CEO’s Perspective on Health Information Exchange
Defining Health Information Exchange
The United States faces the largest shortage of healthcare practitioners in our nation’s history exacerbated by a growing geriatric population. In 2005 there was one geriatric for every 5,000 US residents over the age of 65 and only nine out of 145 medical schools trained geriatrics. By 2020 the industry is estimated to be short of 200,000 doctors and more than one million nurses.
Never, in the history of US healthcare, have so many demands with so few personnel. As these shortcomings are coupled with the growing geriatric population, the medical community must find ways to provide timely and accurate information to those who need it in a uniform manner.
Imagine if flight controllers spoke the native language of their country, not the current international aviation language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare.
Healthy exchange of information can help improve safety, reduce length of hospital stay, reduce medication errors, reduce repetition in laboratory tests or procedures and make the healthcare system faster, leaner, and more productive.
The aging US population along with those with chronic diseases such as diabetes, cardiovascular disease and asthma need to see more specialists who must find ways to communicate with primary care providers effectively and efficiently.
This efficiency can only be achieved by standardizing the way communication takes place. Healthbridge, a Cincinnati-based HIE and one of the largest community-based networks, was able to reduce a potential disease outbreak from 5 to 8 days to 48 hours with 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 complex and often ineffective.”
United States retailers transitioned over twenty years ago to automate inventory, sales, accounting controls all of which increase efficiency and effectiveness. While it is inconvenient to think of patients as inventory, this may be part of the reason for the lack of transition in primary care settings to automation of patient records and data.
Imagine a Mom & Pop hardware store in any central American square full of inventory on the shelves, ordering duplicate widgets based on a lack of information regarding current inventory. Visualize Home Depot or Lowes and you’ll see at a glance how automation has transformed 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 the exchange of information have been around since 1989, but interfaces have recently developed more rapidly thanks to increased standardization of regional and state health information exchange.
History of Health Information Exchange
Major urban centers in Canada and Australia were the first to successfully implement HIE. The success of this initial network was linked to integration with existing primary care EHR systems. Health Level 7 (HL7) represents the first standardized system of health language in the United States, starting with the meeting at the University of Pennsylvania in 1987.
HL7 has successfully replaced archaic interactions such as fax, mail, and direct provider communications, which often represent duplication and inefficiency. Process interoperability enhances human understanding across health system networks to integrate and communicate. Standardization will ultimately have an impact on how effectively that communication functions in the same way that grammatical standards encourage better communication.
The United States National Health Information Network (NHIN) sets the standards that encourage the delivery of communications between these health networks. HL7 is now in its third version which was published in 2004. The aim of HL7 is to improve interoperability, develop coherent standards, educate the industry about standardization and collaborate with other sanctions bodies such as ANSI and ISO which are also concerned with process improvement.
In the United States, one of the earliest HIEs began in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest HIE in the state. The purpose of the network is to improve patient safety, improve the quality of clinical care, increase efficiency, reduce duplication of services, identify public threats more quickly and expand access to patient records. The four founding groups of the Maine Health Access Foundation, the Maine CDC, the Maine Quality Forum and the Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.
The Tennessee Regional Health Information Organization (RHIO’s) started in Memphis and the Tri Cities area. Carespark, 501(3)c, in the Tri Cities region is considered a hands-on project in which doctors interact directly with each other using Carespark’s HL7 compliant system as an intermediary for translating data in a two-way manner. Veteran Affairs (VA) Clinics also played an important role in the early stages of building this network.
In the delta, the midsouth eHealth Alliance is an RHIO linking Memphis hospitals such as 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. This regional network allows practitioners to share medical records, drug lab values, and other reports in a more efficient way.
Seventeen US communities have been designated as Beacon Communities across the United States based on their HIE development. This public health focus varies based on patient population and prevalence of chronic diseases such as CVD, diabetes, asthma. The community focuses on specific and measurable improvements in quality, safety and efficiency due to increased exchange of health information. The geographic Beacon Community closest to Tennessee, in Byhalia, Mississippi, just south of Memphis, was awarded a $100,000 grant by the Department of Health and Human Services in September 2011.
