Mass. of Activity

Along with talks from a number of prominent industry players, John Halam- ka, M.D., CIO at Boston-based CareGroup Healthcare System—along with a host of other titles and responsibilities—spoke of his many projects and successes in the electronic healthcare information exchange arena.

In Boston, and Massachusetts in general, it's far from business as usual where he has been involved with that state's efforts in two initiatives—the MA-SHARE regional healthcare information or- ganization (RHIO) and the New England Healthcare EDI Network (NEHEN).

Halamka began his talk by showing a slide of his bul- letin board at work which was covered with rules from each payer that must be followed when filing a claim. Clearly such a situation would never yield the efficien- cies everyone in the industry is looking for, he said. In one example, Halamka explained how his group decided to focus on radiology imaging support, along with financial workflow and e-prescribing.

• Transports HIPAA-compliant transactions

• Has a low-cost of ownership

• Delivers a close-to "all-player" solution to connectivity

• Makes the most of the participating organizations' in- vestment in existing "legacy" systems

• Can be integrated on each organization's terms into claims payment and provider service processes (on the payer side) or into patient access and revenue cycle processes (on the provider side).

• Reduces bad debts and other fi nancial exposures by im- proving administrative effi ciencies

• Shortens the elapsed time to achieve EDI at an appropri- ate transaction volume level

Source: http://www.nehen.net

With insurers requiring extremely high-level authorizations for sophisticat- ed imaging tests, some physicians were reluctant to order them, even if they felt it was medically necessary, he sug- gested. Other physicians, however, were apt to order every imaging test in the book, just to makes sure they were cov- ered should a lawsuit take place down the road. A balance had to be struck be- tween utilization and clinical evidence.

Halamka worked with the American College of Radiology to create a dynamic decision support application that physicians and insurers could agree on. Designed using a service-oriented ar- chitecture and Web services, the Web-based system is used by providers to determine the most appropriate imaging test for a given patient. After entering infor- mation on a series of screens, the physician is shown the five most appropriate tests in order of relevance. While physicians are able to choose any one of those five—even the lowest rated test—they cannot order a test outside of those five.

Active Projects:

• e-Prescribing

• Gateway Project

• Education Project

Previous Projects:

• Bioterrorism Syndromic Surveillance (BSS)

• Community Master Patient Index (MPI)

• Electronic Health Records

• Electronic Patient-Centered Communication

• MedsInfo-ED

• Pathology Database Query

• Physician Credentialing

• Secure E-mail

Source: http://www.mahealthdata.org

Thus, a balance was struck between providers and insurers, between ordering any test, no matter what the particulars of the case, and having authorization denied for a justifiable and necessary imaging scan.

The system also serves to educate providers as they move through the screens. In fact, Halamka said 10 percent of the high-tech radiology tests originally or- dered are changed once a provider moves through the application's questions.

After a result is given, the provider can either elec- tronically send the order to an imaging center or hos- pital in the area or print out an authorization for the patient to take with them.

"We built Napster for healthcare", Halamka said of NEHEN, the peer-to-peer electronic data interchange network. The system, he said, could be used to de- termine eligibility in real time, with authorizations available "almost" in real time. Average accounts re- ceivable days in Massachusetts fell as a result of using the system, down the 47 days, "much less than it used to be", Halamka said.

When MA-SHARE was created as Massachusetts' RHIO, it was organized as a separate entity from NEHEN. According to Halamka, that was because RHIOs—at that time and perhaps still today—did not boast a successful financial model, while NEHEN was doing just fine. But that all changed when MA- SHARE began facilitating e-prescribing.

"E-prescribing has created business sustainability for our RHIO," he said. Pharmacies, he explained, receive the transaction but don't have access to the clinical records, maintaining privacy.

But how much information is too much. Halamka noted that when it came to physicians being notified of unfilled scripts, that was not something they were happy to do without.