Defining a Health Information Exchange
The United States is facing Sky Bird, the largest shortage of healthcare practitioners in our country’s history, compounded by an ever-increasing geriatric population. In 2005, one geriatrician existed for every 5,000 US residents over 65, and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it uniformly.
Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. Healthy information exchange can help improve safety, reduce the length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner, and more productive. The aging US population and those impacted by chronic diseases like diabetes, cardiovascular disease, and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.
This efficiency can only be attained by standardizing how the communication takes place. Healthbridge, a Cincinnati-based HIE and one of the largest community-based networks, reduced their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, “Interoperability without standards is like language without grammar. In both cases, communication can be achieved, but the process is cumbersome and often ineffective.”
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United States retailers transitioned over twenty years ago to automate inventory, sales, and accounting controls, improving efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid-America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes, and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the “art of medicine” is a barrier to more productive, efficient, and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.
History of Health Information Exchanges
Major urban centers in Canada and Australia were the first to implement his successfully. These early networks’ success was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has successfully replaced antiquated interactions like faxing, mail, and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks of health systems to integrate and communicate.
Standardization will ultimately impact how effective communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on its third version, which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.
In the United States, one of the earliest HIE’s started in Portland, Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The network’s goals are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups, the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum, and Maine Health Information Center (Onpoint Health Data), began their efforts in 2004.
In Tennessee, Regional Health Information Organizations (RHIO’s) were initiated in Memphis and the Tri-Cities region. Cars park, a 501(3)c, in the Tri-Cities region, was considered a direct project where clinicians interact directly with each other using Carespark’s HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta, the midsouth eHealth Alliance is an RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical Center, and UT Medical. These regional networks allow practitioners to share medical records, lab values, medicines, and other reports efficiently.
Seventeen US communities have been designated as Beacon Communities across the United States based on their hies development. These communities’ health focus varies based on the patient population and prevalence of chronic disease states, i.e., CVD, diabetes, asthma. The communities focus on specific and measurable improvements in quality, safety, and efficiency due to health information exchange improvements. In Byhalia, Mississippi, just south of Memphis, the closest geographical Beacon community to Tennessee was granted a $100,000 grant by the Department of Health and Human Services in September 2011.
A healthcare model for Nashville to emulate is located in Indianapolis, IN, based on geographic proximity, city size, and population demographics. Four Beacon awards have been granted to communities in and around Indianapolis, Health and Hospital Corporation of Marion County, Indiana Health Centers Inc, Raphael Health Center, and Shalom Health Care Center Inc. Also, Indiana Health Information Technology Inc has received over 23 million dollars in grants through the State HIE Cooperative Agreement and 2011 HIE Challenge Grant Supplement programs through the federal government. These awards were based on the following criteria:1) Achieving health goals through health information exchange 2) Improving long term and post-acute care transitions 3) Consumer mediated information exchange 4) Enabling enhanced query for patient care 5) Fostering distributed population-level analytics.
Regulatory Aspects of Health Information Exchanges and Healthcare Reform
The Health and Human Services (HHS) department is the regulatory agency that oversees health concerns for all Americans. The HHS is divided into ten regions, and Tennessee is part of Region IV, headquartered out of Atlanta. Anton J. Gunn is the first African American elected to serve as regional director and brings a wealth of experience to his role based on his public service regarding underserved healthcare patients and health information exchanges. This experience will serve him well as he encounters societal and demographic challenges for underserved and chronically ill patients throughout the southeast area.
The National Health Information Network (NHIN) is an HHS division that guides the exchange standards and governs regulatory aspects of health reform. The NHIN collaboration includes departments like the Center for Disease Control (CDC), social security administration, Beacon communities, and state HIE’s (ONC).11 The Office of National Coordinator for Health Information Exchange (ONC) has awarded $16 million in additional grants to encourage innovation at the state level. Innovation at the state level will ultimately lead to better patient care through reductions in replicated tests, bridges to care programs for chronic patients leading to continuity, and finally, timely public health alerts through agencies like the CDC based on this information.
Dollars fund 12 The Health Information Technology for Economic and Clinical Health (HITECH) Act from the American Reinvestment and Recovery Act of 2009. HITECH’s goals are to invest dollars in community, regional, and state health information exchanges to build effective networks connected nationally. Beacon communities and the Statewide Health Information Exchange Cooperative Agreement were initiated through HITECH and ARRA. To date, 56 states have received grant awards through these programs totaling 548 million dollars.
