In Columbia Mo., Missouri Health Connection (MHC)—the state-designated health information exchange (HIE) network—has the motto of “One Connection for a Healthier Missouri,” and the organization’s senior leaders have taken to making that dictum a reality.
MCH was started in 2011 as an executive order by former Gov. Jay Nixon as part of the HITECH Act. But once federal funding dried up, as it did for many HIEs across the country, MHC’s strategy needed to shift to remain sustainable in a competitive landscape. The organization hired Angie Bass—previously a health policy research analyst for the Missouri House of Representatives and a project analyst for the Missouri Department of Mental Health—in 2012 as program manager, but Bass quickly rose through the ranks to become MHC’s president and CEO.
Under Bass’s leadership, MHC has become one of the nation’s largest health information exchanges, covering a territory of more than 69 thousand square miles with more than 22 million patients in its network. Bass recently spoke with Healthcare Innovation Managing Editor Rajiv Leventhal about MHC’s journey, the biggest challenges that exist today for HIEs, how the organization is providing value for its members, and more. Below are excerpts from that discussion.
Can you give me a brief history of MHC? How was the HIE formed?
We were started in 2011 under the original ARRA/HITECH funding. We organized as a private 501(c)(3), so we used $14 million in federal [funding] to get ourselves off the ground with the initial infrastructure and onboarding [of participants], and we’ve been a self-sustaining organization and member-funded since 2014.
We waver between being the second and third largest HIE in the country based on the size of our master patient index, which is over 22 million patients, as well as based on the sheer geography that we serve. One unique thing about Missouri is that we have several large health systems that are headquartered in the state, but we also have facilities that are outside of the state, spread throughout the Midwest. We have providers in all the states that border Missouri, up to Wisconsin and down to Louisiana. So even though we predominantly serve this state, we do have a Midwestern focus as far as the geography and territory that we do and intend to serve.
We have more than 80 hospitals and hundreds of clinics, and since we have so many integrated delivery networks and health systems, that means we have all of the ambulatory clinics and facilities that go along with them. So, that’s thousands of physicians and even more practitioners that have access to our HIE services, either through an integrated query-based interfacing, our clinical portal, our push-based alerting, or through public health. We have a variety of services, and we have thousands of [participants] who can actively receive real-time information on patient data.
What kind of data is currently being exchanged via your network?
The quality of data is our highest priority. The type of data being exchanged includes everything in ADT [admission, discharge, transfer] feeds [using HL7 standards], as well as in continuity of care documents [CCDs]. And then we have some public health interfacing for meaningful use. From an HIE perspective, we can transact anything.
The limitation is not on our ability to be interoperable between disparate systems, but [rather] the limitation is the vendors being able to export the data out of their own systems, and then allowing the customers they are serving—the healthcare providers—to be interoperable.
For instance, the meaningful use certification around what should be included in a CCD is not the entire patient record; it’s just a subset of data. The meaningful use certified version doesn’t include the critical pieces of information that most every clinician wants, such as discharge summaries, notes, and H&Ps [histories and physicals]—all the things that are very relevant and necessary for good care coordination and transitions of care.
What we have been very focused on in the last 18 months is going back to each of our data contributing participants—so everyone who is giving us an ADT and everyone who is sending us CCDs—and expanding those interfaces so that we are getting the most robust data. This [involves] going back and working with them to see how we can extract the most data out, such as going back to a raw ADT feed and adding in those notes and other content that’s necessary. Sometimes that’s challenging, not necessarily because it’s the healthcare providers pushing back, but the vendors who are pushing back.
This speaks to the HIE’s value proposition. Can you discuss that further?
One of the things we always stress is the niche that an HIE serves is doing the data normalization of disparate systems. So, being able to extract from one EHR [electronic health record] and normalize the data in a way that makes sense for another EHR vendor to ingest. Inherently, the EHR vendors are not incentivized to do that with each other on their own, though through CommonWell and Carequality, that is what [those associated vendors] are portraying as the goal of that relationship. But it isn’t happening in the real world; it’s not happening from urban to rural, from acute to ambulatory, or between behavioral health and post-acute care. That’s why an HIE is necessary.
Meaningful use [regulations and incentives] left out post-acute and behavioral health providers, meaning none of the EHR vendors [in that space] need to be meaningful use-certified, so they are playing catch-up. That has been devastating to the industry from an interoperability perspective. Where are the vendors stepping up to help serve [these providers]? But the HIEs are; they are helping these providers with transitions of care as they move onto EHR systems.
HIEs are, for the most part, vendor-agnostic, not-for-profit [companies] that are truly doing a community good and service for providers that need to be interoperable because not everyone will be on an Epic or Cerner EHR. There are going to be those specialty and rural practices that need all the help they can get from a health IT perspective, and that’s what an HIE is there for: to be the intermediary for state agencies to interact with HIEs, and also with the federal government.
We are very focused at the community level, while SHIEC [the Strategic Health Information Exchange Collaborative] and other organizations are doing great work in trying to work with Congress and the state governments to bring awareness about the need for HIEs and the value they serve for the public and private sectors. We are competing against those large EHR vendors that are aligning for their own self-interest needs. And that’s kind of how the game is played, but we aren’t going anywhere. I am confident about that.
How is MHC handling issues such as patient consent?
Here in Missouri, we don’t have any state mandates on the books regarding actual patient consent for HIEs one way or the other, but we have chosen to be an “opt-in” model based on certain laws that are on the books regarding specially protected information that goes above and beyond 42 CFR Part 2 data and other HIPAA requirements. So we choose to be super conservative when it comes to patient consent. But it does need to be addressed at a federal level. We need to bring technology and consent into parity. We also need to make sure that wherever that clinician lands, wherever parity exists, that the vendors can support it.
How are federal policies such as TEFCA (ONC’s Trusted Exchange Framework and Common Agreement) playing a role in your operations?
The first draft of TEFCA did not take into consideration these vendor requirement pieces. It’s all the HIEs’ responsibility to make sure they can transact every specific piece of data, but there is no teeth in requiring the EHR vendors to be able to send that data out to an HIE, without charging their customers an obscene amount of money for an additional interface cost. So I think the intention of TEFCA is good to increase interoperability on a national scope, but I think the framework on the initial release was flawed.