To Be the State HIE, Or Not To

After Hurricane Katrina left death and destruction in its wake, Mississippi learned the value of the electronic health record, as physician practices that weren’t entirely flooded, dried their paper records on the sidewalk. Out of this tragedy sprung the hope of the Mississippi Coastal Health Information Exchange. James S. McIlwain, M.D., CEO and President, IQH & Co-Chairman of the Mississippi Health Information Infrastructure and Task Force Grant Administrator for the Mississippi Coastal Health Information Exchange, spoke with HCI associate editor about what challenges he and his team have been facing trying to put together the pieces of this coastal health information exchange.

Healthcare Informatics: What were the overarching goals for setting up MSCHIE and how it was formed?

McIlwain, M.D.: Mississippi was very fortunate to finally recognize the value of having electronic healthcare data. Following Katrina we’ve had offices that had troubles with their medical records. We had doctors drying their medical records out on the pavement. There were very few doctors that had electronic medical records. Some of those offices who did [have EMRs] were damaged and flooded. They were trying to get their hard drives revived. It would have benefited us to have had electronic health records.

We see electronic health records and the exchange of information as vital to transforming health care delivery both to improve quality and reduce costs. Our governor supported this and created an executive order [in March 2007] to form a taskforce to suggest ways to increase adoption of EHRs by providers and create an exchange of information. Just having electronic data is good, but it’s not the ultimate high point where we needed to be. So the taskforce looked at the problem and created a pilot project in which we were able to get funding to use in the coastal area to create an information exchange Mississippi Coastal Health Information Exchange. We even thought about putting an ‘f’ on there for ‘foundation’ and calling it MISCHIEF, but we didn’t think that would go over well. [chuckles]

We sat around with a lot of technology people—I’m not a technology person—we formed some smaller workgroups to plan the system we wanted to have. We did have a $4.8 million grant through our state to apply to the coastal area to reinforce electronic health information. It had a timeline of one year, but we got an extension and were able to extend it for a couple of years. So that grant is up now up in August 30. IQH [the federally designated Quality Improvement Organization (QIO) for Mississippi under contract with Centers for Medicare & Medicaid Services (CMS)] has a nonprofit corporation that volunteered to administer the grant. We actually contracted with the Department of Information Technology Services, which is the state agency that does the information systems for the state of Mississippi. We contracted with them to do a procurement process, write an RFP, do an evaluation, and review the contract and go through that process for us. They did a good job. We had eight national vendors that submitted a proposal and went through an evaluation process. Medicity [based in Salt Lake City, Utah], the company that was selected had the best cost and technical processes.

In phase one [which began on Oct. 29, 2008], we started creating this exchange. We originally had three stakeholders Singing River Health System, which had two large hospitals on the coast and Memorial Hospital of Gulfport, which was three of the 11 hospitals on the coast. Along with Coastal Family Health Center, which was a federally-qualified health center that had nine clinics on the coast that did outpatient medical treatment. So those were our original stakeholders for our phase one, which was the first year. They became live in January [2010], and we’re working on phase two now. The difficulty is how do we sustain this to phase three and keep it going after that?

HCI: Can you tell me what’s going on in phase two, as well as a little about the outreach training campaign you’re working on?

McIlwain: We have a lot of value with this [HIE] by offering active medication history in real-time. We then found out that people wanted laboratory results, so we added that to it, plus other reports from hospitals. We established a value proposition that we’ve been using to include radiology reports in phase two. We are also about to start connecting to PACS [picture archiving and communication systems]. We’ve also added additional hospitals and physician offices that will be going live in the next month or so. When you have people come onboard and go-live, you have to train them to use the system, and we’ve accomplished that. We have more than 600 people trained on the system.

Part of the concern is the privacy and security of health information. We’ve developed a training packet on privacy and security issues related to the exchange that will be available on the Internet, as a short 15 minute course to be required to validate before being approved to use the system.

HCI: Did Medicity or MISCHIE set that up?

McIlwain: It’s going to the property of MISCHIE, but Medicity had a big hand in setting it up. So that’s an innovative thing. And we want to make sure everyone understands their role in privacy and security when they use this.

HCI: And can you tell me a little about the HIE platform itself? Is there a centralized repository for the data or is it a provider to provider network?

McIlwain: It’s a hybrid. It does contain a centralized database. But for example, Medicaid doesn’t like to store their data into our central data repository, so they can buy their own data repository. Or we have a record locator service, which is a federated model that we can reach out to them to get the information to put in our system. Some institutions don’t like to be on a central database, so we have the ability to reach out and get what we need. We feel like that’s the best model there is.

