Overcoming Competition in Private HIEs

In recent years, the number of live private health information exchanges (HIEs) has been mushrooming and outpacing that of the public sector. In both sectors, organizations must reach a consensus among stakeholders over a variety of issues like governance, data sharing agreements, and so forth. A relatively new HIE, Carolina eHealth Alliance (CeHA), a Charleston, S.C.-based private HIE, is a good example of how competing systems can collaborate on patient care. With that said, CeHA has had to make some concessions in the face of competition.

CeHA is an emergency department (ED) alert system that started in spring 2011 in the Charleston area and which links 11 EDs at four main hospital organizations: Medical University of South Carolina (MUSC), Roper/St. Francis, Trident, and Summerville Medical Center. Frank Clark, Ph.D., CIO and vice president, MUSC, originally had the idea of CeHA after hearing about an HIE sharing electronic health information across major emergency departments in Memphis, Tenn. A Vanderbilt study released last fall by the Journal of the American Medical Informatics Association showed the Memphis HIE reduced hospital admissions, reduced radiology tests, and produced an annual cost savings of nearly $2 million.

Clark believed his region could do something similar. He wrote up a grant proposal to the Duke Endowment (based in Charlotte), and became the principal investigator for a $2.4 million grant received in November 2008. A third party facilitator was brought in to assemble the hospital CEOs to form the board of CeHA, a nonprofit. (In the future CeHA may pursue becoming a 5013c, says Clark.)

Clark says that an initial challenge was for these highly competitive organizations to move beyond organizational interests to think about patient care benefits and eventually concur on data-sharing agreements. Frank says that ED physicians saw the benefits of an exchange immediately, and lobbied their CEOs to come together.

What remains of this competitive nature is the design of the CeHA interface itself. No data is permanently stored in CeHA, or is able to be saved into an organization’s electronic health record (EHR). Christine Carr, M.D., medical director, MUSC Emergency Services, says CeHA auto-populates data from patient registration, rather than operating via physician query. When a patient registers and chooses not to opt-out, CeHA queries the edge servers of the participating organizations to aggregate and consolidate key electronic portions of their medical records. A green checkmark in the interface indicates that CeHA has clinical information on the patient, such as emergency department/clinic notes, discharge summaries, lab/pathology and radiology results, care/referral data, prescriptions/e-prescriptions, and problems lists from the past 180 days. This information appears in a temporary virtual record that the physician has four hours to view, and afterwards is cleared upon patient discharge. Carr says she plans lobby for the exchange to extend the amount of data shown back to a year. “We are not finding that the delay caused by the additional query into the edge servers is causing a lot of delay,” she says.

At present, CeHA does not share images, only written radiological notes and documents. Clark says CeHA hopes to begin sharing images in the future and have the ability to link into the respective organizations’ PACs, as well as have the ability to import continuity of care documents into the organization’s EHR. However, Clark says that one of the biggest issues, data sharing concerns, makes participants loathe to having data stored permanently. “Given their competitive nature they didn’t want someone to be mining the data, or trying to lure the patient to another facility,” says Clark.

Cost, Time Savings
“AHRQ released a paper recently saying that more than 50 percent of emergency departments report that they are operating over capacity, so by using health information exchange we create capacity, in that we decrease ED length of stay for patients that have information [in the exchange],” says Carr. CeHA recently finished a study on the benefits of the exchange. Carr knew the study would end up showing cost savings for the participating organizations, but had no idea to what degree

The web survey that she directed polled ED physicians every time they viewed a patient’s record in CeHA, showing a total savings in avoided testing and services of $219,020 from one ED (50,000 visits) in 45 days, with an annual estimated savings $879,020. The most significant reduction of tests was CAT scans and abdominal scans. Not only were cost savings seen, but patients experienced ED stays that were on average an hour and 30 minutes shorter because of avoidance of unnecessary tests. “Having access to meds, labs, and diagnosis notes really allows the physician to more quickly deliver care,” Clark says.

Working with Veterans Affairs
CeHA is working on another use case now with the Naval Health Clinic Charleston in conjunction with the Veterans Affairs Virtual Lifetime Electronic Record (VLER) program. “When a veteran is seen in a civilian facility, [physicians] are trying to improve and expedite the [viewing of the] continuity of care document,” says Clark.  Last fall, CeHA started testing Direct messaging via the Nationwide Health Information Network (NwHIN), through a state HIE node.

This year, CeHA plans to focus on expanding the organizations participating in the exchange and add independent primary care groups to the mix. Beyond the initial Duke Endowment grant, CeHA received an additional $600,000 from the Duke Endowment for software implementation and costs. For operational sustainability, the board is exploring collecting annual fees and in kind contributions from organizations.