History of Health Information Partnership TN (HIPTN)
In Tennessee, the Health Information Exchange has been slower to progress than places like Maine and Indiana, based in part on our state’s diversity. The delta has a vastly different patient population and health network than middle Tennessee, which differs from eastern Tennessee’s Appalachian region. In August of 2009, the first steps were taken to build a statewide HIE consisting of a non-profit named HIP TN. A board was established at this time, with an operations council formed in December.
HIP TN’s first initiatives involved connecting the work through Carespark in northeast Tennessee’s s tri-cities region to the Midsouth ehealth Alliance in Memphis. State officials estimated a cost of over 200 million dollars from 2010-2015. The venture involves stakeholders from medical, technical, legal, and business backgrounds. The governor in 2010, Phil Bredesen, provided 15 million to match federal funds in addition to issuing an Executive Order establishing the office of eHealth initiatives with oversight by the Office of Administration and Finance and sixteen board members. By March 2010, four workgroups were established to focus on technology, clinical, privacy and security, and sustainability.
By May of 2010, data sharing agreements were in place, and a production pilot for the statewide HIE was initiated in June 2011 along with a Request for Proposal (RFP), which was sent out to over forty vendors. In July 2010, a fifth workgroup, the consumer advisory group, was added. In September 2010, Tennessee was notified that they were the first states to have their plans approved after a Program Information Notice release (PIN). Over fifty stakeholders came together to evaluate the vendor demonstrations, and a contract was signed with the chosen vendor, Axolotl, on September 30th, 2010.
At that time, a production goal of July 15th, 2011 was agreed upon, and in January 2011, Keith Cox was hired as HIP TN’s CEO. Keith brings twenty-six years of tenure in healthcare IT to the collaborative. His previous endeavors include Microsoft, Bellsouth, and several entrepreneurial efforts. HIP TN’s mission is to improve access to health information through a statewide collaborative process and provide security infrastructure in that exchange. HIP TN’s vision is to be recognized as a state and national leader who supports measurable improvements in clinical quality and efficiency to patients, providers, and payors with secure HIE.
Robert S. Gordon, the board chair for HIPTN, states the vision well, “We share the view that while technology is a critical tool, the primary focus is not the technology itself but also improving health.” HIP TN is a nonprofit, 501(c)3, solely reliant on state government funding. It is a combination of centralized and decentralized architecture. The key vendors are Axolotl, which acts as the umbrella network, ICA for Memphis and Nashville, with CGI as the northeast Tennessee vendor.15 Future HIP TN goals include a gateway to the National Health Institute planned for late 2011 and a clinician index in early 2012.
One of the original regional health exchange networks, Cars park, voted to cease operations on July 11, 2011, based on a lack of financial support for its new infrastructure. The data-sharing agreements included 38 health organizations, nine communities, and 250 volunteers.16 Carespark’s closure clarifies the need to build a network that is not solely reliant on public grants to fund its efforts, which we will discuss in this paper’s final section.
Current Status of Healthcare Information Exchange and HIPTN
Ten grants were awarded in 2011 by the HIE challenge grant supplement. These included eight states’ initiatives and served as communities we can look to for guidance as HIP TN evolves. As previously mentioned, one of the most awarded communities lies less than five hours away in Indianapolis, IN. Based on the similarities in our health communities, patient populations, and demographics, Indianapolis would provide an excellent mentor for Nashville and the hospital systems that serve patients in TN. The Indiana Health Information Exchange has been recognized nationally for its Docs for Docs program and how collaboration has taken place since its conception in 2004.
Kathleen Sebelius, Secretary of HHS, commented, “The Central Indiana Beacon Community has a level of collaboration and the ability to organize quality efforts effectively from its history of building long-standing relationships. We are thrilled to be working with a community that is far ahead in the use of health information to bring positive change to patient care.” Beacon communities that could act as guides for our community include the Health and Hospital Corporation of Marion County and the Indiana Health Centers based on their recent awards of $100,000 each by HHS.
A local model of excellence in practice EMR conversion is Old Harding Pediatric Associates (OHPA), which has two clinics and fourteen physicians who handle a patient population of 23,000 and over 72,000 patient encounters per year. OHPA’s conversion to electronic records in early 2000 occurred due to the pursuit of excellence in patient care and the desire to use technology in a way that benefitted their patient population.
