Defining a Health Information Exchange

The
United States is facing the largest shortage of healthcare
practitioners in our country’s history which is compounded by an ever
increasing geriatric population. In 2005 there existed one geriatrician
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 in a uniform fashion.
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. A healthy information exchange
can help improve safety, reduce 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 along with those impacted by chronic disease 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 the manner in which the communication takes place.
Healthbridge, a Cincinnati based HIE and one of the largest community
based networks, was able to reduce 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.”

United States retailers transitioned over twenty
years ago in order to automate inventory, sales, accounting controls
which all improve efficiency and effectiveness. While uncomfortable to
think of patients as inventory, perhaps this has been part of the reason
for 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 successfully
implement HIE’s. The success of these early networks 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 been successful in replacing antiquated
interactions like faxing, mail and direct provider communication, which
often represent duplication and inefficiency. Process interoperability
increases human understanding across networks health systems to
integrate and communicate. Standardization will ultimately impact how
effective that 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 it’s 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 goals of the network 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) initiated
in Memphis and the Tri Cities region. Carespark, 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 a 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 in a more efficient manner.

Seventeen
US communities have been designated as Beacon Communities across the
United States based on their development of HIE’s. 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. The closest
geographical Beacon community to Tennessee, in Byhalia, Mississippi,
just south of Memphis, 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. In
addition, 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
department of Health and Human Services (HHS) 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. The Regional Director, 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 specifically
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 a division of HHS that guides the standards of
exchange 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.12 The Health Information
Technology for Economic and Clinical Health (HITECH) Act is funded by
dollars 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 which are
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 the diversity of our
state. The delta has a vastly different patient population and health
network than that of 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 areas like 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 and in September
2010 Tennessee was notified that they were one of the first states to
have their plans approved after a release of Program Information Notice
(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 the infrastructure for security in that exchange. The vision for
HIP TN is to be recognized as a state and national leader who support
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 technology
itself, but improving health”. HIP TN is a non profit, 501(c)3, that is
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 vendor in northeast Tennessee.15 Future HIP TN goals include
a gateway to the National Health Institute planned for late 2011 and a
clinician index in early 2012. Carespark, one of the original regional
health exchange networks voted to cease operations on July 11, 2011
based on lack of financial support for it’s 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 it’s
efforts, which we will discuss in the final section of this paper.

Current Status of Healthcare Information Exchange and HIPTN

Ten
grants were awarded in 2011 by the HIE challenge grant supplement.
These included initiatives in eight states and serve 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 who serve
patients in TN. The Indiana Health Information Exchange has been
recognized nationally for it’s Docs for Docs program and the manner in
which collaboration has taken place since it’s 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 in an effective manner 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 as a result of
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 their practices in
the areas of 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 full
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 patients information that can be accessed from
anywhere and contains a full history of the patients medical record, lab
tests, physician network and medicine list. To entice providers to
enroll in the statewide HIE tangible value to their practice has to 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 then
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 point of contact for the
patient.

One piece of the puzzle often overlooked is the patient
investment in a functional EHR. In order to bring together all the
pieces of the HIE puzzle 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) who assist
providers with educational initiatives in areas like HIT, ICD9 to ICD10
training and EMR transition. Qsource, a non-profit health consulting
firm, has been chosen to oversee TNrec. To ensure sustainability it is
critical that Tennessee build a network of private funding 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 of 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 the case of Carespark,
has to come from 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
other state HIE’s. 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 amounts 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 recognition by President Obama 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 who interact with them. In
terms of government dollars available, meaningful use incentives exist
to encourage hospitals to meet twenty of twenty five objectives in the
first phase (2011-2012) and adopting and implement 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 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.

Perhaps the most
compelling argument to building a functional Health Information Exchange
is patient and community safety. The Healthbridge reduction in disease
outbreak detection of 3-5 days is a perfect example of this safety
benefit. Imagine the implications in the case of a rampant virus like
avian or swine flu. The goal is to avoid a repeat of the 1918 influenza
outbreak and ultimately save the lives of our most at risk. Rick Krohn
of Healthsense makes the case for a socially responsible HIE that serves
those who are chronically ill, uninsured and homeless. As the taxpayers
ultimately bear the societal burden for our country’s healthcare
coverage, the need to reduce redundancies, increase efficiency and
provide healthcare worthy of the United States is imperative. Right now
our healthcare is in the Critical Care Unit it’s time to stabilize it
through operational excellence starting with our hospital. Let’s rebuild
the Tower of Babel and enhance communication to provide our patients
the healthcare they deserve!