A health care model for Nashville to replicate is located in Indianapolis, IN based on geographic proximity, city size and population demographics. Four Beacon awards have been awarded to communities in and around Indianapolis, Marion County Healthcare and Hospitals Company, Indiana Inc Health Center, Raphael Health Center, and Shalom Inc Health Care Center.
In addition, Indiana Inc. Health Information Technology. has received more than $23 million in grants through the State HIE Cooperation Agreement and the 2011 HIE Challenge Grant Supplement program through the federal government. This award is based on the following criteria: 1) Achieving health goals through the exchange of health information 2) Enhancing long-term and post-acute care transitions 3) Consumer-mediated information exchange 4) Enabling increased demand for patient care 5) Fostering distributed population-level analysis.
Regulatory Aspects of Health Information Exchange and Health Service Reform
The Department of Health and Human Services (HHS) is the regulatory agency that oversees health issues for all Americans. HHS is divided into ten territories and Tennessee is part of Region IV headquartered in Atlanta.
Regional Director, Anton J. Gunn is the first African-American to be elected as regional director and brings a wealth of experience to his role based on his public services especially regarding underserved healthcare patients and the exchange of health information. This experience will serve him well as he faces the social and demographic challenges of underserved and chronically ill patients across the southeast region.
The National Health Information Network (NHIN) is a division of HHS that guides exchange standards and regulates regulatory aspects of health reform. NHIN collaborations include departments such as the Centers for Disease Control (CDC), social security administrations, community Beacons and state HIEs (ONC).11 The Office of the National Coordinator for the Exchange of Health Information (ONC) has provided an additional $16 million in grants to encourage innovation at the national level. country.
Innovation at the state level will ultimately lead to better patient care through a reduction in replicated tests, bridging care programs for chronic patients leading to continuity and ultimately timely public health alerts through agencies such as the CDC based on this information.12 Technology The Health’s Information for Economic and Clinical Health Act (HITECH) is funded by dollars from the American Reinvestment and Recovery Act of 2009.
HITECH’s goal is to invest dollars in the exchange of public, regional, and state health information to build an effective network of connected countries. The Beacon Community and Statewide Health Information Exchange Cooperation Agreement was initiated through HITECH and ARRA. To date 56 states have received grant awards through these programs totaling $548 million.
History of the National Park Health Information Partnership (HIPTN)
In Tennessee, the Health Information Exchange is slower to develop than places like Maine and Indiana based in part on our state’s diversity. Delta has a very different patient population and healthcare network from central Tennessee, which is distinct from the Appalachian region of eastern Tennessee. In August 2009 the first steps were taken to establish a statewide HIE made up of a non-profit organization called HIP TN.
A board is currently established with an operations board being formed in December. HIP TN’s first initiative involves linking work through Carespark in a three-city area in northeastern Tennessee to the Midsouth eHealth Alliance in Memphis. State officials estimated the cost at more than $200 million from 2010-2015. The venture involves stakeholders from medical, technical, legal and business backgrounds.
Governor in 2010, Phil Bredesen, provided 15 million to match federal funds in addition to issuing an Executive Order establishing an eHealth initiative office with oversight by the Office of Administration and Finance and sixteen board members. In March 2010 four working groups were formed to focus on areas such as technology, clinical, privacy and security and sustainability.
As of May 2010, data sharing agreements are in place and trial production for statewide HIEs began in June 2011 along with Requests for Proposals (RFPs) sent to over forty vendors. In July 2010, a fifth working group, the consumer advisory group, was added and in September 2010 Tennessee was notified that they were one of the first states to have their plans approved following the release of the Program Information Notice (PIN).
