HIE Sustainability Built on Solid Use Cases

To create a truly sustainable health information exchange (HIE), those in the industry say that, for starters, the exchange must be built on a solid use case. No one can attest to this more than Brian Yeaman, M.D., a family medicine physician and CMIO of 324-bed Norman Regional Health System (Norman, Oklahoma). Yeaman is one of the many clinicians that uses SMRTNet, a publicly-owned network of affiliated HIEs spanning the state of Oklahoma that was developed in 2005.

SMRTNet is a conglomeration of eight exchanges that defines its own goals and parameters around governance and has a central management committee. SMRTNet is currently connected to more than 27 million records from 45 unique contributing facilities, covering more than 2.6 million patients and 7 million encounters. SMRTNet incorporates clinics, hospitals, and lab data into one location, and the network was identified by the National eHealth Collaborative as one of twelve national HIE leaders in a report last year.

The local exchange that Yeaman is a part of was built around the Greater Oklahoma City Hospital Council four years ago. The Council came together to create a return on investment from uninsured ER patients. SMRTNet helped the exchange complete its legal and governance due diligence, as well as privacy planning. Initially, Yeaman sat on its clinical committee, but then became the HIE’s network director.

Despite the intensely competitive market, all hospitals in the greater Oklahoma City area and many clinics associated with those hospitals contribute to the local exchange. “This isn’t a tool to get advantage on your neighbor,” says Yeaman. “This is a tool to truly do care coordination and manage patients, and reduce all of our costs by hopefully reducing some of the duplication of testing. But we’re not using it as a tool to compete with one another or define our markets.” Most hospitals are on different platforms, and all are connected to the SMRTNet infrastructure, powered by the Kansas City-based Cerner. The exchange receives more than 5,000 clinical hits a month, and did a large revamp in the last year to meet clinician requests.

Clinical information like lab results, medications, drug allergies, CPT (Current Procedural Terminology) codes, ICD-9 codes from clinic and hospital visits, are currently shared in SMRTNet. To access the exchange, Yeaman clicks a link in his electronic health record (EHR) that connects directly to a web-based view SMRTNet, and structured data can be imported to populate a patient’s chart in his EHR. There are also search tabs that provide different ways of slicing and dicing the patient’s data. “The data from day one has always been clinical,” Yeaman says. “There’s no payer data, and the payers are not involved in the SMRTNet network to date. And I think that is a really strong statement for the clinician and why SMRTNet has been so clinically relevant; no one mines the data.” [To hear more about why SMRTNet is not seeking out payer-involvement just yet, listen to this podcast with Dr. Yeaman.]

Yeaman attests to the benefits of HIE in his practice by relating a particular use case that happened a few weeks ago. A patient was looking under the hood of her car, and a squirrel popped out and scared her, causing a fall and subsequent subdural bleed. Yeaman was able to see what happened at the ED, as well as notes from her cardiologist appointment where her medications were changed, which all helped inform his care delivery. “Usually it will take seven to 12 days for a specialist to send me a note to tell me what they may or may not have done during that visit; but this was [viewed] on the fly, which I think is a pretty powerful use case,” he says.

Usage fees for SMRTNet are based on the amount of interfaces and facilities a healthcare organization connects. Health systems can pay from $10,000 to $20,000 for one hospital depending on the bed count to upwards of $60,000 to $80,000. Yeaman says that physicians in Norman pay $40 a month for access to both their local HIE and to SMRTNet. “If you look at sustainability models nationally, what is being charged right now for HIE isn’t very sustainable unless you have large amounts of money,” he says. “I think that is what makes us unique is we approached this from a clinical use case from day one, not from a payer perspective, not from a meaningful use perspective.”

Accountable Care, Lessons Learned
Yeaman says that SMRTNet is a key component in his organization’s plans toward accountable care. Although he says his system is not going to apply for the Medicare Shared Savings Program, it will move toward a clinical integration model and partner with its self- employed physician group to do quality reporting.

The road to becoming an accountable care organization (ACO) is not always smooth, as Yeaman sees it, as the risk can be potentially greater than the reward; like for instance in the costs of quality reporting. “Just in terms of the costs of delivering those reports and because of the nature of our HIE and how long we’ve been doing this, we realized how difficult this is to generate those quality reports at the HIE-level, and even at the EHR-level to the depth of some of the expectations for the accountable care program, and that these reports would actually come out accurate,” he says.

Throughout the process of setting up his local exchange, Yeaman cites many lessons learned. For one, “something is not always better than nothing,” he says. When his HIE was just coming online, two main hospitals in Central Oklahoma City had yet to share information. This caused providers not to log onto the HIE since they were not seeing the crossover data needed for their patients. However, utilization went up significantly after the two organizations joined up.

Another lesson learned, Yeaman says, is that true quality reporting is a work in progress. EHR clinical documentation must be firmly embedded in clinician workflows, and if providers do not put the right information in the right place, then quality reports are less than reliable. “Just because you have all the tools in place doesn’t mean all your reports will come out right because they’re not putting the data in the right structured field that allows your report to run correctly.” Yeaman says it takes years for reliable reports to be run, and his practice has been providing assistance to steer clinicians to improve documentation on specific measures.

With a recent Agency for Healthcare Research and Quality (AHRQ) grant, SMRTNet will be providing clinical decision support (CDS) as a hub-layer service. The HIE is currently doing a patient and provider perception study that should be released this fall. But for now, Yeaman says SMRTNet is creating efficiencies during patient registration and for clinical benefits for physicians during patient encounters.

To hear more about SMRTNet , tune into this podcast with Norman Regional Health System CMIO Dr. Yeaman.