OHPA established a cross-functional work team to improve its practices in facilities, personnel, communication, technology, and external influences. Noteworthy was chosen as the EMR vendor based on user-friendliness and the similarity to a standard patient chart with tabs for files. The software was customized to the pediatric environment, complete with patient growth charts. Windows was used as the operating system based on provider familiarity. Within four days, OHPA had 100% compliance and use of their EMR system.
The Future of HIP TN and HIE in Tennessee
Tennessee has received close to twelve million dollars in grant money from The State Health Information Exchange Cooperative Agreement Program.20 Regional Health Information Organizations (RHIO) need to be fully scalable to allow hospitals to grow their systems without compromising integrity as they grow.21and. The systems located in Nashville will play an integral role in this nationwide scaling with companies like HCA, CHS, Iasis, Lifepoint, and Vanguard. The HIE will act as a data repository for all patient’s information that can be accessed from anywhere and contains a full history of the patient’s medical record, lab tests, a physician network, and medicine list.
To entice providers to enroll in the statewide HIE, tangible value to their practice must be shown with better, safer care. In a 2011 HIMSS editor’s report, Richard Lang states that instead of a top-down approach, “A more practical idea may be for states to support local community HIE development first. Once established, these local networks can feed regional HIE’s and connect to a central HIE/data repository backbone. States should use a portion of the stimulus funds to support local HIE development.”22 Mr. Lang also believes the primary care physician has to be the foundation for the entire system since they are the main contact point for the patient.
One piece of the puzzle often overlooked is the patient investment in a functional EHR. To bring together all the HIE puzzle pieces, patients will need to play a more active role in their healthcare. Many patients do not know what medicines they take every day or whether they have a living will. Several versions of patient EHR’s like Memitech’s 911medical id card exist, but very few patients know or carry them.23 One way to combat this lack of awareness is to use the hospital as a catch-all and discharge each patient with a fully loaded USB card via case managers. This strategy also might lead to better compliance with post-in-patient therapies to reduce readmissions.
The implementation of connecting qualified organizations began earlier this year. To fully support organizations to move toward qualification, the Office of National Coordinator for HIE (ONC) has designated regional education centers (TN rec) that assist providers with educational initiatives in areas like HIT, ICD9, and ICD10 training and EMR transition. Qsource, a non-profit health consulting firm, has been chosen to oversee TNrec. To ensure sustainability, Tennessee must build a private funding network so that what happened with Carespark won’t happen to HIP TN.
The eHealth Initiatives 2011Survey Report states that of the 196 HIE initiatives, 115 act independently of federal funding, and those independent HIE’s break-even through operational revenue. Some of these exchanges were in existence well before the American Recovery and Reinvestment Act in 2009. Startup funding from grants is only meant to get the car going, so to speak, the sustainable fuel, as observed in Carespark, has to come from the value that can be monetized. KLAS research reports that 54% of public HIE’s were concerned about future sustainability while only 35% of private HIE’s shared this concern.
Hospital Implications of HIP TN (A Call to Action)
From a Financial perspective, taking our hospital into the future with EMR and an integrated statewide network has profound implications. In the short term, the cost to find a vendor, establish EMR in and outpatient will be an expensive proposition. The transition will not be easy or finite and will involve constant evolution as HIP TN integrates with another state hies. To get a realistic idea of the benefits and costs associated with health information integration. We can look to HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37 million dollars in avoided services and 15 million in productivity reduction.
Specific areas of savings include paper or fax costs $5 versus $0.25 electronically, virtual health record savings of $50 per referral, $26 saved per ED visit, and $17.41 per patient/year due to redundant lab tests, which amount to $52 million for a population of 3 million patients. In Grand Junction, Colorado Quality Health Network lowered their per capita Medicare spending to 24% below the national average, gaining President Obama’s recognition in 2009. The Santa Cruz Health Information Exchange (SCHIE), with 600 doctors and two hospitals, achieved sustainability in the first year of operation and uses a subscription fee for all the organizations interacting with them.
In terms of government dollars available, meaningful use incentives exist to encourage hospitals to meet twenty-five objectives in the first phase (2011-2012) and adopt an approved EHR vendor. ARRA specified three ways for EHR to be utilized to obtain Medicare reimbursement. These include e-prescribing, health information exchange, and submission of clinical quality measures. The objectives for phase two in 2013 will expand on this baseline. Implementation of EHR and Hospital HIE costs are usually charged by the bed or by the number of physicians. Fees can range from $1500 for a smaller hospital up to $12,000 per month for a larger hospital.