eHealth Exchange Simplifies Data Sharing

Healthcare leaders find that one of the benefits of the eHealth Exchange is the single data use and reciprocal support agreement.

This article first appeared in the September 2016 issue of HealthLeaders magazine.

As other health information exchange methods struggle to gain nationwide traction, one method, which originated in the federal government, and replaces lengthy negotiations between providers with a standardized data-sharing agreement, continues to gain adherents.

The eHealth Exchange started its operational life in 2009 as the Nationwide Health Information Network, sponsored by the Office of the National Coordinator. In 2012, NHIN became the eHealth Exchange, and its governance came under the management of the Sequoia Project, formerly known as Healtheway.

By using agreed-upon standards from HL7 and other industry organizations, and support already built into much electronic health record software, the eHealth Exchange provides a way for clinicians to query for records on given patients from around the network, and use the network as a secure way to send and receive Continuity of Care Documents to other nodes on the network.

One benefit of the eHealth Exchange: a single, agreed-on set of rules of the road—a data use and reciprocal support agreement that all participants abide by. Such agreements, when hammered out two health organizations at a time, make for very slow going to advance interoperability at scale.

A major implementation of eHealth Exchange crystallized recently when Intel Corporation, seeking to control its own employees' healthcare costs and increase employee convenience, launched its Connected Care initiative for its employees, and began requiring providers to join eHealth Exchange as a way to move patient records to and from local clinics, including Intel Health for Life clinics available on-site at its company campuses.

Intel Corporation, which self-insures its 50,000 U.S. employees and their 80,000 dependents through several national plans, spends approximately $680 million annually on healthcare benefits.

"That's a very significant amount we could be using in research and development and innovation, and the costs keep going up," says Prashant Shah, director of engineering at Intel Health and Life Sciences, based in Hillsboro, Oregon. "Intel was trying to innovate in this space. How can we get better outcomes at lower cost and increase patient satisfaction? We kept encouraging the national networks to innovate and do a lot more robust care coordination and patient-centered medical home-type models, but progress was very slow."

Intel's impatience with the pace of healthcare transformation helped it decide to self-insure its employees and work directly with providers, and to require providers to join the eHealth Exchange so records could follow patients from primary care offices to specialists and to on-site clinics. Setting up what Shah calls this ACO-like network, initially at a smaller Intel employment site in New Mexico in 2013, "was relatively simple and easy," he says.

When expanding the concept to Intel employment centers in Oregon in 2015, Intel convened local providers, including Kaiser Permanente, Providence Health & Services, the Portland Clinic, and employer on-site care provider Premise Health, to outline how they would meet Intel's ACO-like objectives, describing the clinical processes required.

"Intel has been in healthcare [as a technology supplier] for a long, long time," Shah says. "One of the key barriers to any progress being made in healthcare is the lack of interoperability. Since we hold the purse and we'll be creating these contracts and measuring these health systems, let's bake the interoperability language right into the contracts that we sign with these health systems through HR."

Because Intel employees travel between campuses in Oregon and Arizona, a model built around eHealth Exchange allows for a privacy-preserving interoperability that follows the employees from provider to provider, Shah says, and as use of eHealth Exchange expands nationwide, the potential for further continuity of care grows. In all of 2015, Intel's providers exchanged more than 42,000 Continuity of Care Document Architecture (CCDA) documents as responses to queries, Shah says.

Intel's contracted Arizona healthcare clinics, on-site and off-site, part of the Arizona Care Network, joined the Connected Care effort in 2016.

"Given my background in health IT, I did not want a point-to-point integration" between each healthcare provider, Shah says. "They're really expensive, and they're hard to maintain, and it's a one-off for the health system, and it's not something that the health system likes.

"I wanted to require something that was standards-based that runs on a national network. So we looked at various national networks, and the most mature one from our perspective was eHealth Exchange. Lucky for us, both Kaiser and Providence, at least a large portion of their network was already on eHealth Exchange. They were exchanging CCDA data with the Social Security Administration, and we said, 'Why can't we use the same network for the care coordination between our on-site clinics and the health systems?' We decided to go in for the eHealth Exchange."

Intel made a point of adopting eHealth Exchange and Direct Messaging even though in markets such as the Portland area, the Epic EHR is predominant. However, Intel also was planning to roll out the interoperability model in Arizona, which had a highly heterogeneous EHR ecosystem. This required that the interoperability architecture be completely EHR vendor-agnostic.

"We don't believe this is a one-year effort where we set this whole architecture up and we go live and shake hands and call it done. We are always evolving."

"The thing that fundamentally drives Intel is open data," Shah says. "So let's actually set an example for the industry how this can be done."

