EXECUTIVE SUMMARY
As the health information exchange (HIE) concept evolves forward across the U.S. healthcare industry, leaders of different HIE organizations are pursuing divergent strategies that meet the needs of their regions. But a key, largely unresolved, issue around the sustainability of funding remains common across the sector.
As the healthcare industry moves toward meeting the meaningful use requirements around clinical data exchange, different regions and states are approaching health information exchange (HIE) very differently. According to a June report from the Orem, Utah-based KLAS, about 100 HIE organizations that use commercial solutions are live and sharing patient data. No one model has proven to be the standard for success. With a very broad range of governance and operating models, the resulting HIEs all have singular sets of experiences compelling their information exchange. And with public grants for HIEs resulting from the Health Information Technology for Economic and Clinical Health (HITECH) Act, long-term sustainability in this space remains the leading question HIEs face.
DIVERSE BEGINNINGS
Just like snowflakes, each HIE has a unique genesis. HealtheLink, the eight-county western New York State HIE whose service area includes Buffalo and Niagara Falls, got its start in 2004 when the Buffalo Academy of Medicine published a white paper on the interoperability of moving clinical information among a patient's healthcare providers, with the help of the neighboring physician community, the University of Buffalo, local public health agencies, and others. Several state and federal grants followed that helped pave the way, including one under the Health Care Efficiency and Affordability Law (HEAL NY) in August 2008. Now, HealtheLink has more than 700 providers and 3,000 users (including physician staff) sharing health information.
The Utah Health Information Network (UHIN) had a different start from that of most HIEs. It began in 1993 as an electronic administrative exchange, sharing claims, remittances, eligibility orders, and other HIPAA-compliant data exchanges, and now covers 90 percent of the medical providers in Utah. After a couple of false starts, UHIN started sharing clinical health information this year. According to UHIN President and CEO Jan Root, Ph.D., the organization first went down the path of trying to get clinical information to pay claims, and subsequently found out that that methodology wasn't effective. “We have to start with clinical information on the clinical side, then figure out how to get that to the billers secondarily,” says Root. “That's what we're doing now with the Axolotl product [San Jose, Calif.]; it's really designed for clinicians to use.”
The Michiana Health Information Network (MHIN), which serves more than 3,200 community healthcare professionals in northern Indiana and southwest Michigan, began gathering community support in 1994, and cemented financial stakeholders for the remainder of the ′90s. From 1999 to 2005, the basis of the exchange was jumpstarted with the participation of the South Bend Medical Foundation, an organization that provides cost-effective laboratory and blood banking services to communities in Indiana, Michigan, Kentucky, Ohio, and Illinois, and the six-facility Saint Joseph Regional Medical Center in north central Indiana. Thereafter, the exchange kicked into high gear with more providers joining in. Now the exchange includes more than 1,000 physicians, seven hospitals, more than 15 extended care facilities, radiology practices, and more.
PHYSICIAN EMR ADOPTION
For a healthy information exchange, physicians need to have electronic medical records (EMRs) in their practices. In many regions where HIEs are sprouting up, there is still a dearth of paperless practices. Besides offering EMR products with membership, HIEs are employing other initiatives to encourage and support EMR adoption.
MHIN's approach to enticing members to adopt is to survey what relevant data sources they need. “Is there some disparate piece of data [needed], whether it's an endoscopy study or PET-CT scan from someone?” asks Tom Liddell, executive director of MHIN. “We keep what we call our Top 10 list, and we publish that to the community.” The organization also uses viral marketing like e-mail and lunches to increase education and bolster adoption. MHIN uses the Kansas City-based Cerner Corp.'s PowerChart EMR for longitudinal records, Axolotl for clinical messaging and workflow, and Irvine, Calif.-based Mirth Corp.'s open source integration engine for interoperability, plus a number of secondary tools for analytics. “I'm not so much hung up on ‘I'm a one-vendor platform solution’ because I don't see the kinds of things we're doing lend themselves [to that],” Liddell says.
HealtheLink's EMR adoption program, funded by a $7 million grant award by the HEAL NY program, gives physician practices $5,000 toward the purchase and implementation of EMRs. With the help of another grant, physicians treating the adult diabetic population can be eligible for even more reimbursements. HealtheLink also offers providers a learning lab with monthly events that allow physicians to get hands-on training on EMR products. Participants also get face-time with large players, including Allscripts (Chicago) and McKesson Practice Partner (San Francisco), as well as smaller vendors, such as Medent (Auburn, N.Y.) and Pulse Systems (Wichita, Kan.). “We're not dictating who [providers] should purchase from, but we've done the initial job of narrowing it down to seven, and they're among the most prominent players in our community,” says Daniel E. Porreca, HealtheLink's executive director.
‘FILLING THE WELLS’
An ongoing challenge for HIEs is, as UHIN's Jan Root puts it, “filling the wells”-that is to say, getting physicians and hospitals to buy into the HIE concept. On May 10, UHIN sponsored the Utah Healthcare Connectivity Day to celebrate their services. The site of the celebration, Promontory Point, carried rich symbolism, as it was the nexus for the transcontinental railroads, which put the Pony Express out of business. Since UHIN started accelerating this year, it has succeeded in getting the participation of Utah's four major hospital systems-HCA/MountainStar, IASIS, Intermountain Healthcare, and University of Utah Health Sciences Center (based in Cottonwood Heights, Utah; Franklin, Tenn.; Salt Lake City, Utah; and Salt Lake City, Utah, respectively)-as well as that of clinics, payers, and government bodies around the state.
