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The new effort is designed to enable the Beacon communities to generate in a systematic way “actionable, rigorous evidence” that shows how to use health IT to enhance patient care and reduce costs, according to the network sponsors, ONC, AcademyHealth and the Commonwealth Fund, in a July 26 announcement.  

Academy Health promotes healthcare research and policy, and the Commonwealth Fund is a foundation that advocates for a high-performing healthcare system.

Beacons, which are funded by the Office of the National Coordinator for Health IT, are communities of healthcare organizations around the country using electronic health records (EHRs) to improve specific patient outcomes.    

Examples of some of the Beacon goals are involving diabetic patients to participate in managing their health and reducing emergency department visits and hospital readmissions.

The network will enable the Beacons to build a knowledge base through increasing the yield of evidence from projects by coordinating evaluators with external experts to resolve research challenges and expand distribution of the information.

The network will also bring together leaders and experts on topics like reducing hospital readmissions, measuring provider performance using multiple data sources, and getting the most out of the use of EHRs in physician practices. The participants will also develop issue briefs and case studies examining tough policy and evaluation challenges and emerging promising strategies and early trends.

The Beacons offer a critical opportunity to gather data on what works and what doesn’t when building a health information infrastructure, said Dr. Farzad Mostashari, the national health IT coordinator. “The Beacon Evidence and Innovation Network will help ensure that we have strong evidence to support decision making moving forward on ways to improve health and health care,” he said.

[Also: ONC 'beacons' and exchanges build footing for future ACOs.] 

AcademyHealth laid the groundwork for the network by performing assessments to identify the evidence gaps and information needs of community and national policymakers and another to highlight the capacity of participating Beacons to produce quality evidence on their intended outcomes. The Beacons’ data will inform “real-world strategies to improve the delivery, quality and value of health care,” said Lisa Simpson, AcademyHealth CEO.

The Commonwealth Fund will provide evaluation expertise and gather the knowledge gained from the Beacon projects, which have “the potential to lead the nation in accelerating innovations and improvements in the way health care is delivered” said Dr. Anne-Marie Audet, Commonwealth Fund vice president.

View Original Article on Government Health IT  

Washington, D.C. March 30, 2011– New models of care, such as patient centered medical homes and accountable care organizations, must emphasize value-driving elements of advanced primary care–enhanced access, better care coordination, use of health information technology to support care transformation, and payment models that reward coordinated care. For the first time, stakeholders across a range of sectors have reached a consensus on how to make this happen. The Patient-Centered Primary Care Collaborative, in partnership with The Commonwealth Fund and the Dartmouth Institute for Health Policy and Clinical Practice,has released Better to Best: Value-Driving Elements of the PCMH and ACO. The report was funded by the Milbank Memorial Fund. This document represents a powerful demonstration of solidarity among thought leadersfrom health plans, physicians, academics, employers, federal payers and consumers on how to make the medical home and ACO support better care forindividuals; foster better health for the community; and help reduce or control costs.

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1: Inland Northwest Health Services (INHS) | Spokane, Wash.
Data sharing across competing facilities sparks better care
INHS provides EMR services to 750 physicians and hosted practice management services in eastern Washington and northern Idaho.

Currently there’s a backlog of 100 physicians waiting to be added into the system for data-sharing benefits, says Mike Smyly, chief business development officer for the Information Resources Management (IRM) division of INHS. “Data sharing has changed the culture of our community from ‘How do I protect the data from my competition’ to ‘how do I share the data with my competitors for better patient care?’ ”

Thirty-eight hospitals are currently linked to INHS’ master patient index (MPI)—via a GE Centricity EMR for physician services and Meditech’s Enterprise Medical Record for hospitals; another six hospitals have recently signed on to participate in the exchange. Meditech’s electronic MPI has been leveraged to integrate patient data among inpatient and ambulatory clinical data, Smyly says.

In addition, INHS provides analysis services for EMR implementation and customization for physicians and hospitals. INHS also has implemented a “community image store” in collaboration with its radiology partner, Inland Imaging, where referring hospitals send images via Inland Imaging’s integrated PACS.

INHS’ hosted EMR services cost a 650-bed hospital 25 percent to 30 percent less than what the hospital would have paid to deploy an EMR itself, Smyly says.

“If you can establish trust in a community … you take away data as a competitive advantage and focus on results,” he says.

