And Tennessee may not be the only state changing direction. With limited grant funding and tight time frames, others also are re-evaluating ambitious goals of creating an infrastructure that would allow searching for patient records across hospitals and doctors’ offices statewide. Instead, states are downshifting to more incremental plans that start with enabling email connections between providers or that focus on supporting state Medicaid organizations. (HIEs — health information exchanges — are not to be confused with health insurance exchanges, which are being set up to allow consumers to comparison-shop for health plans.)
Tennessee intended to offer enterprise services, including links to an immunization registry, electronic lab results for reporting to the Department of Health, and compiled patient medication histories. “Our plan was to create a network-of-networks model that would connect existing RHIOs [regional health information organizations], not be a replacement for them,” said HIP TN CEO Keith Cox, who was hired in January 2011 to run the statewide operation and develop enterprise and value-added services for the network.
“Tennessee has been a leader in many HIE efforts, and we have a lot of experience in developing models of collaboration,” Cox said. “And as a state and a region, we are following and even anticipating the trends and visions that have been set forth for almost a decade.” Although the state received $11.6 million in federal grant funding to create the HIE, Tennessee officials say the new aim is to ensure that Tennessee providers meet the expected information exchange goals of Stage 2 meaningful use criteria of the incentive payment program funded by the American Recovery and Reinvestment Act of 2009. The new initiative, known as Direct, will be the basis, in the near term, to accomplish this.
“The board supported the change in direction and remains committed to the national vision for an interoperable health-care information infrastructure,” Cox explained. “It was very disappointing to think we would wind down after hundreds of stakeholders volunteered their time to work on an HIE framework,” he added. “However, all remain passionately committed to making this work for the state.”
Tennessee’s abrupt change in direction is unusual, but the frustration expressed there about the difficulty of the HIE process is common. For instance, in May, California replaced Cal eConnect, the nonprofit organization created to develop the state’s HIE. That effort is now led by the Institute for Population Health Improvement at the University of California, Davis. Cal eConnect had struggled with several changes in leadership. A joint statement from the California Health and Human Services Agency and Cal eConnect noted that the Cal eConnect board determined that as a startup with a large board, it was “not able to move fast enough to implement approved programs.”
Changing Role
One challenge that public-sector HIEs face is competition from private HIEs being set up by health systems to support patient-centered medical homes and accountable care organizations. In Connecticut, the three main hospital systems are expanding rapidly by buying hospitals and physician practices, and building out their own private HIE architectures that are tied to specific electronic health record vendors. “That is changing the thought process about the role the state HIE will play,” said David Gilbertson, CEO of the Health Information Technology Exchange of Connecticut. “What is the incentive for providers to connect to us? One is to fill the gaps and offer access to the providers that are not part of these organizations,” he said. “Another is to provide access to public health and Medicaid data. Those are the value propositions.”A snapshot of the development of statewide HIEs reveals a patchwork quilt with widely varied levels of activity and success. Some states have been working on transmitting health data for almost a decade, although even these exchanges struggle with financial sustainability. Other states are still doing planning and governance work. Because the federal funding was part of the stimulus bill, it must be spent in the next year and a half. That aggressive timeline puts the states in a difficult situation. “If the question is, can they complete a robust exchange in that time frame, the answer is probably no,” said Julia Adler-Milstein, an assistant professor at the School of Information at the University of Michigan. “But will information exchange increase considerably? For the majority of states, the answer will be yes.” However, if any progress at all on exchange is considered success, that is setting the bar rather low, added Adler-Milstein, whose research focuses on policy and management issues related to the use of IT in health-care delivery.
States are being forced to reassess their role in HIE, said Rick Ratliff, global connected health managing director for consulting firm Accenture. “Pennsylvania did an initial procurement over a year ago for planning a fully functionalHIE for the whole state,” he said. That procurement has been pulled, and a new procurement is likely to be much more modest, he said, taking advantage of exchange efforts already going on and with the state playing a much smaller part.
The states that are going to stand up a sophisticated central technology platform are few and far between, Ratliff said. “But it still makes sense for them to provide some shared services such as registry services for chronic disease management,” he said. States may focus on a smaller set of core government initiatives including public health reporting. “If the HIE can offer visibility into Medicaid members and increasing efficiency on their behalf,” he added, “that can be a key driver.” For instance, the Alabama Medicaid Agency has been the lead agency for the development and implementation of that state’s HIE plans. And the Arizona Medicaid program is offering incentives over the next three years to offset costs for providers to join the Health Information Network of Arizona.
HIE Models
Adler-Milstein contributed to a 2012 Robert Wood Johnson Foundation report on the state of U.S. health information technology. It used a model created by Deloitte that groups the state approaches to fostering HIE into four types:Elevator: States with an elevator model focus on rapid facilitation of exchange capabilities to help clinicians meet stage 1 of the federal “meaningful use” requirements to earn electronic health record implementation incentive funding. These states typically start with very limited health IT adoption and exchange activity locally or at the state level. Thus, they need to rely on a technical approach that can be built quickly and does not require mature infrastructure. Examples of elevators include Illinois and Wisconsin (and perhaps now Tennessee), Adler-Milstein said.
