Despite infusions of federal funding, numerous state-sponsored initiatives, and the development support being provided by private consulting firms, health information exchanges (HIEs) are evolving forward in a fragmented and non-uniform way at the state level.
The reasons for this ongoing fragmentation and lack of uniformity are as diverse as are statewide HIEs themselves. But one underlying reason, say industry observers, appears to be a residual conceptual framework in healthcare that derives from the Bush administration-era focus on the idea of building a national health information network (NHIN) based on the building blocks of what initially were called regional health information organizations (RHIOs). Under that thinking, the idea was that once RHIOs got up and running, they could be linked into statewide networks, which would then be linked together to form a national network.
Instead, the American Recovery and Reinvestment Act of 2009 (ARRA) has ended up putting the burden squarely on the shoulders of each state to plan, design and build its own statewide HIE - whether or not a state government chooses to incorporate existing regional networks into that HIE.
As a result, say CIOs who are involved in statewide HIEs, current efforts to build statewide HIEs are forcing all those involved in every state that is creating an HIE to essentially invent the wheel each time. For example, notes Pamela McNutt, senior vice president and CIO of Methodist Health System in Dallas, Tex., a state government can receive a grant “to hire consulting groups to help physicians - not hospitals - incorporate EMRs into their practices. But that only pays for consulting,” she notes.
Meanwhile, state governments can also can obtain grant money to assist them in building a statewide HIE- if they already have the plans in place. They can also apply for HIT workforce grants that will pay for selected schools in any state to train the workforce needed to install, build and maintain the network's infrastructure, McNutt reports.
Additionally, individual providers can get incentive dollars based on their billing volume of Medicaid or Medicare patients, but only after they have installed and can prove that they are using an EMR. “The goal is that every physician will be on an EMR by 2017 or they will be penalized by reduced reimbursements,” McNutt says.
This cash incentive was further explained in a letter dated September 1, 2009 that was sent to state Medicaid directors by the Centers for Medicare and Medicaid Services (CMS). That letter explained to providers the funding available to Medicaid healthcare providers “to purchase, implement, and operate certified electronic health record (EHR) technology. These payments, while not direct reimbursement for certified EHR technology, can be paid at up to 85 percent of the federally-determined ‘net average allowable costs’ of such EHR technology, including support and training for staff, up to statutory limits.”
Forward movement in Texas and Georgia
As a result, state governments, and some provider organizations, are beginning to move forward. Two states in which activity is proceeding are Texas and Georgia. Methodist's McNutt reports that Texas has received a $29 million grant for “planning and interstate activities” involving a statewide HIE but that these efforts are only in the planning stage.
The state does, however, have a number of regional HIEs that are also in the planning stage or operational. These include the Critical Connection Central Texas Cooperative based in Austin; the Harris County Healthcare Alliance based in Houston; Healthcare Access San Antonio; and the Integrated Care Collaboration based in Austin.
And while McNutt's own healthcare system uses the HL7 standard to connect electronic medical records (EMRs) in six hospitals and 10 clinics, she says interoperability issues need to be addressed if a statewide HIE is to succeed. “The idea is that free enterprise will reign,” she says. “But that's difficult because people are using different systems.”
Meanwhile, in Georgia, Ron Strachan, senior vice president and CIO of Wellstar Health System in the Atlanta suburb of Marietta, says the private exchange his health system currently is building - which uses HL7 wherever possible - may eventually be rolled into a statewide HIE. But he also says that Wellstar would retain some of the infrastructure for its own internal use. At any rate, it will probably take the state at least two years before it's ready to launch anything on a statewide basis, he adds.
As is typical in other states, Georgia is home to a number of regional initiatives, including an otolaryngology network based in Atlanta and the Athens-based GARHIO, which encompasses a six-county region containing over 250,000 consumers.
In addition, the Atlanta-based Georgia Office of Health IT and Transparency has launched a Health Information Exchange Pilot Program which provides matching funds to health care organizations so they can plan and implement their own HIEs; the Rx Exchange Project, which compiles medication histories on Medicaid patients as well as those served by the Department of Social Services, the Department of Corrections and the Department of Juvenile Justice; and a program designed to provide Medicaid providers with electronic health records which, in conjunction with the Georgia Medicaid Management Information System, will serve as the linchpin for the statewide HIE.
