NEHII’s Major Policy and Technology Thrust Connects Nebraska Healthcare As Never Before

April 9, 2020
Jaime Bland, of the Nebraska Health Information Initiative, shares her perspectives on what’s been learned so far in her state’s data-sharing efforts in the context of the COVID-19 pandemic

At a time when leaders across the entirety of the U.S. healthcare industry are moving forward assertively to address all aspects of the COVID-19 pandemic, some believe that the moment has never been more ripe for the leaders of health information exchanges, given the capabilities that HIEs have to collect, store, and appropriate share and exchange key data points and other forms of information.

One advantage that HIEs—particularly statewide HIEs—have, is their positioning as neutral, “white hat” honest brokers of data and information, have, is their existing relationships with hospitals, medical groups, health systems, health plans, public health departments, and state, county, and local governments. And in some states, the positions of the statewide HIEs have only been enhanced even more by the need for all those stakeholder groups to collaborate to address public health issues around the pandemic.

One statewide HIE that was already well-positioned was the Omaha-based Nebraska Health Information Initiative (NEHII). As explained on its website, “NEHII provides for seamless access for clinicians to information that is agnostic to health system, EHR vendor or payer. NEHII enables clinicians to query health records from data sharing facilities to find information on a patient, in near real time, enhancing the workflow delivery of safe, effective, high quality care.” Among the types of data stored and managed by NEHII are prescription medications; allergies; lab results; radiology reports; and other test results.

With regard to public health reporting, NEHII’s website also notes that “NEHII has partnered with Nebraska Department of Health and Human Services-Public Health to provide an option to hospitals and providers in Nebraska seeking to submit syndromic surveillance, laboratory and immunization data.” Indeed, because NEHII was already the mandated organization to which providers across the state had to report syndromic surveillance data, it was optimally positioned to be a data and information broker in the current situation.

In fact, on March 18, NEHII posted on its website the text of an open letter to providers across Nebraska, co-signed by Dannette R. Smith, the CEO of the Department of Health and Human Services of Nebraska (DHHS), and Jaime Bland, the CEO of NEHII. The text of the letter read thus:

“Dear Health Care Facilities and Health Care Providers: Due to the Coronavirus (COVID-19) outbreak and the Nebraska State of Emergency Declaration, the Nebraska Department of Health and Human Services (DHHS) Division of Public Health and the Nebraska Health Information Initiative (NEHII) are requesting your help in timely reporting in order to aid the state of Nebraska in providing essential responses to the COVID-19 outbreak affecting our communities. In addition, please see the Office of Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) February 2020 bulletin regarding HIPAA Privacy and Novel Coronavirus.”

The letter continued, “The COVID-19 outbreak falls under mandatory reporting requirements for syndromic surveillance. In light of the current situation the Department requests all health care facilities, health care providers, and labs connect to NEHII to send admissions, discharge, and transfer (ADT) files, labs, and syndromic surveillance, including syndromic surveillance data captured within ambulatory settings. Connections to NEHII would be at no cost to the facility, provider, or lab and will improve and ease the required reporting process. This will aid the state of Nebraska in providing timely response to the COVID-19 outbreak and in providing resources at the local level to keep our communities safe. Your partnership in these efforts will help us get you the resources you need to respond safely and effectively.”

The letter concluded with contact information at DHHS, and the signatures of the two CEOs.

New partnerships launched

It is in that context that NEHII’s leaders announced on March 31 their partnership with the Marina del Rey, Calif.-based 4medica and the Lincoln, Neb.-based KPI Ninja, around the development of a new lab analytics solution by those two healthcare IT vendors, “to support the rapid treatment, prevention and spread of the COVID-19 (coronavirus) pandemic.” A press release published on that date noted that “The COVID-19 Alerts and Reporting Solution integrates the 4medica Lab Hub™ and KPI’s Ninja Universe analytics platform to provide real-time lab pandemic analytics and ADT notifications. Commercial laboratories such as Quest Diagnostics, LabCorp, BioReference Laboratories and public health laboratories send results to 4medica to normalize and match to the right patient identity. The validated data is then submitted to the Ninja Universe platform to analyze and share with the appropriate front-line providers, public health agencies and patients.” And it noted that “Nebraska Health Information Initiative (NEHII) is the first health information exchange using the solution to analyze the risk, prevalence and characteristics of COVID-19 cases and perform risk stratification analysis of other social resources and factors impacted by the virus across the state of Nebraska.”

NEHII’s Bland stated in the press release that “The COVID-19 Lab Alerts and Reporting Solution augments our HIE to report accurate, knowledge-based data that informs life-saving decisions and community emergency prevention efforts at a time of unprecedented need.” Her statement was followed by statements from Gregg Church, president of 4medica, and Vineeth Yeddula, CEO of KPI Ninja.