2: Norman Regional Health System (NRHS) | Norman, Okla.
An infrastructure for pushing ambulatory data
Getting facilities and federal agencies to exchange ambulatory data is no simple task, but that doesn’t mean it can’t happen. NRHS has 75 physicians connected in the Norman, Okla., region and is looking to expand to federally qualified health centers (FQHCs) in the state, says Brian A. Yeaman, MD, CMIO at NRHS. The exchange is being used to help reconcile medications and problem lists, among other daily operations, he says.

In January 2010, NRHS, comprised of three hospitals, went live with Oklahoma Physician Health Exchange (OPHX), built on eClinicalWorks HIE software, to integrate ambulatory data. To broaden its reach, NRHS, as a part of Greater Oklahoma City Hospital Council, also has joined SMRTNET, a regional health information organization (RHIO) based in Norman. The SMRTNET RHIO currently includes 3 million discrete patient encounters in the network and includes data from more than a dozen Oklahoma hospitals. 

Currently, OPHX—which facilitates electronic referrals and reconciliations—is sustained by monthly subscription fees of $25 per provider.

The SMRTNET/OPHX integration is driven by not duplicating a large number of interfaces: “We have a hub for ambulatory data now, with a lot of bidirectional interfaces,” says Yeaman. “Without strong HIE, we are going to continue to live in silos and we have to move away from that and construct an information network to allow greater communication.”

3: MedVirginia | Richmond, Va.
First HIE to connect with NHIN, VLER
MedVirginia, formed in 2000 by a coalition of Virginia not-for-profit hospitals and physicians, boasts a couple of firsts. In 2009, MedVirginia was the first community-based HIE service provider to harness the Nationwide Health Information Network (NHIN) framework, to streamline disability determination for veterans. And in December 2010, it became the first community-based HIE to connect to the Virtual Lifetime Electronic Record (VLER), a collaboration between Veterans Affairs (VA), the Department of Defense (DoD) and civilian health systems that connects the health records of the active-duty military personnel and veterans, says Michael Matthews, CEO of MedVirginia, based in Richmond.

Data are stored on a central database and comprise radiology reports, diagnoses, procedures performed, OR notes and discharge summaries. Currently, 14 hospitals are providing data to the exchange, as are two reference labs with about 115 physician practices and 1,100 physicians accessing data through a secure provider portal, he says. 

Since harnessing the NHIN framework, MedVirginia has reduced the disability determination period from 84 days to 46 days and processed more than 5,000 disability determination requests. In some cases, the turn-around time has been shortened to one to two business days, Matthews adds.

“When you talk in terms of [saving money on items like] paperclips, it’s hard to monetize” the benefits of information exchange, he says. However, faster collection of medical evidence does translate into cost savings by reducing the amount of time it takes to receive a payment following service, according to a case study by MedVirginia. The study showed that, as a result of the MedVirginia-NHIN-SSA data exchange, Richmond-based health system Bon Secours realized $2.1 million in payments on uncompensated care cases that the facility might not have collected otherwise, Matthews says.

4: HEALTHeLINK | Buffalo, N.Y.
‘The value is the data’
As a Beacon Community and a RHIO, Western New York Clinical Information Exchange (a.k.a. HEALTHeLINK) has built a repository of 40 million results, with 1.7 million results added to the exchange on a monthly basis.

HEALTHeLINK currently has more than 90 percent of the lab reports and nearly 75 percent of the radiology reports available for the eight counties in its service territory. HEALTHeLINK uses Axolotl Elysium tools to provide clinical messaging and clinical data delivery functions to physicians, says Daniel E.Porreca, executive director. “You’ve got to be careful not to focus solely on the technology,” he says. “It’s for better care. The value is the data.”

Major projects under way at HEALTHeLINK include an initiative to set up an EMR-to-EMR exchange that will package relevant clinical information from primary care providers into a CCD and send it via HEALTHeLINK between disparate EMRs, says Porreca.

HEALTHeLINK went live with the first such exchange between primary care and specialists four months ago and is looking to upload the second EMR from a second vendor for the exchange during the current fiscal quarter, he says.

As a Beacon Community, HEALTHeLINK is putting into place technology such as telemonitoring to create a wider, deeper information base about the diabetic population and to facilitate better communication between patients and providers.

