A new report examines the complexity around the incomplete path towards statewide interoperability in California, looking at the challenges involved, the potential solutions available, the journeys of several other states towards statewide interoperability, and possible options in the near future.
The online introduction to the report, entitled “Expanding Payer and Provider Participation in Data Exchange: Options for California,” notes that “States have struggled for decades to establish infrastructure that allows for the efficient and secure sharing of health information, despite it being associated with improved quality and reduced duplicative services and associated costs. California has made some progress, including the growth of regional health information organizations (HIOs), but significant gaps remain. As a result, many residents still receive care in settings that do not have their complete health records, which can lead to care that is inefficient at best and dangerous at worst.”
The report was written for the California Health Care Foundation, which describes itself as “dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo,” by Manatt Health, a legal and consulting firm that is a part of Manatt, a multidisciplinary, integrated national professional services firm” based in Los Angeles.
This report outlines the following policy, contracting, and financing levers available to states working to advance interoperability — the ability of health care entities to seamlessly exchange patient data — including their pros and cons. It notes that “California’s path began over two decades ago when the Santa Barbara County Care Data Exchange, a regional health information organization (HIO), blazed a trail by establishing an HIE program among hospitals, physicians, and other providers in the county. Years later, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided billions of dollars in financial incentives to increase the adoption of electronic health records (EHRs) and HIE, with mixed success. The HITECH Act created three programs that would galvanize stakeholder collaboration and commitment to HIE across California. The State HIE Cooperative Agreement Program, MediCal EHR Incentive Program, and Regional Extension Center Program supported widespread adoption of EHRs in hospitals and ambulatory practices and clinics that are certified to electronically exchange information using national standards.”
Meanwhile, “Some of the artifacts from these programs remain and continue to support provider adoption, such as the availability of Medi-Cal administrative funding; others, such as the former “state-designated entity” for HIE, Cal eConnect, the Statewide HIT Coordinator position, and public-private California HIE Advisory Board have since shuttered or been discontinued, largely leaving HIE in the hands of the state’s health systems and regional HIOs. The lack of an HIT Coordinator with a broad charge to coordinate pubic and private health information technology and exchange efforts across a state as large and complex as California has resulted in a leadership vacuum.”
Still, “Today, the state’s nine largest regional HIOs support exchange in 35 of 58 counties in California, representing approximately 22 million of the state’s 40 million residents. Despite progress, significant holes in California’s HIE landscape remain. Many providers use capabilities native to their EHRs to exchange individual patient information with other health systems. These are important functions that can support episodic care coordination but are insufficient to manage population health, which requires analytics and the ability to aggregate data across providers, payers, and human services organizations. Many health systems have also established private HIE initiatives as a means of creating narrow networks that limit data sharing participation to a limited set of invited health systems and providers. A significant portion of the state is now covered by closed narrow-network or enterprise exchanges, and many independent and safety-net providers are not invited to participate. As a result, many residents receive care in settings that do not have their complete health records, potentially leading to adverse health events and poor outcomes.”
What’s more, even though the report notes that, while “Regional nonprofit HIOs have emerged as one potential solution to California’s interoperability challenges among safety-net, independent, and rural providers… California’s HIOs… California’s HIOs, however, have struggled to realize their aspirational role as universal conduits of HIE. Today, only half of California’s hospitals participate in HIOs, and 23 counties lack any significant HIO presence.” Why? “Many HIOs continue to grapple with sustainability and, without critical mass in the communities they serve, face an uphill battle developing a value proposition that can compete with private HIE initiatives.”
The report notes that what is needed is “the right mix of state public policy, financial support, and aligned market incentives,” to encourage providers to participate in HIEs/HIOs.
The report then goes on to provide a detailed set of recommendations, focusing on the following “levers” that could be used to advance interoperability across California. Those are:
Ø Public-private advisory councils
Ø Quality- and value-based collaboratives
Ø Financing for HIE infrastructure, service development, and onboarding
Ø Contracting
Ø Regulatory rulemaking and directives by state purchasers and regulators
Ø Executive orders
Ø Legislation
Ø Measurement and reporting
Briefly, public-private advisory councils could “guide HIE programs and recommend policies and standards,” while “Quality and value-based collaboratives have been used to design and develop programs that may require HIE and pay providers who have met specified milestones. Participation in such collaboratives,” the report notes, “may be voluntary or required under a state’s contract with a Medicaid managed care plan or through a plan’s contracts with its providers.”
