How HIEs are Becoming Essential to Clinicians

The forces that are making health information exchanges essential include exchanging summaries of care when EHR integration is not yet present and responding to business pressures such as accountable care.

This article appears in the September 2015 issue of HealthLeaders magazine.

As the industry turns its attention to interoperability, the nation's health information exchanges—some regional in nature, some statewide—are helping clinicians avoid productivity-sapping phone calls and faxes, and meet some challenging meaningful use requirements.

The forces that are making these HIEs essential include streamlining workflow utilizing Integrating the Healthcare Enterprise's EHR-to-EHR integration and Direct secure messaging connectivity built into meaningful use–compliant EHR software, exchanging summaries of care when EHR integration is not yet present, and responding to business pressures such as accountable care.

Pennsylvania: Making the transition

The Keystone Health Information Exchange connects 20 hospitals, 239 physician practices, and 30 home health locations primarily located in 31 counties in central, northern, and northeastern Pennsylvania, as well as 69 long-term care facilities spread throughout the state.

"We first went live in 2007 with a pretty rudimentary system of just connecting a few provider portals that were being offered by different healthcare systems and making it available through a single platform," says Jim Younkin, director of KeyHIE. Younkin is also IT director for external customer relations at Geisinger, a system that operates and participates in KeyHIE and itself serves more than 2.6 million residents throughout 44 counties in central and northeastern Pennsylvania.

In 2009, with funding from the U.S. HHS Office of the National Coordinator or Health Information Technology's Beacon Communities program, KeyHIE enabled a registry and information repository based on Cross Enterprise Document Sharing (XDS), a health IT standard developed by the nonprofit organization IHE, for storing and retrieving documents for providers who belonged to KeyHIE.

In fall 2013, use of KeyHIE leapt when it activated a notification service. "Any time a patient presented at a hospital or emergency department participating in KeyHIE, either as an inpatient or at an ED, we would send those alerts," Younkin says.

At the same time, KeyHIE successfully connected EHR software that had the ability to consume records via IHE's XDS protocol and present these records to clinicians as part of their regular workflow—a marked improvement from traditional HIEs, which require separate log-in via a physician portal to access information. In May 2015, 559 users of the HIE accessed information via the portal, with 461 using XDS-powered access within the EHRs themselves.

Those users include one of Geisinger's area competitors, Susquehanna Health, a four-hospital integrated health system, Younkin says. From within Susquehanna's Cerner Soarian EHR, clinicians can click on a link that will connect them to KeyHIE and bring back a list of documents associated with that patient. "My understanding is that that is just at a document-level consumption at this point, but we have similar functionality with customers using Allscripts; Epic does consuming, and there's a regional EHR called Medent, and we have set up with that as well," Younkin says.

KeyHIE is just in the process of finishing a multiyear migration of its HIE technology platform from an earlier technology offering by Caradigm to Orion Health HIE technology, he says.

One challenge for KeyHIE has been the varying degrees to which participating organizations obtain consent from patients to release their records to other members of the HIE. For instance, Geisinger asks registering patients to sign an authorization allowing Geisinger to share their information with other members of the care team. But those patients would have to sign the same authorizations at other organizations where they registered.

"The challenge is that some organizations were good at asking patients to sign this, and some were very lax, and as a result, the organizations that were good at getting them signed were the ones who were frustrated, because when they went to access data from organizations that were lax at getting them signed, they found many times the data wasn't available," Younkin says.

Another KeyHIE feature helps participating healthcare organization bridge an oft-criticized gap in care coordination by connecting data from long-term care facilities and nursing homes to inpatient and ambulatory EHRs.

Those facilities often lack EHRs of their own, which prompted KeyHIE to offer them its Transform service, a low-cost software tool that allows nursing homes and home health agencies—with or without an electronic health record—to contribute patient assessment information to any HIE.

"Transform allows us to take patient assessment data from a nursing home or a home health agency that normally would be sent to CMS or their billing process," Younkin says. "We've used the HL7 standards as well as IHE profiles to generate a Continuity of Care Document from the nursing home and home health settings." CCDs facilitate transitions of care that are required for providers participating in the meaningful use EHR incentive program.

Four hospitals and four group practices in KeyHIE saved money by using the organization's patient portal to fulfill meaningful use stage 2 requirements to have a patient portal, despite efforts by the EHR vendors of those organizations to sell them separate patient portals, Younkin says.

New Jersey: Pockets of success

Four regional HIEs divide the state of New Jersey, says Linda Reed, RN, vice president of behavioral and integrative medicine and CIO at Atlantic Health System a Morristown, New Jersey–based system with multiple hospitals and more than 1,599 licensed beds, which is a founding member of Jersey Health Connect, one of the four HIEs. Providers in the state hope to bring all four together but face funding and technological challenges.

Now integrating 30 hospitals, Jersey Health Connect uses RelayHealth technology and, at the end of 2014, says it saw a sharp increase in providers contributing health summaries via the HIE, rising from around 100 in November to nearly 900 in December.

One reason Jersey Health Connect has grown rapidly is that the HIE was set up so patients had to explicitly opt out of the HIE; if they didn't, their records would be available throughout the HIE, Reed says. "It looked like our governor at one point was going to go after opt-in, but we all rallied, got our government people involved, and he did just let it ride as an opt-out. Otherwise, we would have just had to close up shop."