“While we’ve done a lot, we realize we have a long way to go,” says Porreca.

5: Quality Health Network (QHN) | Grand Junction, Colo.
‘We created a medical neighborhood’
QHN was created as a RHIO by a collaboration of Mesa County Independent Physicians Association (IPA), Rocky Mountain Health Plans (RMHP), St. Mary’s Hospital and Community Hospital. The goal was to provide quality care to the 150,000 patients in Mesa County.

QHN went live in 2005; currently about 85 percent of physicians in Mesa County are connected to the system, says Dick Thompson, executive director of QHN. “We created a medical neighborhood so not only are the hospitals and labs connected, but also … surgical centers and home health hospices and pharmacies.”

Services range from results delivery to e-prescribing, electronic referrals, CPOE and web-based population management tools. QHN also offers an “EMR lite” that includes clinical decision support, but does not provide scheduling and billing, says Thompson.

QHN delivers 125,000 lab and radiology results per month to providers as well as tens of thousands of progress notes, e-prescriptions, referrals and other clinical messages. That breadth of data helps to populate a longitudinal patient record, providing aggregate data across QHN’s community. One provider was able to decrease medical record staff by 25 percent to 30 percent because of the connectivity; another eliminated a referral coordinator and replaced that position with a clinician because care coordination is handled electronically, says Thompson.

Sustainability will continue to be a major hurdle that HIEs must clear, but as these five efforts show, funding isn’t the only metric to watch. When it comes to building an HIE that works, one formula for success definitely does not fit all.

Source CMIO.net

• Achieving health goals through health information exchange
• Improving long-term and post-acute care transitions
• Consumer-mediated information exchange
• Enabling enhanced query for patient care
• Fostering distributed population-level analytics

The ONC-funded State HIE Cooperative Agreement Program promotes secure exchange of health information to enable patient-centered care and providers’ achievement of meaningful use requirements.

Learn more about the funding opportunity for this important initiative.

The Office of the National Coordinator for Health Information Technology

“In America, innovation doesn’t just change our lives, it’s how we make a living,” he said. “Our free enterprise system is what drives innovation. But because it’s not always profitable for companies to invest in basic research, throughout history our government has provided cutting-edge scientists and inventors with the support that they need. That’s what planted the seeds for the Internet. That’s what helped make possible things like computer chips and GPS.”

In 2009, Obama signed the American Recovery and Reinvestment Act into law, supporting healthcare IT innovators for developing and healthcare providers for adopting healthcare IT. Many observers have said without this support, the healthcare industry would not make it over the tipping point to health information exchange.

[Read more about ARRA funding for healthcare IT.]

The Obama Administration has faced a steep uphill battle with Republicans over the federal deficit, and he took the issue head on in his speech, siding with Republicans in the need for fiscal responsibility. As in the past, he nodded toward keeping programs that could help to lower costs in the future. For healthcare, this means the advancement of healthcare IT to lower costs and increase quality of care. It also means retaining grant programs such as the Beacon Communities, state HIE exchanges and accountable care organization pilots – all funded as part of the Accountable Care Act.

“I recognize that some in this Chamber have already proposed deeper cuts, and I’m willing to eliminate whatever we can honestly afford to do without,” he said. “But let’s make sure that we’re not doing it on the backs of our most vulnerable citizens. And let’s make sure what we’re cutting is really excess weight. Cutting the deficit by gutting our investments in innovation and education is like lightening an overloaded airplane by removing its engine. It may feel like you’re flying high at first, but it won’t take long before you’ll feel the impact.

Obama called for the expansion of America’s infrastructure, including high-speed wireless connection in rural areas. “Within the next five years, we will make it possible for business to deploy the next generation of high-speed wireless coverage to 98 percent of all Americans,” he said. “This isn’t just about a faster internet and fewer dropped calls. It’s about connecting every part of America to the digital age. More broadband access means patients will be able to have face-to-face video chats with their doctors.”

[See more ways the digital age has improved patient care.]

Obama said America has made great strides over the last two years in using technology and getting rid of waste. “Veterans can now download their electronic medical records with a click of the mouse,” he added.

Justin Barnes, chairman emeritus of the Healthcare Information and Management Systems Society’s EHR Association and vice president of government affairs at Greenway Medical, has been closely tied with advising the White House and Congress on healthcare IT since 2003.