HealtheLink has been steadily growing, with the recent addition of the 171-bed Niagara Falls Memorial Medical Center, and the 179-bed Mount St. Mary's Hospital (Lewiston, N.Y.), in April. In August, Windsong Radiology Group, with locations in Williamsville, Amherst, Hamburg, Lancaster, and West Seneca, all in western New York, became the first independent radiology practice to start submitting patient records and reports electronically with HealtheLink, and anticipates sharing 300,000 radiology reports annually.
Recently, MHIN secured a partnership with Indiana University School of Medicine in South Bend to develop educational curriculum focused on HIE. In May, Elkhart General Healthcare System, which is comprised of the 325-bed Elkhart General Hospital and 14 multispecialty physician practices, joined MHIN as well. Besides being able to receive hospital reports, laboratory results, and radiology reports directly into their EMR systems, MHIN will make clinical messaging and integration services available. Most recently in August, 84-bed Sturgis Hospital in Sturgis, Mich., linked up to the exchange.
DISPARITIES IN GEOGRAPHY, FUNDING
Geography plays a large role in how health information exchanges evolve. Not only does population density affect how healthcare providers link up to the exchange, it also affects the HIE's operating structure. Root acknowledges that certain HIE models might not work everywhere in the U.S., using as an example the East Coast model, which she says treat HIEs like a “public utility” where the state dictates the entity in which members exchange info. “That particular model doesn't seem to be successful in the West,” says Root. “In Utah, if I tried to do that, I'd be tarred and feathered.”
Geography not only shapes the role of an information exchange, but also the nature of its funding. As can be seen from the even geographic dispersal of the 15 federal Beacon Community grants awarded in May, the information exchange's location does matter. Two Beacon Community grants totaling $30.3 million were recently awarded in September to Detroit and Cincinnati, making it clear that only one award per state was given. Additional funding was awarded earlier this year from the State Health Information Exchange Cooperative Agreement Program under the HITECH Act. Fifty-six states, eligible territories, and State Designated Entities (SDEs) were awarded grants totaling $547.7 million to advance information exchange across their states and develop partnerships with the federal government.
HealtheLink has received many grants, including the $16.1 million Beacon grant, the largest awarded. The organization plans to put the grant towards registries to measure patient outcomes, as well as point-of-care alerts and reminders for the primary and specialty care of diabetic patients. There will be development of patient home monitoring systems to connect patient activities to physician EMRs. The organization will also target congestive heart failure and pneumonia patient care for quality improvement.
Across the country, HealthInsight, a nonprofit organization dedicated to improving the healthcare systems of Nevada and Utah, received $15.8 million from the Beacon Community program. HealthInsight will be partnering with UHIN to improve diabetes management performance measures, reduce health system costs throughout the region, and increase availability, accuracy, and transparency of quality reporting. The Utah Department of Health also nabbed a $6.3 million State HIE Cooperative Agreement Program grant and will be working with UHIN on health information projects.
SUSTAINABILITY CHALLENGES
One of the commonalities of many HIEs is the similar challenges they face. An early challenge for all three HIEs, whose leaders were interviewed for this story, was gaining support for the concept and necessity of an HIE among healthcare providers. Now, the challenge for HIEs is trying to inch their way, provider by provider, toward 100-percent adoption in their regions. That means “pulling those last few organizations through that still have the mindset that if they lock up their data, it's somehow going to be better for their health enterprise,” says MHIN's Liddell.
Sustainability is also an ever-present issue, as there really haven't been many longstanding HIEs in the industry. Even with all the public monies coming out of the HITECH funding, the challenge is how to survive and prosper once the grants dry up. “When people talk about sustainability, I'm like, ‘we're the epitome of it,’ because when you sit down and look at us, you have to generate revenue and have ROI to be viable, or people won't participate,” Liddell says. He notes that he applied for a Beacon grant, but doesn't ever want to rely solely on public funding. His organization is also leading the development of the Indiana Health Information Technology (IHIT) nonprofit, an organization consisting of the state's five health information organizations that will disperse the $10.3 million State HIE Cooperative Agreement Program grant it received in March.
Root takes a very shrewd stance on the issue of sustainability. She emphasizes that UHIN is a business first and foremost. “We will only sell stuff to our members that they will pay for. I think a lot of HIEs that bit the dust did not have a good business case,” she says. “They came from the perspective, ‘we just want to improve the quality of care,’ and it's a good perspective; it's just not a sustainable perspective.”
COLLABORATION IS KEY
One sentiment echoed among HIEs is that partnerships among community hospitals, payers, and physician practices are paramount for success. Liddell cites the participating hospitals in the information exchange as partners in MHIN's success. He also credits the rich history of HIT in the region as part of the culture of achievement. “We're very fortunate that there are 40 to 50 health IT professionals that have stayed in the area, it's those kinds of things, and it's trust as much as anything,” he says.
Porreca notes that part of HealtheLink's success relies in the strong alliance among stakeholders. “One of the things that is huge in our community is that the major hospitals and health plans have been working together in collaborative fashion, along with other stakeholders including public health, our university, and other community groups,” he says.
Root keeps in mind that her members are physicians, not patients. She states that UHIN's main goal is providing valuable services like discharge summaries, lab results, medication histories, as well as other data to the physician. Root says her main value proposition is “how to get doctors the information in a way that brings the doctor benefits, not the patient, since the patient is not paying for this.” Also, UHIN evaluates how much physicians would pay for certain HIE technologies and then offers the services significantly below that cost. Root reasons that because UHIN is a nonprofit organization, offering smart products to physicians will be enough to spur participation, and the fact that participation is voluntary makes it an added necessity to provide value.
Healthcare Informatics 2010 October;27(10):24-28