HCI: What is the governing structure of MSCHIE?

McIlwain: We [have] a governing board with 11 members. We tried to choose [a mix of] organizations and state agencies. It’s a public/private board, so it’s not just a state agency. It involves stakeholders too.

We formed a consumer committee, which has 22 consumer members throughout the area. They have been active and approved policies and approved an ‘opt-out’ procedure that all patients will be able to be put into the exchange, so they can ‘opt-out’ rather than ‘opt-in.’ We also have a committee with compliance and security officers of the hospital that will set up procedures for the coastal area.

We’re in the process of discussing if it should be a local nonprofit, more like a regional health organization, or not. Now we’re faced with the fact that we have stimulus money to create the Mississippi health information network, and it’s been recommended since we’ve had so much good success with the platform on the coast that it should just meld into the Mississippi health information network. And we are still trying to decide if that means that MSCHIE will become the state network or it will become a regional organization that joins the state network that uses Medicity platforms. We have to make a decision in the next few months.

The difficulty is sustainability after the grant is gone. It costs money to maintain and implement new services. We have had legislation to create the Mississippi health information network, and we’ve had approval for a governance body for that network. The thoughts is it’s probably going to be that MICHIE becomes a regional network, but we still don’t know what the ONC (the Office of the National Coordinator for Health Information Technology) is going to pay for and what they won’t and how do we work that into our project.

For example we have Biloxi Regional Medical Center, a large health system on the coast that belongs to a corporate entity HMA [Health Management Associates Inc.], they are very excited about this. They are going live in a month. They have 11 other hospitals in our state, so all it will take is a push of a button to put them in the exchange and they’ll be eligible for all the incentives.

All the hospitals along the coast will be live by the end of this year except Garden Park Medical Center, [in Gulfport, Miss.]. We already have about 36 physician clinics onboard, and we need another 100. By the end of the third year, we’ll have everyone connected that wants to. The coast has been a little bit more ahead on EHR adoption than the rest of the state.

HCI: Can other hospitals that aren’t located on the coast join in MSCHIE?

McIlwain: They can join. They can either get a centralized database, or if they want to become federated, since we’re a hybrid model, it can be a very easy thing to join. For example, Delta Health Alliance is a nonprofit organization that has been working in the Mississippi delta to supply electronic health records for physician offices. They were awarded a $14 million Beacon Grant over three years, and we’re preparing contracts for them to join MSCHIE since we have the exchange capability, and they have the physicians. So that will help us cover the delta and the coast. [There’s] a health system out of Tupelo that has their own nursing home/home health agency and about 40 physician clinics that are connected electronically to them. They would be ready to connect with us, but they’re redoing their system. But they’re an example that would cover a large part of Mississippi that would join.

HCI: What kind of phase three initiatives are you planning?

McIlwain: We’d also like to connect to the federal VA [Veterans Administration] and Department of Defense that has a large hospital on the coast as well as Keesler Air Force Base. There’s a small exchange in Mobile, Alabama and other parts of Alabama that we may connect to where there are active referrals.

HCI: How did you get involved with MSCHIE?

McIlwain: I’m a family physician. I left practice about five years ago to become medical director of a large hospital in Jackson. Then I became medical director of IQH. We’re the QIO for Mississippi for Medicare and we also do the Tobacco Quit Line for three states. I just had a personal interest in using electronic health records and exchange of information, and I feel it’s the way to improve the quality of care in Mississippi.

HCI: Besides sustainability, what other challenges have you met while setting up MISCHIE?

McIlwain: The other challenge was the readiness of the stakeholders to commit to do this. The grant did pay for developing interfaces for them, but there was time and effort required for their staff to do this also. They had an investment to make, so they had to decide to join or not. At first before all this funding happened, we were hoping to have five stakeholders the first year, but we only had three, although they were more than adequate.

HCI: Beyond the grant, how are you going to continue to fund MSCHIE?

McIlwain: I think there are several ways people are doing this. There’s a subscription model, where members pay a cost to join. We tend not to want to charge physicians, although there may be some minimal cost. Another way is to charge those who benefit the most, and that’s been a problem because the payers, for example insurance companies, have benefited the most. We may very well prevent unnecessary hospital admissions; we prevent duplication of lab services because doctors have the information at hand. I don’t know if they’re going to want to join. Then there’s the ones who use it the most, based on transactions, like when you use electricity, you pay for how much you use. So there are different methods, or a combination of all of those will be done.