“This is the eighth year in a row that healthcare IT has been a part or prominent part of the president’s State of the Union Address,” Barnes noted following the speech. “While the debate will certainly continue on exactly how we go about creating and implementing policy, it was very encouraging to hear the increased vigor supporting additional investments in innovation around biomedical research and information technology.”

Despite a rousing speech, the proof will be in the policies, Barnes said. “That is certainly what keeps many of us engaged to collaborate and help educate while watching out for how these policies can effect care providers, patients, hospitals and all of us as taxpayers. I believe we all have the common goal though to create a smarter, more sustainable healthcare system in America.”

HealthcareITNews
January 26, 2011

In this issue of the Archives, Romano and Stafford report on the effect of electronic health records (EHRs)—both with and without clinical decision support (CDS)—on physician adherence to evidence-based guidelines. They used data from the National Ambulatory Medical Care Survey1 (NAMCS) and the National Hospital Ambulatory Medical Care Survey2 (NHAMCS) to evaluate physician performance on 20 quality indicators. The results that Romano and Stafford found were dismal. The investigators observed no consistent difference in guideline adherence among providers who used paper medical records compared with those who used either an EHR alone or an EHR with CDS.

This lack of effect of CDS on provider behavior was surprising given the strong effects previously reported in randomized controlled trials of these systems. In their most recent review of CDS systems, in 2005, Garg et al3 examined 100 well-designed studies on outcomes of CDS, which together evaluated a total of 3826 practitioners or practices and more than 92 895 patients. Forty-four of the 60 trials (73%) evaluating CDS systems that gave providers guidance without being asked for help (akin to the ones considered in the current study) showed that automated CDS had positive and often large effects on provider behavior and care processes.

Many differences between the design and guideline targets of the trials summarized by Garg and colleagues and Romano and Stafford’s study could explain the discordance between their outcomes. First, and most important, the current article tells us nothing about which CDS guidelines were implemented in the systems that they studied. Practices and EHRs vary considerably in the number and type of CDS rules that they implement, and we do not know whether the CDS rules implemented by the practices that participated in the surveys addressed any of the 20 quality indicators evaluated by Romano and Stafford. Second, the current study and Garg and coauthors’ review considered very different categories of guidelines. Most of the guidelines (60%) in Romano and Stafford’s study concern medication use; none of them deals with immunizations or screening tests, which were the dominant subjects in the studies reviewed by Garg et al.3 Furthermore, in our experience, care providers are less willing to accept and act on automated reminders about initiating long-term drug therapy than about ordering a single test or an immunization. The third difference is that the current study examined the outcome of a single visit, while most of the trials reviewed by Garg and colleagues observed the cumulative effect of the CDS system on a patient over many visits. Finally, the data available from NAMCS/NHAMCS may be limited compared with what is contained in most of the EHRs used for Garg and coauthors’ trials. For example, the NAMCS/NHAMCS instruments have room to record only 8 medications, even though at least 17% of individuals older than 65 years take 10 or more medications.4

Regardless of the differences, we know from multiple randomized controlled trials that well-implemented CDS systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level. The results of Romano and Stafford’s study suggest not. However, we suspect that the EHR and CDS systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data; a 2005 survey of Massachusetts physicians supports this concern.5 On the other hand, we are not surprised that EHRs without CDS do not affect guideline adherence, because without CDS, most EHRs function primarily as data repositories that gather, organize, and display patient data, not as prods to action.

Although EHRs without CDS may not improve adherence to clinical guidelines, they are (1) a necessary precondition for having CDS (without electronic data, there can be no electronic support functions); (2) valuable for maintaining findable, sharable, legible, medical records; and (3) when they are amply populated (ie, they contain at least 1 or 2 years of dictations, test results, medications, and diagnoses/problems), physicans love them because there are no more lost charts or long waits on the telephone for laboratory results. Most large institutions create rich clinical repositories by pulling in all the data from their internal laboratory, pharmacy, radiology, and dictation systems. They can do this because they control their source systems and can distribute the linking costs over a large base of users. Office practices, on the other hand, have neither of these advantages because they are smaller units of care and obtain their corresponding data from external sources. Therefore, their efforts to create repositories are stunted by the high costs of interfacing to the external system and translating that content into something that their system can understand. It does not have to be this way. The standards that are needed to deliver data from external sources to office practices already exist. Indeed, an implementation guide for laboratory messages was promulgated by the US Department of Health and Human Services in 2008.6

