Healthcare leaders will generally agree that the electronic exchange of health information is critical to improving the quality and efficiency of the nation’s struggling healthcare infrastructure, one in which costs rise faster than inflation. But for most patient care organizations, effective health information exchange (HIE) remains quite challenging.
In Indiana, however, the Indiana Health Information Exchange (IHIE) is building a model that has potential to blaze the trail for other HIEs across the U.S. In 2004, IHIE was launched to help lower Indiana’s staggering healthcare expenses and improve the state’s consistent poor rankings in leading health indicators. In the years since its inception, IHIE has continuously been working to flip that script, first, through its DOCS4DOCS (D4D) Service, a clinical messaging application in which more than 25,000 providers in over 6,000 locations throughout Indiana receive clinical results as the ordering physician.
IHIE officials say that the D4D Service is the backbone for the delivery of three million monthly clinical visit summaries and 17 million monthly clinical results to healthcare providers in Indiana. Launched 11 years ago by IHIE, the D4D Service served to standardize the way patient information was presented and streamlined, and how this information was received across an entire community and state. When messages come in, IHIE does a provider lookup for which providers are supposed to get those clinical results, says Keith Kelley, vice president of solution delivery at IHIE. “We do that lookup, and then look at the physician’s delivery preference. All 25,000 physicians have given us a preference of how they want to get results—workflow is very important to them. Then we deliver that result to the physician in the way they want to receive it,” Kelley says.
For providers, this service proves especially beneficial for the transitions of care requirement in the Centers for Medicare & Medicaid Services’ (CMS) meaningful use program, which mandates that eligible professionals electronically transmit summary care records for transitions of care and referrals. While most of the country was attempting to do this task with Direct secure messaging, there were issues with Direct, including email messages that didn’t fit the workflow of physicians, as well as many physicians not having Direct email addresses, Kelley says.
“We were able to leverage D4D and the delivery preference, so we built a solution where the sending organization sent us the CCD [Continuity of Care Document] to get to the next provider of care. We did the physician lookup, looked at the delivery preference, and delivered the CCD the same way they get their other results such as labs and radiology reports,” Kelley says, noting that now, IHIE is also set up to send a CCD to any Veterans Affairs (VA) facility in the country—inpatient or outpatient. Further, today, IHIE is the largest provider of transition of care summaries in the U.S.; by mid-2015, IHIE delivered more than 1.2 million CCDs for over 56 hospitals and their providers, its officials note. Kelley adds that the service has a “FedEx effect, in that it’s all about getting the result delivered within 30 minutes quickly, accurately, and securely.”
As such, at the Indianapolis-based Community Health Network, providers connected to IHIE no longer have to wait hours, days, or weeks to get information they have requested from other facilities, says Christina Grindle, network provider medical informatics consultant and network IHIE operations analyst at Community. Grindle is in charge of onboarding new providers to IHIE, as well getting a feel of what providers like and dislike about the HIE. “One of the things that we have found is that doing Direct is laborious on both our part and the other connector that we’re trying to connect to,” Grindle says. “Practices often don’t have the ability or the right people to view the Direct connection. IHIE makes it easy.”
When the D4D service was started, IHIE had five large Indianapolis based health systems sign up for it, which gave it the critical mass needed 11 years ago to get the service going and make it viable, Kelley says. “What we see in other parts of country is that they try to start a clinical messaging service or transitions of care service with one or two senders, but you really need that critical mass to get going,” he says. Now, though, because electronic health records (EHRs) are better at delivering results, the value proposition isn’t as much on getting the message delivered, but about workflow, EHR integration, and how it’s delivered, Kelley says. “We have evolved to meet that changing demand,” he says.
To this end, IHIE recently launched its latest enhancement to deliver information contained in the D4D system directly to providers’ EHR systems. In fact, as of December 2015, more than 4,000 providers on 28 different EHR systems are now participating in this service. One such collaboration in December between IHIE and Indianapolis-based St. Vincent Medical Group (SVMG), a member of Ascension, allows the more than 900 SVMG physicians to receive patient information and results via integration with the organization’s athenahealth EHR system, Kelley says.
Community Health’s Grindle further notes how the provider-specific preferences make for a more enjoyable user experience, a sentiment that is agreed by Dawn Ross, R.N., clinical informatics director at Indiana University (IU) Health, also in Indianapolis. Ross says that previously, the organization’s health information management department would deliver these clinical documents, a procedure now entirely done via the HIE. “Our physicians can decide what they want, how they want it, and who they want it from,” she says. “We have an integrated EHR at IU Health, and if a patient is at one of our hospitals and then goes to the office setting for a follow-up appointment, the office physician can decide through his or her HIE filters what he or she wants to see, such as discharge summaries from one hospital, but not another. This process cuts down on the amount of papers in our offices, and the amount of opportunities to have things escape and land in the wrong hands,” Ross explains.
In addition to the D4D Service, part of IHIE’s care continuity system includes a community-wide repository called the Indiana Network for Patient Care (INPC). Related to the D4D Service, but separate, the INPC, accessed via IHIE’s CareWeb application, draws upon the clinical information passed through IHIE and delivered to the ordering physician via the D4D Service and the clinical abstracts. In essence, the INPC is a virtual EHR, providing information not just from a single source or singe health system to the ordering physician, but from information from IHIE’s entire hospital network, as it contains more than four billion pieces of clinical data from some six million patients.
“With the INPC, we take that same lab result or radiology report and we tear it up into its individual data elements, and store it in a series of repositories so that it’s available from a patient-centric perspective,” Kelley notes. The idea, he continues, is that when the patient shows up to that next provider of care, whether it’s scheduled or not, a patient summary can be assembled and made available to the clinician, who can unlock access to everything known about that patient. As Kelley puts it, “We are parsing the data, normalizing it, and making it available on demand to that physician based on a specific patient encounter.”