“The COVID-19 Alerts and Reporting Solution make sense of the confusing collection of data to prevent the transmission of COVID-19,” Church said. “While interoperability is a persistent challenge in the U.S. healthcare system, we’ve proactively built a solution that interprets the data into clear, succinct and actionable knowledge to help healthcare organizations address critical COVID-19 pandemic issues quickly and efficiently.” And Yeddula noted that “The solution immediately equips frontline healthcare workers with the right, accurate data they need to perform their jobs at the highest level.  Whether this is a first responder’s having real-time data to locate the best hospital to transfer a patient or a state authority needing a density map to pinpoint case surges regionally, the solution’s detailed output supports decision-makers strategizing and allocating appropriate emergency response and resources for people requiring the greatest amount of aid,” he added.

Earlier this week, Bland, Church, and Yeddula spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding their partnership, and the broader landscape of HIE activity in the context of the current COVID-19 pandemic. Below are excerpts from that interview.

When you look at the current situation around the COVID-19 pandemic, and how well HIEs are positioned right now to be ‘honest brokers’ of data and information for the healthcare system, what are your thoughts?

Jaime Bland, NEHII: For us, it’s really culminating in, this is what everybody prepared for. This is the ‘why’ of HIE. We’re able to turn around provider data in such areas as bed management, lab results, and so on, very quickly, from the providers to the Department of Health. And that data can be repurposed for these types of use cases. And I’ve shared it with CMS [the federal Centers for Medicare and Medicaid Services], with the governor, and other elected officials, and they were super-impressed that we were able to do this, but only because of common infrastructure around EMPIs [enterprise master patient indexes] makes that possible. And in critical-access hospitals, you need that relationship with Medicaid.

I’ve had several calls with the state government today. And there are so many asks of hospitals right now. The number of this, the number of that. And we’re saying, we’ve got the data, how do you need to see the information? And a lot of the asks are around COVID-19 patients—around the number of available beds, etc. And because we’ve moved to LOINC [the LOINC, or Logical Observation Identifiers Names and Codes, standard] for labs, with 4medica—that’s where that information pays off, because we’re able to turn this around for the government of Nebraska in two weeks. And for many people, recently, the logic of HIE has clicked, including the logic of statewide HIE, and why everybody needs to be on the same platform. If anything, our position has strengthened.

You just mentioned having participated in several calls today; which organizations and entities were involved in those calls?

On the public health side, on data completeness, we were asked, are SNFs [skilled nursing facilities] reporting, how many SNFs are reporting, and have there been surges [of care demand]? On the Medicaid side, we’re helping them to understand who in the population is on immune-suppressants, who’s at high risk for contracting the disease, so they can do some outreach there, helping them target their resources and communicate with those members of the population.

What is the public health landscape around preparation for COVID-19 in Nebraska right now, compared to in other states?

I’m not sure when the stay-at-home order was put in place, but it was several weeks ago in the Omaha area. [EDITOR’S NOTE: Technically, no formal stay-at-home orders have been issued anywhere in Nebraska; but what Gov. Pete Ricketts has done is to have issued a series of “Directed Health Measures,” which encompass a number of requirements, including the closing of the dining areas of restaurants and bars, limit public gatherings to a maximum of 10 people, eliminate school classes, etc., which are similar to the stay-at-home orders in other states. The first DHM was issued on March 18, for Cass, Douglas, and Sarpy Counties, and over time, all counties in the state have been covered by the DHMs.] And they’ve been looking at our data around key points. They can see by zip code where lab positives are going up. And they’re looking at bed occupancy and preparedness in the Omaha area. Nebraska Medicine has a biocontainment unit, and did work before in the Ebola space, so they did have some command center preparedness. What does a SNF look like in their ADTs and infection rates? And what is the preparedness by county? Those are some of the data points we’re looking at with our partners, and looking at different data models as well.

Meanwhile… we have some advantages in our ADTs that others don’t have. We’ve been able to look at staffed beds and validate whether it was an ICU bed, and build a bed capacity solution. And we knew the numerators and denominators, because it was built into our system that it was a COVID order. That was the chaos in the beginning; nobody knew the denominators.

When did the task force go live?

We stood up our COVID-19 response task force on March 13. We’ll have a PPE [personal protective equipment] dashboard, and is there a data standard for ERP systems, so we can remove manual entry of information.

Who’s on the COVId-19 response task force?

Myself, our KPI Ninja partners, and then the Department of Health and Human Services, the governor, are end-users now.

Walk me through what you’ve been doing?