The Clean Water Act puts the responsibility on the upstream producers of impure water to clean it up. It does not make economic sense for each of the downstream users to do the cleanup work before they can use the water. The same principle should apply to health care data. The upstream data producers should deliver clean data that can be imported into downstream EHRs without additional work or cost. Compared with the work that would be required for each site to clean and standardize the data that they receive, it would take just a fraction of the effort for the data sources to tighten up their electronic reporting so that it strictly conforms to national format, content, and code standards.7 We could imagine it being as easy as the importing of bank statements to Quicken. Although many large national laboratories do offer electronic reports that follow such format and code standards, most diagnostic services, hospitals, dictation services, and other clinical data sources do not, because the current national incentives to automate and standardize medical data apply to the downstream EHRs, not to the systems that feed them. This has to change. Office practices and the medical societies that represent them have to demand clean, well-standardized data feeds for their EHRs, and policymakers need to support this requirement. Only when EHRs carry rich repositories can we expect EHRs to reach their promise and CDS to have measurable effects on a broad range of quality measures at the national level.

AUTHOR INFORMATION

OMAHA, Neb., January 20, 2011 — NeHII, Inc., Nebraska’s statewide integrator for Health Information Exchange, today announced Dr. Harris A. Frankel, President of the NeHII, Inc. Board of Directors, has been selected to receive the eHealth Physician Advocate of the Year Award from the eHealth Initiative (eHI). Dr. Frankel was selected to receive this award,  which is given annually to honor improvements in the quality, safety and efficiency of healthcare through the use of information and information technology.

Jennifer Covich Bordenick, CEO of eHI said, “We are proud to honor Dr. Frankel with the eHealth Physician Advocate of the Year award. His outstanding leadership and accomplishments exemplify the unique ability of physicians to effect significant positive change on behalf of their patients.”  In addition to Dr. Frankel, awards were also issued to: eHealth Organization of the Year – Carolinas HealthCare System – LiveWELL! Carolinas; eHealth Organization of the Year – Institute for Family Health; eHealth Advocate of the Year – Public Sector, Managing Director, Manatt Health Solutions, formerly Deputy Secretary of Health Information Technology, California Health and Human Service Agency.

Dr. Frankel, a practicing, board-certified neurologist received the award for his leadership and commitment to technological advancements leading to the implementation of NeHII. Beginning in 2005, Dr. Frankel championed the development of NeHII and led its pilot implementation in March 2009. Since that time NeHII has, under his guidance, grown to encompass 60 percent of the Nebraska population.

“Dr. Frankel’s tireless effort in bringing both physicians and consumers into the NeHII program is commendable,and he deserves the recognition for which he is being nominated,” said Nebraska governor Dave Heineman. He added, “NeHII is a perfect example of how technology and citizens alike can provide better efficiency and accessibility and improve safety and security in the delivery of healthcare. Dr. Frankel has served as a catalyst in bringing these important components together to realize the benefits of NeHII.”

In addition to his leadership of NeHII, Dr. Frankel maintains a full-time neurology practice and is on the active staff of several Omaha area hospitals. He is the immediate past president of the Metropolitan Omaha Medical Society and has served on the boards of multiple professional and community organizations. He volunteers as a clinical assistant professor in the Department of Neurology at the University of Nebraska Medical Center. He is the former chief resident for the Department of Neurology at Parkland Memorial Hospital and the Dallas VA Medical Center.

“As a practicing physician, I have seen the value of health information exchange in clinical practice. The ability to aggregate patient health information from disparate sources enhances the quality, efficiency, and safety of the medical care I provide to my patients,” says Dr. Frankel of his experience with NeHII. “Moreover, it allows for improved coordination of care, not to mention reducing unnecessary and duplicative testing. In the end, however, it is not just about the technology, but rather employing the technology to “meaningfully use “ health information to achieve higher quality, more cost effective and safer medical care, with the goal of improving patient outcomes,” he concluded.

Dr. Frankel received the eHealth Physician Advocate of the Year Award during the Fourth Annual eHealth Conference and Awards Reception held as part of eHI’s 2011 Annual Conference in Washington, D.C. on January 19. At the reception, eHI honored two individuals and two organizations that demonstrate leadership and excellence in eHealth.