Over fifty stakeholders gathered to evaluate the vendor demonstration and a contract was signed with selected vendor Axolotl on 30 September 2010. At that time a production goal of 15 July 2011 was agreed and in January 2011 Keith Cox was hired as CEO of HIP TN. Keith brings his twenty-six year tenure in healthcare IT into the collaboration.
Previous efforts include Microsoft, Bellsouth and several entrepreneurial ventures. HIP TN’s mission is to improve access to health information through a collaborative process across the state and provide the infrastructure for security in that exchange. HIP TN’s vision is to be recognized as a state and national leader supporting measurable improvements in clinical quality and efficiency to patients, providers and payers with safe HIE.
Robert S. Gordon, chairman of the board of HIPTN conveys the vision well, “We agree that although technology is an important tool, the main focus is not technology itself, but improving health”. HIP TN is a non-profit, 501(c)3, that relies solely on state government funding. It is a combination of centralized and decentralized architecture.
The main vendors are Axolotl, which acts as an umbrella network, ICA for Memphis and Nashville, with CGI as vendor in northeast Tennessee.15 Future HIP TN goals include a gateway to the National Institutes of Health planned for late 2011 and an index of clinicians in early 2012.
Carespark, one of the original regional health exchange networks decided to cease operations on 11 July 2011 due to lack of financial support for its new infrastructure. The data-sharing agreement includes 38 health organizations, nine communities, and 250 volunteers.16 The closure of Carespark makes clear the need to build a network that does not rely solely on public grants to fund its efforts, which we will discuss at the end of this paper.
Current Status of Health Information Exchange and HIPTN
Ten grants were awarded in 2011 by the HIE Challenge Grant Supplement. This includes initiatives in eight states and serves as a community we can guide as NP HIPs develop. As previously mentioned, one of the award-winning communities is located less than a five hour drive in Indianapolis, IN. Based on similarities in our healthcare community, patient population and demographics, Indianapolis will provide an excellent mentor for Nashville and the hospital system serving patients in TN.
The Indiana Health Information Exchange is nationally recognized for its Docs for Docs program and the way collaboration has been going since its conception in 2004. Kathleen Sebelius, Secretary of HHS commented, “The Central Indiana Beacon Community has the level of collaboration and ability to effectively manage quality efforts from a history of relationship building.
long term. We are excited to work with a community that is far ahead in the use of health information to bring about positive change in patient care.” Community beacons that can act as guides for our community include Marion County Hospitals and Healthcare Companies and Indiana Medical Centers based on their recent award of $100,000 each by HHS.
A model of local excellence in ESDM conversion practice is Old Harding Pediatric Associates (OHPA) which has two clinics and fourteen physicians treating a patient population of 23,000 and more than 72,000 patient encounters per year. The conversion of OHPA to electronic records in the early 2000s occurred as a result of the pursuit of excellence in patient care and the desire to use technology in ways that benefit their patient population.
OHPA formed cross-functional work teams to improve their practices in the areas of facilities, personnel, communications, technology and external influence. It is important to be selected as an EMR vendor based on user friendliness and similarity to standard patient charts with tabs for files.
The software is adapted to the pediatric environment complete with patient growth charts. Windows is used as an operating system based on the familiarity of the provider. 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 nearly twelve million dollars in grant money from The State Health Information Exchange Cooperative Agreement Program.20 Regional Health Information Organizations (RHIOs) must be full-scale to enable hospitals to develop their systems without compromising integrity as they grow.21 and systems located in Nashville will play an integral role on this national scale with companies such as HCA, CHS, Iasis, Lifepoint and Vanguard.
HIE will act as a data warehouse for all patient information that can be accessed from anywhere and contains a complete history of patient medical records, laboratory tests, doctor networks, and drug lists. To entice providers to enroll in true statewide HIE values for their practice must be demonstrated by safer and better care. In a 2011 HIMSS editor’s report Richard Lang stated that instead of a top-down approach “A more practical idea might be for states to support local community HIE development first.
