Colorado HIE Usage Study Shows Most Benefit to Those With Medicaid

A study published in the Journal of Clinical Medicine shows healthcare provider participation in health information exchange in Colorado is associated with reduced emergency department visits and inpatient admissions. The study found a positive impact across patients with all insurance types, with the most significant benefit to those with Medicaid coverage. 

Kelly Joines, the study’s co-author and chief strategy officer at nonprofit Contexture, which runs HIEs for Arizona and Colorado, recently spoke with Healthcare Innovation about broader work Contexture is doing as well as the study, which was conducted by the Center for Improving Value in Health Care (CIVHC), the organization that runs the state’s all-payer claims database.

Using data from the all-payer claims database between 2017 and 2019, the study examined outcomes for more than 42,000 patients, comparing a control group of clinics that do not participate in an HIE to those that subscribe to Contexture’s PatientCare 360 web-based portal for medical record access, its Results Delivery solution for populating patient test results directly into the provider’s EHR or both. 

The results showed an 11% decrease in ED visits among patients with Medicaid coverage compared to an 18.5% increase at control clinics. The study also found clinics using HIE services experienced easier care coordination and reduced administrative burdens, with providers reporting streamlined access to outside test results and patient histories.  

Joines joined CORHIO during its 2009 inception, driving IT operations and becoming the chief information officer. When CORHIO announced plans to merge with Health Current, Arizona’s HIE, forming the regional organization Contexture in 2021, she led the integration activities and is now chief strategy officer. 

HCI: Before we talk about this study, can you say what was the most challenging thing about the merger between CORHIO and Health Current? 

Joines: I would say one lesson is that if you have two organizations with amazing cultures, it doesn't mean that you can bring them together on day one and get one amazing culture. That takes time. 

HCI: Let’s turn to this study. Was one of the goals to look at the difference between how the providers accessed the data — through the web portal vs. tools that are directly integrated into their EHR?

Joines: It wasn't, but that's what I want to do next. When HIEs were created 15 to 20 years ago, there were two foundational goals. Number one was that providers said please get me the results that I ordered into my EHR, so I don't have to have a fax. I need that in my workflow. So that's what our results delivery tool does. 

The other one was give me a longitudinal or 360-degree view of this patient in front of me. That is the portal. We chose to use those for the study because if you're participating in the HIE in Colorado, you most likely had both of those tools, in addition to some new things. But one of our primary goals is to keep our providers and their staff in their workflows, in their EHRs, in their tools. So our portal, with a longitudinal view, is sort of the lowest common denominator of all of our other solutions that are actually integrated. We do a lot of integration of what we call a smart summary, bringing that longitudinal data into the EHR. We also do a lot of notifications or alerts — not just that your patient has hit the ED, but also alerts for gaps in care. 

HCI: Is the HIE itself actually generating care gap notices? Because usually I think of payers or third-party vendors as doing that in value-based care contracts.

Joines: Yes. In Colorado we take part in an electronic clinical quality measures program with our state Medicaid department. We have that longitudinal view. A primary care provider can't decide if I've had a mammogram or not if she doesn't have my image results back, but because we're connected with the imaging center, we can say, yes that's done. 

HCI: Study results of this kind argue for getting as many providers as possible using HIE services. Do you have an idea of what percentage of providers in Colorado are using HIE services? 

Joines: This is a hard question, because we never have a good foundation for the denominator. But I estimate that in Colorado we're at about 80% and what we're missing is a handful of our rural hospitals for reasons that are probably obvious to you. But I am excited about moving forward because we have the foundation of the last mile — dentists, physical therapists, occupational therapists — providers who have been perceived as ancillary services to traditional clinical healthcare providers.

HCI: What about skilled nursing facilities and behavioral health? Do you have good coverage in those areas?

Joines: We have good coverage for skilled nursing facilities. In Colorado, we had a great grant about 15 years ago from our Medicaid department that has helped behavioral health organizations participate by being able to view the data. They have not started participating by sharing data because a lot of those are Part 2 organizations. However, we're doing a platform upgrade and integration with our three regions that goes live in February, and that will provide the tools for the Colorado Front Range that we have not historically had to appropriately share that data in the portal. The western slope of Colorado, which was previously Quality Health Network, and Arizona, previously Health Current, have already been doing behavioral health integration, so CORHIO is catching up.

HCI: Are there other carrots or sticks that the state could use to get that last 20% onboarded? Or could value-based care contracts require HIE participation?

Joines: This is where Arizona's done a really good job in their state Medicaid department on differential adjusted payment programs, and really incentivizing participants to join the HIE. The same is true in Colorado with our state Medicaid department. We have contracts with them that pay the implementation fees for participants to join us. In the long term, you pay your subscription fees, but getting some of those initial implementation fees out of the way is valuable, because these organizations have to pay their EHR vendors for the integration to work with us and pay us. So it's a double hit.

HCI: You mentioned upgrading to a new platform soon. Are you staying with the same vendor, but a new solution? 

Joines: Yes, we’re staying with Health Catalyst, which has been the CORHIO vendor since the beginning of time. It has not been the QHN and Health Current vendor, so for them it's a migration. We’ve been tying all that together, and that will go live in February.

We're sort of a hybrid. We have Health Catalyst for the data coming in and some of our key products, like our portal and our results delivery, but then we've got a best-of-breed situation as well, for our notifications and a bunch of other solutions. 

One of the biggest advantages of this upgrade is having a modern data platform and data warehouse, where we can integrate the data from all three regions and be able then to put things on top of that. It positions us to continue forward with FHIR and with other ways to get at the specific pieces of data that people are interested in rather than just turning on a firehose of data. I always think about this pediatric anesthesiologist who was our prior board chair. He would say to us: “It’s great that you have all this data, but I need just three pieces of information before I put a child to sleep before surgery. Don't make me comb through all that other data.”

HCI: Are there other questions you'd like to ask of the data?

Joines: I have so many. I would like to understand what you and I talked about before — the difference in outcomes and usage — whatever’s measurable — between going out to our portal vs. the tools and the data that's integrated into their EHRs. Also, this study showed a drop in ED visits, but I would like to study what is impacting decreasing inpatient admits. We have closed loop referrals for social determinants of health, and we’re busy integrating that data. I want us to talk about HIE as health data, not just healthcare data. We have anecdotal experience in Colorado with our closed loop referral system that if you've had any sort of social intervention — housing, food, whatever — in the last six months, hospital admits have gone down. I want t to start looking at that more broadly.

HCI: And I know that Colorado is working to develop the Colorado Social Health Information Exchange as a network to securely share physical, behavioral, and social health information between providers involved in whole-person care.

Joines: Yes, exactly. And there's been a long road, with funding and getting people on the same page in terms of thinking about how it works. One issue is that practices may go to refer someone out and there's no access, because there are just not enough community-based organizations out there or not enough bandwidth.