These services have proved valuable for Charles E. “Chuck” Christian, vice president of technology and engagement at IHIE since last April, and longtime CIO at Good Samaritan Hospital in Vincennes, Ind. Christian, who was Good Samaritan’s CIO for 26 years, started collaborating with IHIE in 2010. “One of the value propositions for us was that healthcare is provided both locally and regionally,” Christian says, giving a scenario in which a patient goes to Indianapolis for heart surgery, but then gets into trouble after being transitioned home, and now wants to go to the ER. “The physician in the ER has no information about any treatment that occurred during the patient’s admission and requisite surgery in Indianapolis,” he says. “The ability to open up the patient’s general record of all information regardless of where the care in Indiana has occurred, so that the physician can have access to that information and can look at any report or document being uploaded to INPC, becomes a viable and valuable historical record for that patient,” Christian says.
Bucking the Trend
To date, HIEs have had a myriad of struggles, including but not limited to: defining the return on investment for their provider community; getting stakeholders to agree on governance and policies; developing standards; determining how to exchange information with competing organizations; and maintaining financial sustainability. While IHIE isn’t foreign to these challenges, it has put the right policies in place to help reduce their burdens.
Governance: IHIE’s governance structure was put in place in the mid 1990s by its creator, the Indianapolis-based Regenstrief Institute, a medical and public health informatics research organization. The governance group at IHIE is made up of all of its customers, in addition to other stakeholders, Kelley notes. “We have a representative governance model that works very well, and the federal eHealth Exchange has used a lot of the structure that we have established that we have created as a model for their national network,” he notes.
Kelley tells the story of when one of the first Medicare Pioneer accountable care organizations (ACOs) in the country came to IHIE and wanted to have access to all of the data for their Medicare ACO patients. “Previously you had to have a physician-patient relationship through some encounter before getting that data,” Kelley says. “We said that we can’t make that tough of a decision and we have to take it to our governance group. So we did that and told them that this Pioneer ACO wants us to share all of the information about their 25,000 Medicare ACO patients with them so they can better manage their population. We asked, ‘Will you grant them access to your data for that purpose?’ We thought that request would get declined, but after a 30-second pause, these senior executives from health systems realized they would soon need that information for their own ACO patients, so they approved it unanimously for that use case,” Kelley recalls. Christian adds that when you’re a steward of information, like IHIE is, and you have aggregation, like IHIE does, there has to be a consensus process about who gets access to the information.
Competition: Kelley says that competition among healthcare organizations will never completely vanish, but that Indianapolis, with five large health systems, makes for an ideal size for an HIE. “One of the tenets we had when the exchange was formed was that CEOs were coming together and saying we should not compete on the data, but on what to do with the data. This is what’s right for the physician and patient, so this is what we should do,” he says. However, he adds while that might work for a market the size of Indianapolis, for a market like Chicago, it’s difficult to get all of those health systems in a room and agree to that. “We do have challenges with hospital systems and payers; there is still a data sharing challenge between those types of organizations. There is competition there regarding withholding data rather than sharing it. We have overcome that, though it hasn’t been easy,” Kelley says.
Interoperability standards: The sheer act of building Health Level Seven International (HL7) interfaces and normalizing the data within such a large community is something that no other state or community has accomplished, IHIE officials attest. “HL7 has quite a bit of variability and lots of options, so that makes it challenging,” Kelley says. “Even today, when we work with hospitals and well-known EHR vendors, we still get non-standard HL7 messages that don’t adhere to this strict standard. But we have managed that, as well as those millions of messages that we process,” he says. All of this integration work used to be outsourced, first to Regenstrief, then to the AT&T Healthcare network, but as of March 2015 it started to be done internally, notes Kelley.
“We’re one of the few HIEs in the country that eats our own cooking, if you will,” adds Christian. “That’s one of the things that make us agile. We work with our customers in providing services they need related to the operation rather than waiting upon a vendor-formulated solution that provides enhancements that may or may not be what our customer wants,” he says.
Setting the Pace
Certainly, as a pioneer HIE organization, IHIE, now the largest of its kind in the U.S., connecting more than 30,000 healthcare providers in 17 states, has developed a model that others can replicate. Kelley points to two aforementioned factors, above all, as the main reasons for success: having control of its software development integration and listening to its customers, rather than trying to sell them something. “We have engaged in the strategic planning process with full support from our board, which includes our largest customers and other stakeholders, and we listen to what they want us to do and align our objectives with theirs,” he says.
To this end, Kelley notes that at first, IHIE was set on hitting homeruns by trying to develop the next great application, but after feedback from its customers, it started to aim for doubles in which services can be delivered in a fairly short amount of time. He gives an example that is as simplified as sign-on, when a provider can, with a single click, hit a button that logs he or she into IHIE’s repository -based access and land on that patient he or she is looking for. “We have rolled that out with Epic and with Cerner, and our customers deem that as highly valuable, and it’s something we can deliver on in a relatively short amount of time,” Kelley says.
Christian adds that as the industry moves into more risk-based reimbursement models and as large HIE customers get into risk pools with ACOs, access to information becomes much more important to organizations’ business models. “Being able to help manage the coordination of care throughout the course of a patient’s [lifetime] will be extremely important,” Christian says. “If you look at what’s coming from CMS, by 2018, they want the grand majority of the care they are paying for to be [mostly] at risk. So it’s really important for us to manage and provide data to help inform the care processes along the way.”