Once formed, these local networks could feed regional HIEs and then connect to HIEs. .center./backbone of data storage. The state should use some of the stimulus funds to support local HIE development.”22 Lang also believes that primary care physicians should be the basis for the entire system as they are the primary point of contact for patients.
One piece of the puzzle that is often overlooked is the patient’s investment in a functional EHR. To put all the pieces of the HIE puzzle together, patients need to play a more active role in their health care. Many patients do not know what drugs they take each day or whether they have the will to live.
Several versions of patient EHRs such as the Memitech 911 medical identity card exist, but very few patients know of or carry it.23 One way to combat this lack of awareness is to use the hospital as a shelter and release each patient at full cost. USB card through the manager. case. This strategy may also lead to better adherence to post-patient therapy to reduce readmissions.
Implementation of linking eligible organizations began earlier this year. To fully support organizations moving towards qualification, the Office of the National Coordinator for HIE (ONC) has appointed a regional education center (TN rec) which assists providers with education initiatives in areas such as HIT training, ICD9 to ICD10 and the EMR transition.
Qsource, a non-profit health consulting firm, has been selected to oversee TNrec. To ensure sustainability, it is very important for Tennessee to build a private funding network so that what happened with Carespark does not happen to HIP TN. The 2011 eHealth Initiative Survey report states that of the 196 HIE initiatives, 115 acted independently of federal funding and from those independent HIEs, breaking even through operating income.
Some of these exchanges existed long before the American Recovery and Reinvestment Act of 2009. Initial funding from grants was only meant to run cars, so sustainable fuels, as observed in the Carespark case, must come from monetizable value. The KLAS research reports that 54% of public HIEs are concerned about future sustainability while only 35% of private HIEs have this concern.
Hospital Implications of HIP TN (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 of finding a vendor, establishing an inbound and outpatient EMR will be an expensive proposition. The transition will not be easy or limited and will involve constant evolution as HIP TN is integrated with other state HIEs.
To get a realistic picture of the benefits and costs associated with the integration of health information. we can see HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37 million dollars in avoided services and 15 million in decreased productivity. Specific areas of savings include $5 paper or fax costs versus $0.25 electronically, $50 virtual health record savings per referral, $26 savings per ED visit and $17.41 per patient/year due to redundant laboratory testing totaling $52 million for a population of 3 million . patient.
At Grand Junction Colorado Quality Health Network lowered their Medicare spending per capita to 24% below the national average, gaining recognition by President Obama in 2009. The Santa Cruz Health Information Exchange (SCHIE) with 600 doctors and two hospitals achieved sustainability in first year of operation and use subscription fees for all organizations with which they interact.
In terms of available government funding, there are significant use incentives to encourage hospitals to meet twenty of the twenty-five objectives in phase one (2011-2012) and adopt and implement approved EHR vendors. ARRA defines three ways that an EHR can be used to obtain Medicare reimbursement.
This includes e-prescribing, exchange of health information and submission of clinical quality measures. The objectives for phase two in 2013 will be extended to this baseline. Implementation of Hospital EHR and HIE fees are usually charged based on beds or number of doctors. Costs can range from $1500 for smaller hospitals to $12,000 per month for larger hospitals.
Perhaps the most compelling argument for establishing a functional Health Information Exchange is patient and community safety. Healthbridge’s reduction in disease outbreak detection for 3-5 days is a perfect example of this safety benefit. Imagine the implications in the case of rampant viruses such as bird flu or swine flu. The goal is to avoid a repeat of the 1918 influenza outbreak and ultimately save the lives of those of us who are most at risk.
Rick Krohn of Healthsense filed the case for a socially responsible HIE that serves the chronically ill, uninsured, and homeless. Because taxpayers ultimately bear the social burden of our nation’s health care coverage, the need to reduce redundancies, increase efficiency, and provide the United States with decent health care is critical. Now that our healthcare is in the Critical Care Unit, it’s time to stabilize it through operational excellence starting from our hospitals. Let’s rebuild the Tower of Babel and improve communication to give our patients the health care they deserve!