About eHealth Initiative
The eHealth Initiative is an independent, non-profit affiliated organization whose mission is to drive improvement in the quality, safety, and efficiency of healthcare through information and information technology. The organization is focused  on engaging multiple and diverse stakeholders–including hospitals and other healthcare organizations, clinician groups, consumer and patient groups, employers and purchasers, health plans, healthcare information technology organizations, manufacturers, public  health agencies, academic and research institutions, and public sector stakeholders—to define and then implement specific actions that will address the quality, safety and efficiency challenges of our healthcare system through the use of interoperable information  technology.

About NeHII
NeHII, Inc. is a 501(c)3 non-profit organization with a public/private governance model that includes healthcare providers, payers and the State of Nebraska. NeHII is a statewide Health Information Exchange designed to share clinical and administrative data among providers in Nebraska and neighboring states.NeHII’s purpose is to achieve health care transformation through community betterment collaboration while protecting the security and privacy of medical information.

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eHI link:
http://ehealthinitiative.org/2011-ehealth-award-recipients.html

The passing of the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) has resulted in a continued increase in the number of Health Information Exchanges (HIEs) across the United States. The Pennsylvania eHealth Initiative (PAeHI) remains active in its role “to bring together Pennsylvania’s health care and business stakeholders to develop a vision and a plan for the future of health information technology (HIT) and the secure exchange of health information in Pennsylvania”. How to maintain financial sustainability is a major question raised by community, regional, and state-level HIEs. PAeHI’s 2008 White Paper titled “Building a Sustainable Model for Health Information Exchange in Pennsylvania” laid the foundation for financial sustainability discussions and actions. Recognizing its ongoing importance, PAeHI has now completed this second White Paper to further inform Pennsylvania stakeholders about HIE financial sustainability models deployed and contemplated nationally and in Pennsylvania. Key areas addressed within the White Paper include trends and demographics; approaches for thinking about sustainability; prior planning efforts by the Pennsylvania Health Information Exchange (PHIX) and PAeHI; interview findings with leaders from 11 leading national HIEs on their models and experiences; findings from 26 representatives from 13 Pennsylvania stakeholder groups; current Pennsylvania HIT/HIE initiatives; an assessment of opportunities; and a possible go-forward strategy.

Read more on the PAeHI White Paper Project

A patient shows up at the emergency room unconscious and unable to give a history. Another patient arrives at his primary care physician’s office 3 days after an emergency room visit, and the primary doctor has received no information. A specialist sees a third patient for a consultation and receives none of the critical records needed to help her make the consultation efficient and effective. These scenarios and many others like them, unfortunately, are all too commonplace. The consequences of incomplete information at the point-of-care can be inconvenience, inefficiency, increased costs, and adverse, even life-threatening outcomes for patients.

The major reasons for lack of sharing health information include the fragmented nature of the United States healthcare system and the fee-for-service business model, a model that does not include financial support for health information exchange. Further, most health information technology (HIT) programs are not interoperable, that is, they do not speak to each other.

Health information exchange (HIE), in its current definition, is the electronic sharing of health-related information between disparate partners, based on nationally recognized standards for interoperability, privacy, and security. Without sharing, silos of information persist, physicians function with incomplete information, and tests are unnecessarily  repeated. Information-sharing is particularly important for care coordination of care for older with complicated conditions; chronic disease management; natural disaster and biosurveillance response; and care for a mobile military, veteran, and civilian patient population.

Recognizing these obstacles to sharing, the federal government has taken an active role in promoting HIE as a key component of healthcare reform. In this article, we will describe the
current landscape of HIE in the United States, how different parties are trying to expand it, current obstacles to the expansion, and the future possibilities.

THE HITECH ACT AND HIE
In 2004, President Bush set the goal of an interoperable electronic health record (EHR) system for all Americans by 2014 and established the office of the national coordinator for HIT (ONC). Initial progress towards the goal was slow until the passage of the American Recovery and Reinvestment Act (ARRA) of 2009, which included the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act funded multiple federal programs to promote the adoption of HIT, particularly EHR systems and HIE at the local, state, and national level.

