HIEs: Specialize, Adapt & Survive

Health information exchanges (HIEs) are coming online at a rapid pace, fueled by federal dollars and the demands of an increasingly mobile population. What information is being exchanged? The answer depends on the HIE and the communities it serves. Answer this question correctly, and your HIE’s prospects for survival greatly improve.

Currently there are at least 73 operational HIEs, according to a 2010 report by eHealth Initiative (eHI). This is a jump from 57 operational exchanges in just the last year, and a giant leap from eHI’s first published finding of nine operational HIEs in 2004.

According to eHI, of the 73 operational HIEs, 34 are currently transmitting data that are being used by healthcare stakeholders (Stage 5 on eHI’s seven-stage framework of operational exchanges). Eighteen are transmitting data that are being used by stakeholders and have sustainable business models (Stage 6). The report says 21 HIEs in this group are at Stage 7—that is, they are not only transmitting data that are being used by stakeholders, they also are expanding to encompass a broader coalition of stakeholders.

Exchanging information is only part of the challenge. According to eHI’s report, 18 HIEs claim they’re not dependent on federal funding and are sustained on operational revenue alone.

“A lot of the sustainable organizations select a core group of functions or services to offer initially,” says Jennifer Covich-Bordenick, CEO of eHI. “They don’t try to boil the ocean.”

This is how the Indiana HIE (IHIE) started out. In 2005, IHIE began offering Docs4Docs, an internal clinical results delivery service, with an initial 450 clinical users, says J. Marc Overhage, MD, PhD, president and CEO of IHIE, which has achieved eHI Stage 7 and has grown to include 19,000 physicians and 67 hospitals.

IHIE then branched out to provide Quality Health First, a quality improvement application that incorporates clinical and administrative data as well as claims data from payors to improve patient care, Overhage says. The application gauges how physicians are enacting care, aligns that performance to incentives from payors, and pushes out a measurement to physicians. Quality Health First is getting results, he says: In 2009, IHIE recorded an overall 5 percent improvement in patients who were reaching their objectives in terms of care management.

The Indianapolis-based nonprofit now exchanges lab results, patient demographics and visit information, radiology study results, and information on dictated and transcribed summaries such as discharge notes. IHIE processes approximately 2.5 million results a day via HL7. Data are stored for roughly 12 million patients with close to 4 billion structured results available online, according to Overhage.

To ensure sustainability, “we insist that every service float on its own,” says Overhage. “The clinical messaging revenues have to pay the cost of clinical messaging and an organization’s fair share of the infrastructure costs.”

IHIE avoids using grant funds as operating revenues but instead uses grants for capital. “That’s one of the few ways as a nonprofit we can generate capital for investment,” he says. “The biggest thing that organizations take away is our approach to multiple services that sustain the operation by recognizing the value that’s created for each of the different categories of participants whether its payors, hospitals, laboratories or public health.”

Getting docs on board

Getting an HIE into a clinical practice means getting providers to use the HIE technology, and that’s a challenge, according to Tom Deas Jr., MD, CMO of Sandlot LLC, a wholly owned subsidiary of North Texas Specialty Physicians, based in Fort Worth, Texas.

Sandlot launched its HIE, Sandlot Connect, in 2008. Today, the Stage 6 HIE exchanges clinical information from 1,400 physicians in four counties in the Dallas-Fort Worth area. “As a physician organization, we provide incentives and performance measures that motivate clinicians to initially use the system to get used to the HIE, but once they’ve been in and find how useful the information is, you don’t need any incentive other than that,” says Deas.

Sandlot Connect’s electronic referral management application is picking up steam, says Deas. The application enables physicians to securely exchange e-referrals, and it electronically notifies physicians when a referral is accepted.

Information exchanged in Sandlot Connect includes diagnoses, allergies, medications, certain procedures or events performed, patient visits, radiology, reports, laboratory results and hospital discharge summaries. Sandlot Connect also offers limited e-prescribing capabilities and some interoperability with EMRs. According to Deas, Sandlot has recently added some ancillary providers and nursing homes to its roster of participants.

At this time, Sandlot Connect is fully funded by North Texas Specialty Physicians. “We are pursuing grant and federal stimulus funds to help us grow,” says Deas.

Meaningful Exchanges

Meaningful use requirements are playing a role in the mix of functions that HIE initiatives are providing, reports eHI. Source: eHealth Initiative

Subscriptions and prescriptions

The Nebraska Health Information Initiative (NeHII) is planning for a self-sustaining future. NeHII charges a monthly license fee from data providers based on number of beds. Fees range from $1,500 per month for small critical access hospitals up to $12,000 per month for organizations with 500-plus beds, according to Deb Bass, executive director for NeHII.

NeHII, a Stage 7 HIE, exchanges clinical information for 1.6 million patients, including e-prescriptions, laboratory and x-ray results, and medication history. Data are exchanged via Axolotl’s Elysium platform. Clinicians have generated more than 14,700 prescriptions using the NeHII system, and 97 percent of these orders were electronic, according to Bass. Some 13 million results have been sent to the exchange, including 9 million laboratory results, she says.   Under HIE Cooperative Grant funding from the Office of the National Coordinator for Health IT, NeHII must be revenue-producing in four years based on the value it delivers, says Bass. “We are working diligently to develop business models to support us so we can be as independent from monthly license fees as possible.” In the future, NeHII will offer a revenue-sharing model for participants and HIE advisory consulting services. NeHII also is developing subscription-based HIE services for physicians and consumers for future use, she says.

Value add

The Delaware Health Information Network (DHIN), Delaware’s state-designated entity for HIE, went live in 2007 with a clinical results delivery service for lab, pathology and radiology results and admission face sheets, according to Gina Perez, executive director for DHIN. In 2009, the HIE added new data search functionality, new data contributors and support for new types of transactions. Now DHIN is developing electronic order functions and the ability to report immunization history by 2012, says Perez. Currently, 65 percent of clinicians in the state are exchanging information via the HIE, which is built on Medicity technology.

DHIN’s approach to sustainability includes a combination of state and private funds augmented by federal funds. Every state dollar appropriated must be matched by a dollar from the private sector, according to Perez. The private sector cost is covered by a fee structure based on transactions into the system, she says.

“HIEs need to be nimble and ... constantly look at the needs and value propositions to participating organizations,” says Perez.