HIE Profile: Alabama Creates One Health Record

Come April, the state of Alabama will launch a new statewide health information exchange (HIE)—One Health Record. Alabama Medicaid Commissioner Robert Mullins, MD, looks forward to providers in any setting having access to all relevant patient data.

Before he was appointed as Alabama's Medicaid Commissioner last January, Mullins says he recognized "a real need for portable health records, but I was fairly naïve to what that should be." Perhaps each citizen would carry his or her own thumb drive.  His role as commissioner, however, introduced him to the "impressive sophistication" of the state's Medicaid program. "One of the nicest surprises in this position is the depth of involvement and understanding Medicaid staff had of the need for portable patient data available throughout the state for providers."

Include and involve

Heading up the One Health Record effort is Dan Roach, III, MD, health IT coordinator for the State of Alabama. In this role, Roach helps providers implement electronic records in their practices and teach them about HIE and its benefits. He plans to go live with One Health Record in several health systems this month. These early adopters will serve as "gateways," he says, encouraging other providers to connect through the exchange.

Providers are very interested in the effort, says Roach. "From the beginning, we've made this a transparent, multi-stakeholder effort. The best way to get people involved is to include them." Alabama's HIE is based on a cooperative agreement with the Office of the National Coordinator of Health IT. Thus, the commission has the five standard workgroups—policy, legal, governance, finance and technical—plus one more the state added—communications and outreach. A workgroup represents each area and stakeholders are members of the workgroups. Each workgroup debates policies and procedures, sustainability plans, infrastructure and more. Then, the HIE Commission, the ultimate decision-making body, reviews and signs off on all of the plans.

Roach doesn't view One Health Record as competing with any other HIEs, public or private. "The nice thing about the nationwide HIE architecture is that if there are local exchanges, they can actually connect back to the state exchange and be part of both the state exchange and their provider groups. We're not competing, we're including."

The HIE will function as a hub, says Mullins. "If we set up a hub, [providers] can take whatever system they've developed for their entity and plug in if they meet the criteria."

The clinical workgroup is determining the first data drivers, which will grow over time, Roach says. "We'll start with a limited, attainable set," which includes demographics, diagnoses, history and physical reports, lab results and pharmaceutical histories. The data will connect to public health departments to track immunizations, syndromes and surveillance to satisfy two public health requirements for meaningful use.

Reaching rural providers

A statewide HIE is particularly essential in Alabama. The vast majority of providers are considered rural, with 65 out of 67 counties considered shortage areas. One Health Record is prioritizing primary care practices with 10 or fewer physicians. "One of the guiding principles is to watch out for the little guy," Roach says. "We want to make sure that these small, rural providers have the same opportunities as a multispecialty group in an urban setting. We are removing asymmetries between those types of practices and reaching those providers that otherwise wouldn't be able to do these types of activities."

One Health Record aligns with other Medicaid chronic disease programs in Alabama, says Roach, particularly those addressing the state's large prevalence of both diabetes and asthma patients. The capability to share clinical information between specialists and primary care providers, including case management notes, tasks and goals, "will be transformative for chronic disease," he says.

The right thing to do

Enthusiasm is at a fever pitch leading up to the launch. "We're absolutely excited" about One Health Record, says Richard Caldwell, CIO at Jackson Hospital in Montgomery. "This is the right thing to do. Long before the stimulus package ever provided any funding, we were working with the other hospital in town, as well as other safety net providers, in an effort to put together a health information organization to develop an HIE. This stimulus package and the funding for the HIE was serendipitous."

Jackson is planning to be one of the early adopters to go live this month, after "feverishly working" to get ready to connect, Caldwell says. Efforts included upgrading to a certified version of the facility's EHR and creating a standards-based communication hub that will be used to connect to the HIE and send and receive continuity-of-care documents.

With a large Air Force base and veteran population in Alabama, "we hope to be able to connect the U.S. Department of Defense and the veteran entities to the HIE as well as other hospitals, federally qualified health clinics and independent physician groups," says Caldwell. The majority of the independent groups are on board with the HIE, he says, but there are still some holdouts. "If we can hit 80 percent, that's a huge gain."

A big unknown

Whether that number will be acheived is unknown, as is how One Health Record will maintain its financial sustainability. "That's the rub here," says Caldwell. Funding is a big unknown, he admits, but "if it works and provides the functionality that we expect, I believe we'll find a way to fund it."

A $10.5 million federal grant served as the seed money for One Health Record. In other states, hospitals are paying upwards of $800,000 to participate in an HIE, according to Roach. "That's not going to happen in Alabama," he says. "In my opinion, you have to create value and create a system that works. This is not technology for the sake of technology."

Ongoing funding isn't a priority, Cald-well says, because "we really are looking at providing a higher level of service and care to our patient population. Right now, we're able to look at a specific episode of care in great detail but we can't see the continuum of care at all. We want to see what happened in the emergency room across town as well as what happened in the primary care office or urgent care center when a patient presents in our ER. Physicians are very excited about that."

Overall, Alabama physicians have received meaningful use incentive payments totaling $13.5 million and hospitals have received $14.5 million. "People have us pictured as barefoot hillbillies but this hospital is at about Stage 4 of the HIMSS Analytics metrics," says Caldwell. "We'll be in stage 5 by the middle of next year. Most of the larger hospitals in Alabama are either there or close."