Throughout U.S. healthcare, health information exchange (HIE) leaders are becoming well aware that they’ll need to continue finding new ways to innovate to position their organizations for future success. Last year in Iowa, Stephen M. Stewart was tapped to run the Iowa Health Information Network (IHIN), the official statewide HIE. Stewart, previously a hospital CIO and health IT consultant, walked into a situation that needed a significant turnaround.
In March 2018—about three months before Stewart took over as president and CEO—IHIN implemented a new technology solution from Orion Health as executives of the information-sharing network were looking for robust data management platform to manage growth in data volume, complexity and speed. When Stewart took over, he knew that IHIN’s membership base would need a lot of time to get up to speed with the new data-sharing technology since the old platform was being completely shut down. “Our previous leadership might have underestimated the time it would take to facilitate the changes that needed to be made,” he says candidly.
Nonetheless, over the past 18 months, things have been progressing for IHIN. In 2018, the HIE’s members were already making significant strides in proactive care coordination as they exchanged 3.6 million ADT (admission/discharge/transfer) messages, with nearly 60 sites actively sending information to let physicians know when their patients enter the ER or hospital.
What’s more, Stewart points out that in June 2018 when he took over, there were zero lives in IHIN’s electronic master patient index (MPI)—an electronic database that holds key information on every patient who receives healthcare services—whereas today, there are approximately 1.8 million lives in the MPI. “It’s been a slow and difficult process, but I think we will push well over the 2 million mark by the end of the year,” Stewart says, noting that the last major health system in the state, with 42 hospitals, was scheduled to go live in late November. This health system had been participants of the HIE all along, but following the go-live, will start submitting its data to the network.
Stewart recently spoke with Managing Editor Rajiv Leventhal about IHIN’s latest progressions, how it is continuing to innovate and create value for its members, and what its greatest challenges are today. Below are excerpts of that conversation.
You mentioned that getting data on the network has been slow and difficult at times. Why has that been the case?
I have to be brutally honest; I spent 10 years as a hospital CIO, and it’s not that getting the data [onto an HIE] is a big deal, but it’s more so about getting into the work schedule of those facilities. For example, when an organization is looking at an upgrade of a new version of Epic versus converting data to IHIN, the Epic upgrade will win every time. We once lost a year [with IHIN and a hospital] because the [facility] was two versions out of date with Epic and they had to make a change. It just takes a lot of time since getting the provider’s allocation of IT resources to do the job can be a slow process.
But we are getting there. The population of Iowa is 3.2 million people, and we have participation agreements in place with 702 facilities—that basically covers all the hospitals in the state, multiple clinics, and other organizations, too.
What’s the quality of the data that’s being exchanged on the network today?
It’s never as advanced as you’d like to see it be, but at the moment we’re in the arena of C-CDA [consolidated clinical document architecture] exchange and that is going quite well. One thing we have done, with Orion’s help, is build connections through the eHealth Exchange Gateway, and through that, to CommonWell and Carequality where we can share data nationally. We have also built connections to the Patient-Centered Data Home initiative [which helps patients by proactively alerting their providers when they have a health event away from home], of which we are a member of the western region, so we’re sharing data there.
How is IHIN working to continue to create value for its participants?
We are trying to broaden and strengthen our governance structure. Iowa’s governor recently convened a healthcare roundtable with state leaders, and four subgroups were developed, one of which was data sharing and use. That subgroup came up with 18 priorities they wanted to execute, broken into three tiers.
From that, one process we are working on improving is around lab and radiology results. Members are already sending their lab and radiology reports to us, but if they need that to be shared with a primary care physician (PCP) or a local physician outside of the organization that did the test, rather than each hospital building a network to communicate with them, we will work on building a process that will just route the data to the necessary PCPs.
Another big initiative on our part is managing the cost structure. One of the things we are working on with Orion is creating a multiple HIE presence and instance of the Orion Amadeus platform. Right now, it’s just ourselves and one of the Minnesota HIEs, but we are looking at other sites as well, to combine together and find a way to reduce costs. By collaborating we can reduce each of the individual organization’s costs by some amount, while Orion’s revenue base grows.
The license we have from Orion enables multiple users, and in our instance, they base the use for that on a percentage of our participation. So it’s a real risk/reward sharing [proposition] as we expand and get additional states to come on board—should we be fortunate enough to do so.
What are the core challenges involved with finding new ways to create value propositions?
There is no question that the future of statewide HIEs will be very dependent on the sustainability argument and creating a value proposition. And you create value by doing two things: by providing different services for your participants that they would be willing to pay for, and haven’t paid for in the past; and you also get there by constraining your cost basis wherever possible—not to the point that you are sacrificing what you deliver, but that you are creating creative ways to manage it.
For example, we also handle the required lab reporting for Iowa. Years ago, the state chose a product [for this], and we are working with the Department of Public Health to bring three or four other states onto the same instance of this tool in an effort to reduce costs. For Iowa, the cost of that is over $400,000 per year. So IHIN is working in partnership with the vendor of the software, and if we were to get five states on board, everyone’s costs could go down to about $220,000 per year, and the vendor gets more than $1 million in revenue—so everyone wins. Continuing those collaborative efforts is the way HIEs will have to go moving forward.
Personally, I think some state HIEs will struggle with that if they don’t convene all constituents together and govern the process. That’s a lot more difficult than it seems; the major constituents in these efforts are state government people, and they tend to want to go in a direction that ‘serves their needs.’ But the provider community tends to feel that some of the things the state wants them to do should be funded by the state.
Reconciling those two divergent point of views is not the easiest thing. The good thing is that in Iowa, you now have really strong health policy people that are open minded and interested in finding creative solutions. In the last 12 months, a lot of progress has been made in bridging some of the gaps. And I’m not saying any of these constituents are 100 percent right or 100 percent wrong, but everyone has different needs, so charting that course, through what can be pretty troubled waters, can require a great deal of effort. For private sector folks who want to move quickly, it can be frustrating because it’s an incredibly slow process.
A lot of our counterparts are developing software, and doing things in the big data and analytics arena, and that is a good thing. But it is also challenging in Iowa, because to be successful, a lot of that has to be driven by claims data, and in this state right now, the Medicaid agency is not willing to share claims data, nor is the largest commercial payer. And they have business reasons for that. So to create that in Iowa is a tall task and that can make population health management very difficult.
In the end, I think one of the biggest keys to the future of statewide HIEs will be innovation and collaboration. The 21st Century Cures Act provides some opportunities for funding sources that encourage collaboration in the world of interoperability, and those are discussions that weren’t even taking place just two years ago.