The basic building block for this national strategy is the EHR, which inputs, processes, and stores digital health information for hospitals and outpatient practices. Health information organizations (HIOs) are the organizations that provide the governance,technology infrastructure, and security to exchange health information. A regional health information organization (RHIO) is simply an HIO that covers a defined geographic area, such as a city, region, state or multi-state area. HIOs have the ability to collect and aggregate health data from multiple organizations and electronically share information with EHRs.

The HITECH Act included a Medicare and Medicaid reimbursement program for eligible professionals who use certified EHRs and demonstrate “meaningful use.” Stage 1 meaningful use included the general objectives of e-prescribing, structured data collection, quality reporting, clinical decision support, patient engagement, security assurance, and HIE. HIE is necessary to provide a hospital discharge summary, electronically exchange key clinical information among providers, report quality measures to Medicare/Medicaid or states, perform medication reconciliation, transmit electronic immunization data to immunization registries, and submit electronic syndromic surveillance data to public health agencies.

Currently, most HIE occurs as part of an existing HIO. HITECH funded a new option for statewide and interstate exchange known as the State Health Information Exchange Cooperative Agreement Program, discussed in a later section.

CONNECTING PRACTICES, HOSPITALS, AND CITIES
Approximately 234 HIOs exist in varying operational stages, according to a 2010 study by eHealth Initiative, a not-for-profit organization that has conducted annual HIO surveys since 2005. Seventy-three HIOs claimed to be operational (exchanging some type of health data), and 18 claimed to be sustainable (no federal funding in the past year, operational status, and receiving revenue equal to or exceeding costs). More than half of the HIOs offered the following core services: clinical messaging (electronic test delivery of lab and radiology results, medication data, outpatient visits, and emergency room visits), EHR connectivity, clinical documentation, and alerts to physicians. Fewer than half of the HIOs survey offered the following newer advanced services: e-prescribing, Web-based EHR-HIE combination, public health reporting, telemedicine, medication reconciliation, emergency room use data, transcription, voice recognition, business analytics/intelligence, value-based reimbursement (pay for performance), credentialing, research, clinical decision support, consumer portal, claims clearing house, care coordination, and picture archiving and communication systems.

HIOs such as HealthBridge, located in Cincinnati, Ohio, and Indiana Health Information Exchange,located in Indianapolis, Indiana, are performing well financially and have the support of the medical community. On the other hand, failures such as the Santa Barbara County Care Data Exchange have dissolved primarily due to lack of perceived value by the healthcare community.

In 2010, the State HIE Cooperative Agreement Program funded (via $548 million) 56 states, eligible territories, and qualified state designated entities. The overall goal was to promote standards based statewide and interstate information sharing to meet meaningful use, particularly where none exists currently. Statewide HIE will need to be interoperable with existing HIOs, significant data providers and users (such as Medicaid), and the Nationwide Health Information Network (NHIN).

The NHIN is a collection of standards, protocols, and services that enables the secure exchange of health information over the Internet. Instead of being a specific network, it is actually a “network of networks” connecting disparate healthcare organizations, to include HIOs, federal agencies, and integrated networks. The NHIN primarily will provide a means for large civilian and federal health organizations, to include HIOs, to share information securely. As an example, MedVirginia is sharing information with the Social Security Administration via the NHIN to expedite disability determinations.

WHERE’S THE MONEY?

HIE participation for any given healthcare provider is fundamentally a business decision. The expected net benefit to the provider must be positive so that expected benefits exceed expected costs. These benefits can be monetary in nature, accruing through efficiencies in running a practice or a clinic, or through better use of a reimbursement mechanism. They also can be non-monetary, yielding superior health outcomes through better case management while not affecting the bottom line for the business.

Potential models include monthly or annual pricing on a per physician basis (subscription model), pricing on a per-transaction basis, or some combination of the above (for instance, a monthly fee plus per-record usage cost). Approximately half of the operational HIOs charge physicians a user fee as well as an additional fee to create an electronic interface between an EHR and the HIO. Participants must be willing to collaborate, rather than compete, in data exchange and must be willing to pay operating costs. Organizations must have enough participants to create a “network effect” (enough customers to make it worthwhile) and create subsequent economies of scale to be successful.

One of the more immediate benefits for physicians to participate in information exchange would be to comply with meaningful use objectives as part of the Medicare and Medicaid EHR reimbursement program. Very few HIOs can meet all pertinent meaningful use objectives at this time, however.