But whatever the outcome, and for as long as it takes to establish a statewide HIE, Strachan says, “If you're not able to establish a good governance model, it won't work.”
Testing the waters under Medicaid
While private and regional exchanges have been populating the healthcare landscape, Medicaid HIEs have been slow to get off the ground. But that may be changing. Last year, the District of Columbia announced that its Department of Health Care Finance was set to launch a Medicaid HIE. Implemented by MedPlus, a subsidiary of the Madison, N.J.-based Quest Diagnostics, the Patient Data Hub will connect providers, three hospitals and six clinics via a Web portal and data exchange service.
In addition, in January of this year, CMS announced two demonstration projects aimed at improving quality and efficiency of care for Medicaid and Medicare patients.
Building on the strengths of an existing network in the Indianapolis area, the Indiana project will utilize over 800 providers as a way to ascertain whether payers' data silos and payment incentives for quality and efficiency can be improved through more effective integration and alignment.
In North Carolina, the state's existing North Carolina Community Care Network (NC-CCN) will be expanded to include patients with Medicare/Medicaid dual eligibility. Currently, NC-CCN serves only Medicaid patients as well as certain low-income and uninsured persons.
Eight of the 14 NC-CCN networks and 26 of the state's 100 counties will participate.
Alabama's groundbreaking experiment
The first state in the country to develop a standalone Medicaid HIE was Alabama. In January 2007, that state was awarded a two-year, $7.6 million federal Medicaid Transformation Grant and signed a contract with Affiliated Computer Services Inc., a Xerox company.
Will Saunders, chief operating officer of government healthcare solutions at the Dallas-based ACS Healthcare Services, says that the statewide network his company established for Alabama utilizes a patient data hub to achieve connectivity to individual providers. Those who do not already have an EMR can use a free Web-based “EMR-lite” supplied by ACS. “We want to be EMR agnostic,” Saunders says. “We want to be the network.” Since ACS is working for the state, Saunders says the company hosts and maintains the network. “We're the back-end mechanics,” he explains.
In custom-designing this HIE for Alabama, ACS incorporated a number of unique applications. QTool, for example, is an EMR that includes e-prescribing. It pulls together and aggregates all available patient-related information and securely makes it available to the physician in real time.
The e-prescribing and medication history portion of QTool allows physicians to consult a patient's medical history; check the agency's preferred drug list; enter the prescription; and securely transmit it to the patient's pharmacy of choice.
Also incorporated into this system is a care management program for patients with chronic illnesses (Q4U) and an application (Qx) which allows the Alabama Medicaid Agency to exchange data with other health and human services agencies.
Saunders says that determining this system's return on investment will take some time. “We'll be looking at health sets. How many duplicate CT scans did we stop? How many name brand meds were changed to generics?”
But the future of this particular HIE is up in the air, says Kim Davis-Allen, director of Transformation Initiatives for the Alabama Medicaid Agency.
The state's contract with ACS runs out at the end of September and the state will once again go out for bids. “There's no guarantee who the next vendor will be,” she says. “Everyone has to submit a proposal.”
She also notes that there is no guarantee that the current Medicaid HIE as designed by ACS will eventually be incorporated into the statewide HIE. “It's not a full-functioning exchange,” she said. “QTool is not a comprehensive system.”
Winning over providers also has been a major stumbling block, Davis-Allen says. “We'll take whatever we've learned to get providers to adopt the system. As more providers use it, we'll get more feedback.”
And, she adds, “As we build our statewide infrastructure, we'll bring individuals along with us.”
Davis-Allen admits that her agency has not been able to accomplish everything it set out to do. But she did offer some advice to other states. “It's important to know what you want up-front and then do good testing,” she says. “Start small and then just do it. Don't over-plan it. Start with something that is doable, while working toward statewide connectivity.” The bottom line, as with any HIE, she says, is that “It's not going to happen overnight.”
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Healthcare Informatics 2010 May;27(5):30-33