Jersey Health Connect's success so far has been driven by the hospitals because they collectively realized it was the right thing to do for patients, Reed says.

"New Jersey is a small state," she says. "We've got a hospital on every corner. As a patient, you could be at an Atlantic Health facility today, you could be at a St. Barnabas facility tomorrow, and you could get Robert Wood Johnson the next day."

The CIOs of the respective hospitals realized that the best patient care comes from sharing results, Reed says. "We then convinced some of our colleagues in our facilities that it was the right thing to do, and I think some of them still are concerned that maybe it's not; but when the accountable care organizations started coming around, they now needed to know what's going on down the street: 'Because now I'm the accountable party for this care, and I didn't know that they were in the Robert Wood Johnson ED two weeks ago,' " he offers as an example.

Also, 14 participating hospitals were able to use Jersey Health Connect in 2014 as a means to meet the meaningful use stage 2 requirement for patients to view, download, and transmit records.

Now New Jersey as a state is facing the challenge of integrating three other regional HIEs into a shared infrastructure to handle, among other things, the typical HIE challenge of patient IT matching, but across a state of nearly 9 million people.

The New Jersey Institute of Technology, which itself runs a small HIE based in Newark, hopes to model a new overall statewide health information network after Michigan Health Information Network Shared Services, an HIE hub that oversees and coordinates information from seven regional HIEs in Michigan, Reed says. "It's not unlike the conversation about interoperability in electronic medical records," she says, "except that you have a bigger issue with the patient matching, especially because of the multiple medical records."

The elephant in the room, Reed says, is that vendors now power many HIEs, just as they power EHRs. "They are still going after proprietary stuff, and we see similar things moving into HIE technology," Reed says.

Some vendor-introduced differences are as mundane as whether a vendor takes one identifier in a data field instead of two. Reconciling these differences makes the job of an HIE that much more difficult, Reed says. Even in supposedly well-defined data standards, "There was enough wiggle room for them to interpret some of these things differently."

Another challenge all HIEs face is to go beyond the usual utilization metrics they publish, to much more difficult-to-capture metrics of how the HIE has affected patient outcomes, Reed says.

And finally, the new statewide initiative faces funding challenges. New Jersey is applying for a federal grant but will need more resources. "That's been one of my concerns," Reed says. "We don't want to put any more financial requirements on our members."

New Mexico: Reboot marks rebuilding phase

The New Mexico Health Information Exchange grew out of the state's HIE Cooperative Agreement Program originally funded by ONC in 2010. Operated today by nonprofit firm LCF Research, the HIE faced a major setback in 2012 when a vendor discontinued the product powering the HIE, although the HIE was able to get by until it transitioned to a new technology vendor.

Through a combination of continuing to run that older technology while migrating to new Orion technology, New Mexico's HIE has avoided the fate of some other states, whose HIEs completely shut down.

"We've been fortunate here that the state Medicaid program, Centennial Care, has been a great supporter of this, and they help through their managed care organizations to participate in this," says Thomas East, CEO and CIO of LCF Research. "They're using the HIE for care management for the Medicaid population, so we've been able to spread the costs out to not just healthcare organizations and providers but also payers."

The NMHIC HIE contains 1.2 million uniquely identified persons out of a total state population of just over 2 million. "We make sure the New Mexico Centennial Care Medicaid population is all represented in the master patient index," East says.

In its current rebuilding phase, NMHIC has been able to gain commitments of participation from a statewide diagnostic imaging organization, and the New Mexico Primary Care Association is funding participation for 15 federally qualified health centers, East says. "There's a number of different organizations in the state, and records don't always easily flow when patients move from care setting to care setting, so folks are anxious to get access to records that haven't made their way very effectively the traditional ways via paper or fax," he says.

A challenge NMHIC and other HIEs face is the lack of comprehensive patient records among participating healthcare practices. "We'd ideally like to see folks move closer to a meaningful use 2 transition of care record," East says.

One New Mexico medical practice that finds value in NMHIC is ABQ Health Partners, a 220-physician, multispecialty group based in Albuquerque. ABQ Health Partners was acquired by DaVita Healthcare Partners in 2012.

"The exchange is our only way of getting information easily across systems," says Robert White, MD, MPH, medical director of informatics and quality at ABQ Health Partners.

White recalls seeing a patient "a couple years ago where I was able to see documents that drastically changed what I did with the patient. Compared to asking the patient or calling somebody else and having something faxed, it's far, far better."

While White and his fellow physicians have been able to exchange summaries of care over NMHIC, moving documents via Direct messaging has been difficult. "In the HIE, it's sort of designed to give me the document as well as discrete test results and discrete vital signs," he says. "It's the note about the exam the patient had that I want to see that tells me what to avoid or what needs to be done in follow-up."

As the HIE matures, much of its power will simply live inside EHR software, White says.

"We're going to continue to work with our HIE to embed it in our EHR so clinicians are not having to think about two different systems," he says.

But White also echoes the importance of the New Mexico approach versus HIEs powered exclusively by EHR software itself.

"The payers and the state are really critical, because the HIE doesn't have an automatic business case," White says. "In fact, a lot of people, including some imaging centers and hospitals, don't want to see it succeed, because sequestering data makes their lives easier and more financially productive."

Reprint HLR0915-7