Participation in successful HIOs likely will mean access to an increasing number of administrative and clinical tools such as business analytics, telemedicine, clinical decision support, centralized credentialing, research opportunities, and a variety of reports.

According to the latest eHealth Initiative survey, many HIOs report reduced staff time spent handling or filing lab and radiology results and handling prescription issues. Another potential benefit would be creating one EHR-HIO interface to receive results, as opposed to multiple EHR interfaces to outside labs,hospitals, and imaging centers.

NUMEROUS TECHNICAL AND FINANCIAL OBSTACLES
Physicians may object to any change in workflow, user fees, and EHR interface charges to participate in HIE. They may believe that the benefits accrue more to others, such as payers and state and federal governments.

The most commonly reported obstacle for HIE is a long-term sustainable business plan that does not depend on federal funding. HIOs must have the trust of multiple partners that traditionally have been competitors in the market place. HIOs must provide services that have perceived value to a wide audience, such as clinicians, hospital executives, and practice managers. The lack of widely proven return on investment may cause some clinicians to choose faxes and mail over electronic sharing.

HIE also is impeded by a lack of a universal patient identifier that would greatly improve retrieval of the correct patient record. Another administrative obstacle for all HIT initiatives is privacy and security. HIOs will store voluminous data for thousands of patients that can be breached without adequate protection. Further, depending on the state, patients will need to sign an opt-in or opt-out agreement to allow record sharing. HIE participation could raise new legal issues regarding responsibility for reviewing all pertinent information on a patient.

For electronic record-sharing to take place, data standards need to be developed and adopted. The current document standard is known as a continuity of care record or continuity of care document. Both are XML-derived patient summaries that are similar to a problem summary list but are in a format that can be both generated and read by most EHR systems.

ALTERNATIVES ARISE
Although the government approach currently favors HIOs and statewide health exchanges, other models have been proposed. Some favor an approach called health record banking. This approach is consumercentric and particularly appeals to privacy advocates. Each consumer (patient) would directly control who can access his or her account. Patients would authorize their providers to “deposit” and “withdraw” information from their secure online personal health information. It has even been suggested that the consumer would bear the cost of a nominal subscription fee. To date, however, patients have shown little inclination to adopt electronic personal health records, even though several systems are now available for free from organizations such as Google and Microsoft as well as health insurers.

Another proposed option is to use a nationwide electronic messaging system that already exists, such as Surescripts. Surescripts is the primary messaging system between physicians and pharmacies used in this country for the transmission of electronic prescriptions. Surescripts proposes becoming a health information service provider that offers the ability to exchange clinical messages and patient encounters over a standards-based network between providers. The company plans to offer this service in 2011 and support it by a subscription fee.

Additionally, the government recently has proposed a simpler alternative to HIOs called the DIRECT Project. In this option, which could be available as early as 2011, physicians will be able to push encrypted clinical messages between healthcare partners. Pilot tests will be under way in early 2011, and further details are forthcoming.

THE FUTURE OF HIE

Some see the role of the HIO as an “infomediary” or information-hosting organization that reuses data for more than clinical medicine, such as public health and research purposes. Several HIE vendors are planning to add Web-based EHRs, practice management systems, and business analytics to allow for fully integrated clinical and financial functions. A few HIOs are offering services such as transcription, credentialing, reporting (public health, quality and pay for performance), and patient access to health data through a portal and personal health records. In spite of approximately a dozen successful HIOs, HIOs remain expensive and complex.

Further, the viability of the new State HIE Cooperative Agreement Program is uncertain. States will be required to charge for HIE use, and it is unknown how this requirement will be viewed by data providers and users.

If you haven’t already done so, you will need to make a business decision whether to purchase a certified EHR to receive federal government reimbursement. As part of that decision and as an aid to achieving meaningful use, you also should determine how you will share medical information in the future. Ascertain whether you can use an existing HIO, a new statewide HIE, or a simpler solution such as the DIRECT project or the SureScripts network.

The degree of uncertainty regarding both EHRs and HIE is substantial, but so are the potential benefits to you and your patients. Mature and successful HIE is a rarity today but likely will be standard operating procedure in the foreseeable future.

2010 Advanstar Communications Inc..

Source:  Modern Medicine.com
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