In addition, the provider operating Intel's on-site ambulatory clinics, Premise Health of Brentwood, Tennessee, runs not the Epic EHR but one from Greenway Health, which also supports eHealth Exchange, Shah says. "We actually funded Premise Health to have them onboard on the eHealth Exchange and get that going."

Part of Intel's effort is to continually measure how the system is performing. "We don't believe this is a one-year effort where we set this whole architecture up and we go live and shake hands and call it done," Shah says. "We are always evolving. We made it really clear to the health systems that this is a road map, and we have weekly technical meetings and clinical meetings with them evolving this road map."

The Arizona Care Network, a joint venture between Dignity Health and Abrazo Community Health Network and various independent physicians and specialists, presents a new challenge to Kaiser's Arizona use of the eHealth Exchange, Shah says. "There was a long list of different EHRs that were being used by our provider network," he says. "Obviously, our year one goals are going to be significantly different, but part of the reason why we wanted to go with a national network like eHealth Exchange is we can replicate and scale" eventually to expand to Intel's employee base in California as well.

Encouraging Intel's push was Eric Dishman, who recently left his post as vice president and Intel fellow of Intel's health and life sciences group for the National Institutes of Health to take the lead as director of the Precision Medicine Initiative Cohort Program.

Kaiser Permanente's own experience with the Intel initiative has been encouraging, says Kevin Isbell, Kaiser Permanente executive director of data and analytics delivery, based in Oakland. "If I'm an Intel employee, providers treating me at the Intel clinic will want to know my history and my clinical background, and they're able to query that information from Kaiser's electronic clinical medical record in the Northwest, bring over kind of the classic continuity of care document payload, and have an understanding of my allergies, problem lists, and medications," Isbell says.

"Likewise, we maintain a bidirectional relationship with them so that at the time that care is provided and recorded by Premise Health in the Greenway EMR, that information can also be queried back to our Epic electronic medical record through the eHealth Exchange for follow-up by a primary care physician."

As an anchor member of the original NHIN, Kaiser implemented a pilot exchange back in 2009, between its San Diego region and the U.S. Department of Veterans Affairs. Today, Kaiser clinics in eight states and the District of Columbia are all operational on the eHealth Exchange, Isbell says. And the Kaiser connections keep growing. Recently, Kaiser connected to Virginia Hospital Center in Arlington via the eHealth Exchange, Isbell adds.

"We are definitely an Epic shop," Isbell says. "Wherever possible, especially if another organization is also Epic, we will utilize CareEverywhere." Reasons why include the ability to retrieve full lab results and ancillary reports, such as radiology and pathology reports, not yet available via eHealth Exchange, he says. "eHealth Exchange is our definitely No. 2 most active and voluminous exchange, and primarily because of the federal partners that we're able to connect to."

One of those federal partners on the eHealth Exchange is the Social Security Administration, whose presence on the network drives improved revenue to providers such as Kaiser. Through eHealth Exchange, the SSA was able to fully automate the process of verifying disability claim filings by patients being seen by eHealth Exchange–compatible providers such as Kaiser.

Prior to this automation, "it literally was months from the point of a disability claim filing, and many FTEs, humans involved in that process," Isbell says. "For a place lke Kaiser Permanente, we do hundreds of thousands of those a year. We return a CCD to SSA, and they can complete the verification process and make aware the benefit to the person filing in days versus months."

In the mid-Atlantic area, another eHealth Exchange connection point is Envera Health, the new owner of the MedVirginia health information exchange. The newly christened Envera Data Exchange connects the eHealth Exchange with seven Bon Secours hospitals, three Centra Health facilities, and most recently the Virginia Commonwealth University Health System, says Michael Matthews, chief transformation officer of Envera Health.

In addition, Envera Health connects about 1,000 community physicians to eHealth Exchange via its provider portal, Matthews says.

"We're also expanding the services we're providing to those provider connection points," Matthews says. "For example, most of those are receiving results through our platform, so we take the reference labs and the hospital results that a physician has ordered, and we're able to map those directly into the electronic health record."

According to Matthews, the SSA commissioned a study several years ago showing a 35% drop in turnaround time for disability determination due to use of the eHealth Exchange. This study of eHealth Exchange use at Bon Secours showed that its four Richmond hospitals realized a $2.2 million annual revenue enhancement due to the speedup in disability determination, Matthews says.

"In almost all cases across the country, disability claimants also qualify for Medicaid benefits," Matthews says. "Because we reduced the turnaround time for disability determination, we also reduced the time for them to get Medicaid benefits." This in turn drove higher patient revenues at the hospitals, he says.

In essence, eHealth Exchange is poised to prove itself at ever-larger scales nationwide, Matthew says. "We've demonstrated that multiple disparate parties can operate under a single trust agreement with the common rules of the road. We know how to send out data and receive data and render that in a form that physicians can use."