Meanwhile, with regard to the financing for HIE infrastructure, service development, and onboarding, “the report notes that “Efforts to advance interoperability around the country have largely failed when not coupled with funding, meaningful financial incentives, and/or monetary penalties.” Among the things that state governments can do are to obtain federal administrative funding via the Medicaid HER Incentive Program through 2021; and access federal funding to support HIE adoption through Section 1115 demonstrations in partnership with the federal Centers for Medicare & Medicaid Services (CMS)—though it notes the temporal and financial limitations involved in those approaches.
With regard to contracting, the report notes that “State agencies may use their purchasing power to promote and require interoperability. The most straightforward example of this is through state contracting that may be paired with payments; under CMS guidance, states may pay incentives to managed care plans that meet performance targets.”
With regard to regulatory rulemaking and directives by state purchasers and regulators, the report notes that “State purchasers and regulators may promulgate rules requiring health plans to engage in HIE or promote interoperability among providers. As previously discussed, state agencies may use contracting, licensing, credentialing, or other mechanisms to implement and enforce rules.”
What about executive orders? The report notes that “Governors have authority to direct state regulatory agencies and purchasers to advance interoperability through contracting and rulemaking within each regulator’s or purchaser’s purview.” What’s more, “An enforced statewide directive via executive order with accompanying incentives and penalties would likely have broad impact. An executive order can be done quickly, requiring only the governor’s signature.” On the other hand, “A directive can have a negative impact on the trust between state government and HIE stakeholders, especially if it is developed without broad stakeholder input, and some stakeholders will oppose this path, especially if it is seen as an ‘unfunded mandate.’”
Of course, there is always legislation, which is both “a more direct statewide action than an exedutive order, and which would also “give implementing state agencies clear authority to take action, including through rulemaking,” though inevitably, legislation “would likely encounter signatuifcant debate in the legislature and subsequent reviews by legislative committees before becoming law, which also requires the governor’s signature.”
Meanwhile, “Regardless of the levers deployed in a state, it is critical that the state establish an accompanying measurement and reporting process and infrastructure to establish a baseline, track progress against targets, and inform how policymakers can adjust or craft levers to ensure progress. Measurement and reporting,” the report notes, “are important to evaluating the progress of HIE adoption, increasing transparency and identifying strategies that are working and may be scaled up, as well as identifying strategies that are not working and can be modified or eliminated. The measures most readily available can assess HIE adoption and utilization statewide through a dashboard or similar public setting. More difficult to measure is whether HIE adoption and utilization is impacting patient outcomes, improving provider workflow, reducing costs, and improving overall population health.”
The report then goes on to compare the HIE development policy landscape with the landscapes in Minnesota, Florida, Michigan, Maryland, and North Carolina. Each of those states has a different combination of those above elements, and none have all of them.
Looking at those alternative landscapes, the report notes that “States that have been most successful in advancing HIE have coupled state policy with financial incentives and stakeholder collaboration. In the states surveyed, none of the policy levers guaranteed widespread HIE adoption when employed in isolation. Minnesota’s EHR and HIE legislation furthered EHR adoption, but failed to facilitate cross-network HIE likely due to its failure to include compliance incentives or penalties. Maryland’s regulation has resulted in universal HIE participation among hospitals, but participation rates are lower among ambulatory providers who fall outside the regulation. Florida has used contracting requirements to boost participation in its ENS and direct messaging use cases, but it has struggled to galvanize stakeholders for broader utilization. North Carolina and Michigan have supplemented state policy with additional supports to garner broad HIE participation among a balanced group of stakeholders. In both states, the largest commercial Blue Cross Blue Shield plans have provided private sector support for advancing HIE. North Carolina’s legislation has been furthered by state efforts to provide funding for providers who may struggle with the cost of complying with its requirements. Michigan’s success in advancing HIE has been facilitated by its collaborative and transparent approach as well as effective use of managed care organization (MCO) contracting to require and incentivize HIE adoption.”
Ultimately, the report notes, “Policy and business leaders may consider any number of levers to advance interoperability in California. Some levers contemplated in this brief have been partially deployed (e.g., the California HIE Onboarding Program [Cal-HOP] to provide financial support for HIE), while others such as an executive order or legislation with enforceable incentives or penalties have not. These options are considered below and are not mutually exclusive; most are in fact mutually reinforcing.”
And, the report concludes, “There are many public policy and private market levers available to advance HIE. California can learn from other states that have more effectively used them to accelerate interoperability. A consistent theme in more successful states is the use of a multitude of levers that align business interests of providers and payers. By coupling strong state leadership with sound public policy, leveraging state and private purchasing power, and aligning private payer programs with interoperability goals, some states are finding they can move the market toward more systemic information exchange. These states have also sustained their efforts for a decade or more and recognize that one-off policy directives are not sufficient to get the job done. California likely needs to take a similar long-term, holistic view to create an undeniable value proposition for all stakeholders and make appreciable progress toward a truly interoperable health system.”