It’s been long days and nights. We started with scoping what the data needs were that we needed. So, data on bed occupancy, on labs. So on Friday the 13th, we stood up the first conversations of what we’d need to do to abstract, and that evolved into building applications. So we started scoping what the need was. We heard from the media about numerators and denominators; nobody knew how many people had been tested. We now meet three times a week at 7:30 AM, with an update call, and if we need to refine some of the application elements, we do that. And for the first few weeks, it was getting that information live.

And how is it being used on a daily basis?

The Department of Health can understand where surge capabilities are needed and what capacity is needed, and there’s one place where all the labs are coming in. The normal syndromic surveillance process involves the public health department getting that information coming in. And the public health lab isn’t necessarily connected; they’re getting phone calls and faxes. But if we’re connected to the public health lab, they can get event notification as well.

You’re collecting lab data and moving it to the Public Health Department?

And to the providers. In the past, they would call or fax the data to individual providers, as well as to county health departments; we’re automating that. What’s happening is if they call it back to the provider, but there’s no documentation in the record other than a note or text to indicate that a call was received and that a patient was COVID-19-positive.

Gregg Church: In other states, they’re not even getting the results out to the providers or patients, they’re sitting there as unsolicited test results, not matching providers or patients. In fact, we have a client on the East Coast getting 1,300 test results a day that they can’t match up to patients—both positive and negative test results not getting communicated. We’re seeing that happen in other metro areas.

Bland: And one of the problems is that, by the time results are sent to two or three different places, they’ve lost the patient identifiers.

Church: Or sometimes in these drive-through testing stations, they don’t have the patient contact information.

What have been some of the biggest challenges in bringing all this data together and sharing it, during this pandemic?

Bland: There’s a lot of confusion over what data can be shared with us, and whether we can share it with the Health Department or the Governor. We did just receive an executive order today from the Governor that allows us to receive the information. There are a lot of HIPAA concerns over what can and cannot be disclosed.

Didn’t the National Emergency Declaration and the subsequent CMS announcements change that?

Church: That’s the intent, but some of the large labs aren’t participating even now. And it’s really disconcerting to me is that business rationale or data-blocking, or whatever you’d want to call it, even in a pandemic. That data needs to get out, to help reduce the spread; and you can’t have labs not participating, and it’s a really big problem, and it needs to get up to the executive order level.

Bland: I received a call from a lab, and they said, we see your request and the notification from CMS, but we’re just too busy to respond, and our policies forbid it.

Church: Even with our connections with LabCorp and Quest, the data should get out. It’s coming down to their protecting their turf, whatever they want to call it. It’s not about building interfaces; we have the interfaces and the contacts in place.

Why won’t the big lab companies fully participate?

Church: I think there are two reasons. One, data is king, and it’s a lot to every company, and giving up data means giving up control, potentially. It shouldn’t be, in a pandemic. But I also suspect that the accuracy of the data isn’t fully reliable, and there could be exposure there.

Bland: Testing is complex. If we look at the inconclusive rates in our labs, they’re not insignificant. That’s what they’re protecting. There’s an accuracy rate that’s not fully understood. And so I think that that’s what they’re protecting for themselves. As long as they’re reporting positives through faxes and phone calls, they fell as though they’re doing what they have to. But we still have that problem with the denominator. And tests are just being done and not communicated—by the time the lab completes the test, the personal identifiers are gone. So I’m not sure. The initial pushback was, it’s our policy not to report to HIEs; then, it was, we’re really busy. And finally, now, we have the executive order, and it speaks to issues around diagnostic labs.

What would you say the biggest lessons learned have been so far, there in Nebraska, that you could share with colleagues around the country, in terms of what health information exchange could help achieve elsewhere?

They need to support their HIEs, which are part of the public health infrastructure; that’s how you’re able to respond to a pandemic. You need to be able to respond to mass casualties. We have 100 percent of all pharmacies respond to our data set. And so we can provide information. And when you have over a dozen HIEs, as Minnesota does, you’re getting the data in over a dozen different formats, from numerous different places, and you can’t make sense of that. There has to be a single entity that is working with the data, where we can understand what population need is.

Church: When you do a collaboration, and you’ve got technology companies working together to manage data and normalize it and quickly report that, that’s what this country needs to be doing, for a cause. We know as a vendor in this space, that HIEs provide value. And among those states that don’t support their HIEs, that’s problematic. Vendors like 4medica and KPI Ninja working together, that’s important. And there will be ongoing needs going forward.

Vineeth Yeddula: I truly agree. I think that HIEs are in a unique position, where they have the speed of electronic data and the completeness or comprehensiveness of claims data, and this is the only type of entity that is trusted by several competing entities like providers, payers, and public health. And in a situation like a pandemic, you really want to be able to rely on this data. And the nation is trying to find out basic pieces of information, such as how many tests have been completed. So this is very important.