a healthcare setting that is important, and things like medications and problems and procedure history and allergies are really important, but the majority of care are out in the community. There are other data factors and variables that contribute to peoples Overall Health and how they respond to treatment in the tape and the type of interventions that should be thought about carefully when health plans and Healthcare Organizations are determining how best to improve the quality of their care, and that is the real continuum. A lot of you have heard about social determinants of health, and Health Disparities in social determinants of health are the most single impactful variables that determine how a patient is going to respond to their care. What if the patient doesnt have a home or they are transient or they dont have stability in their home . What if their local supermarket doesnt really look like this with lots of Healthy Options and fruits and vegetables . What if they are like an island and we have local Convenience Store that has a local dont a bunch of junk food . This is not isolated to underinsured or not insured or medical patients, medicaid patients, these are all of our patients in all of our communities. Do they have transportation . And even more importantly, what are their Community Resources to engage in care . Do they have support centres, what kind of resources do they have to engage in their care . What is the level of engagement it doesnt have to be hightech. Theres a very lowtech versions of engagement that patients can be empowered to use to really help with their care. And again, the type of information needs are changing over time and our traditional thinking is that information is expanding to the larger kinds of data sets and information to help with predictions. Going from a population down to an individual patient. So you see the importance of this kind of data in coordinating care and it being liquid and seamless, or the whole Person Care Initiative with some of the initial cases to identify atrisk homeless populations and engage and share that dynamic care coordination as they traverse the care settings. Here in San Francisco, the department of Public Health is engaged in Healthy Cities Initiative which really is to show that the largest proportion of Disease Burden is preventable and not wellmanaged. So had we partner with communities and get data out of our systems to devise and create truly meaningful strategies and interventions in the communities to give the resources across the continuum first at the hands of the patients, but connecting them with the care providers . By doing things like extracting this data and doing what we call geocoding which is spot mapping it throughout the communities, you can identify those who are at the most need for resources and give the resource information to the patients and then measure those outcomes. It goes to show that at scale, what were talking about with interoperability is not just sending my chair summary from one Emergency Department to my primary care provider. It extends and is much more important to that. So some really great initiatives that are coming out of legislation that will drive the meaningful advancement of the use of technologies, which is really meant for Foster Research , improve the Opioid Crisis, coordination of care, but theres a huge emphasis on interoperability and the use of he