A Change in Mindset: Thinking of HIE as a Utility

July 10, 2015
Although health information exchanges struggle with getting providers to add cumbersome query capabilities into their workflow, many are finding success by providing a suite of other services that become invaluable to hospitals, physician practices and accountable care organizations.

Although health information exchanges (HIEs) continue to struggle with getting providers to add cumbersome query capabilities into their workflow, many are finding success by providing a suite of other services that become invaluable to hospitals, physician practices and accountable care organizations.

In a July 9 webinar presentation to the National Capital Area Chapter of HIMSS, Scott Afzal, program director for CRISP (the Chesapeake Regional Information System for Our Patients), the nonprofit HIE organization in Maryland, gave an update on the expanding set of services CRISP provides, all based on having a master patient index that works to link information about patients visiting the 47 acute-care hospitals in Maryland and most hospitals in the District of Columbia as well as numerous other facilities and providers of care.

Afzal talked about the gradual growth of CRISP going back to 2009 as it built infrastructure and governance and then started to stand up services. “We really focused on how to create value and enhance services,” he said. Sustainability isn’t a one-time thing you achieve, he stresses. Like any business, CRISP is in a month-to-month effort to justify the value of what it provides to paying customers. But recently, he added, CRISP has been able “to entrench our services into clinical practice, with things like the prescription drug monitoring program, to the point where we become like a utility.”

One of the things Afzal mentioned was that it isn’t always easy to get a clear sense of usage of HIEs, because metrics aren’t always easy to pull out, and some use different terminologies, so it can be difficult to compare.

The fastest-growing and most popular service CRISP offers is an encounter notification service (ENS), which sends summary alerts to providers and ACOs when their patients or members arrive at the hospital. It also has started sending notices to hospitals when a discharged patient is seen in another hospital. That service has grown to 372 subscribing entities and more than 600,000 notices a month. “It is a highly utilized service,” Afzal said. “That is where I would have started if we could start over again.”

Here is how it works, according to the organization: Hospitals send CRISP real-time encounter messages (called “ADTs”) that carry facility, medical record number, visit IDs, and other information about visits. The ADTs are processed through CRISP’s Master Patient Index (MPI) generating a Unique Identifier (CRISP ID) linking patients across individual hospitals. 

The query portal has not grown as fast. It has grown from only around 3,000 queries a month initially to more than 110,000 per month, a reasonably strong number, Afzal said. There are currently 6,800 users, but there is resistance to using it. “While it is a great tool, query has work flow challenges,” he said. “Not only do you have to have a rich set of data across a wide geography, you have to make it easy to use.” But it is not perceived as easy to use, even if it is faster than any other way to get the data. Clinicians have to log into a separate web site and enter credentials and search information. “We talk a lot about interoperability, but a lot of times what we have is connectivity,” he said, adding that CRISP is working on ways to better integrate the solution with EHRs.

CRISP also offers Direct messaging and a prescription drug monitoring program and is very close to onboarding with the eHealth Exchange to facilitate information sharing with the Social Security Administration regarding disability claims.

CRISP’s Reporting Service is also central to a statewide effort in Maryland to control costs and lower readmissions. A Centers for Medicare and Medicaid Innovation (CMMI) all-payer model demonstration contract established a readmission reduction target that requires Maryland Medicare rates to be equal or below national Medicare rates by 2018. To support the waiver goal, the state approved a readmission reduction incentive program in 2014. This program is the first to measure readmissions both to the same hospital and to other hospitals within Maryland.

Each month, the CRISP ID is linked to other data to run the CMS readmission logic and to perform other inter-hospital analysis. CRISP distributes hospital reports through a secure site called the CRISP Reporting Services Portal.

Afzal went into a nice level of detail in describing how the master patient index from IBM Initiate uses a probabilistic approach to allow for the fact that there is a lot of dirty and incomplete data in the 350 source systems that feed data to CRISP. There are permutations that are close enough that probabilistic algorithms can link them with a high confidence level, he said.

He stressed that the master patient index is the heart of all CRISP’s exchange services. Seeing data not just from your health system but also across the community is the key to delivery reform and to more timely interventions and care management. “These services become central to that type of engagement with a population,” he said.

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