Capacity-Builder: These states focus on providing financial and technical support to bolster existing local exchanges that have comprehensive geographic coverage. Indiana, which already has several mature HIEs, including the Indiana Health Information Exchange, is a good example. “It would be crazy for the state of Indiana to try to stand up something totally new,” Adler-Milstein said. “Instead, they are using grants to try to get more provider groups connected to these existing exchanges.”
At a National eHealth Collaborative meeting earlier this year, John Kansky, vice president of product management for the Indiana HIE (IHIE), said the key to Indiana’s success is keeping the focus on providing value to customers. “We approach it and sustain it as a business,” he said. Affiliated with the Regenstrief Institute, the IHIE connects 90 Indiana hospitals, and 19,000 physicians use it. Its DOCS4DOCS subscription service provides physicians lab and radiology results in a Web-based inbox. The IHIE also offers a service that enables hospitals and physicians to electronically share clinical images.
Orchestrator: States with an orchestrator model focus on building the basic services required to connect existing substate exchanges. A good example is New York, which has nine RHIOs up and running, and its Statewide Health Information Network for New York will create a set of core services that participants will use to exchange information across organizational boundaries. Another state that is orchestrating exchange but not standing up a strong state-level organization is Minnesota. The state decided to certify and regulate exchange as it develops in the private sector, said Marty LaVenture, director of Minnesota’s Office of Health Information Technology.
“Given the limited funds available, it was determined to support a market-based approach,” he said. “As much as others may have wanted us to do this in a big bang, we determined to reduce our risk and do it incrementally.” The government role is oversight — ensuring there’s a fair playing field and that privacy and security guidelines are established and followed. “But we have a fairly thin layer of governance,” LaVenture stressed. So far, the state has certified five health information service providers, including Surescripts and Ability Network.
Public utility: States with a public utility model build a single hub for exchange focused on providing a wide spectrum of HIE services directly to end users and to substate exchanges where they exist. The exchange is either based inside state government or in a nonprofit state-designated entity. Such a model is particularly well suited for small states like Vermont and Delaware that can obtain sufficient stakeholder buy-in, as well as states with sufficient authority and resources to build statewide infrastructure. “Smaller states are more likely to play a broader and deeper role in the exchange,” Accenture’s Ratliff said. “There tends to be more willingness for health systems to come together and to allow a state health department, for instance, to play a significant role in driving governance and standards.”
Maine’s HealthInfoNet, which started in 2004, is a good example of a public utility, even though the organization is nonprofit and sits outside of state government. It’s expected that all Maine hospitals will be under contract to HealthInfoNet by year’s end and will be connected by the end of 2013. The exchange also expects that at least 80 percent of the state’s ambulatory providers will be connected by 2014.
HealthInfoNet’s executives see one early decision as critical: the creation of a commingled central database. (Competing health systems have trouble agreeing to do that because they see their data as a competitive advantage. Most states are using a federated model in which the data is stored in separate places and queried from other locations.) “One key problem with the federated model is that the data is not standardized,” said Dev Culver, CEO of HealthInfoNet. “They can’t create a view of the patient. We put a lot of time into mapping all that data to standards. In a federated model, that is impossible to do.”
In another example of value-added services it can offer, HealthInfoNet is launching the nation’s first statewide medical image archive. The goal is to reduce the cost of storage and transport of electronic medical images and make sharing these images possible through the HIE.
Looking for Support
But even HIEs that are successful in linking providers are still struggling to create a model of sustainability. The Delaware Health Information Network (DHIN) connects all hospitals in the state and 93 percent of providers. Yet Dr. Jan Lee, DHIN’s executive director, is charged with finding ways to make the network financially sustainable once federal and state funding run out. Previously, the state and private-sector providers have split what federal grants have not covered, but DHIN will have to identify value-added services that providers will be willing to pay for, such as unified medication history reports and data analytics on population health. This year DHIN had to go back to the state for an additional $3 million, but Lee said legislators were reluctant to provide that funding and basically said, “Don’t come back next year.”Delaware has been working on HIE for 10 years — “before it was trendy,” Lee said, and it still has issues to work through. She believes that states trying to catch up now face daunting challenges. “Look at Pennsylvania just to our north,” she said. “They have not been able to get off the dime. Issues of competition and mistrust have sent them back to the starting block several times. Now they are getting started and only have 15 months left in the ONC [Office of the National Coordinator for Health IT] funding grants. They cannot get connected in that time,” Lee added. “Dealing with data structure, consent issues, security, consumer advisory groups, broadband coverage — all this takes a long time.”
State HIE governance organizations are spending the most time on business cases and models for sustainability. It seems that the most successful HIEs, such as IHIE in Indiana, have focused on building only those services that stakeholders will pay for. It may be that there isn’t a strong market demand for statewide services, especially in large states where several regional exchanges have already been established. “They should do a needs assessment about how much demand there is for statewide exchange across big regions,” Adler-Milstein said.
Maine’s Culver believes his central data repository is valuable and can make HealthInfoNet sustainable if the HIE can offer analytics tools around it. “To organizations setting up accountable care organizations, there is a lot of value in that data set,” he said. “And if we can demonstrate a significant impact on cost and quality, then we can distinguish ourselves.”
