HIMSS: Lessons learned from five states' HIE implementations

NEW ORLEANS—Comparing the different approaches that five states took to implement a health information exchange (HIE), researchers discovered different technical infrastructure approaches and services provided; however, the states faced common challenges with sustainability and governance, based on research presented March 3 at the Healthcare Information and Management Systems Society (HIMSS) annual conference.

This e-session was compiled by Prashila Dullabh, MD, program area director for health IT at NORC University of Chicago, and Lauren S. Hovey, MA, principal research analyst of healthcare research at NORC.

The State HIE Cooperative Agreement Program was created in 2009 as part of the Patient Protection and Affordable Care Act (PPACA), under the leadership of the Office of the National Coordinator for Health IT (ONC). It was one of several programs, such as the Centers for Medicare & Medicaid Services’ Meaningful Use requirements and ONC’s Direct Project, which aligned under PPACA to support HIEs. Under the State HIE Cooperative Agreement program, ONC granted $564 million in funding to 56 states and territories to enable HIEs.

The purpose of the State HIE Program was to facilitate and expand the movement of electronic health information among providers, healthcare systems and other clinical environments, with the goal of increasing the quality, efficiency and safety of healthcare. The program funds states to develop and implement government structures and state-level policy; privacy and security frameworks, including consent models; sustainability plans, because ONC funding will not be available beyond 2014; technical infrastructure for HIE services; and partnerships among local stakeholders to support and participate in HIEs.

To better understand the implementation process, Dullabh and Hovey, along with additional researchers at NORC, conducted onsite interviews and focus groups from November 2011 to March 2012 with stakeholders in Maine, Nebraska, Texas, Washington and Wisconsin. They focused their areas of interest on implementation approaches, use cases, enablers and challenges. Their interviewees included health IT coordinators, payers, hospital systems, physicians, labs and vendors.

There were varied approaches across the states:

• Maine has a heavy technical infrastructure, and provides an enterprise master patient index (MPI), a provider directory, translation services, record locater services (RLS), authentication services and an audit log.
• Nebraska has a heavy technical infrastructure, and provides an MPI, a provider directory, authentication services, RLS, an audit log and translation services.
• Texas has a thin layer of infrastructure approach, using a local grant program, and a two-phased approach for services. Phase one includes sub-state nodes that provide services, and phase two includes consent management RLS and a gateway to the Nationwide Health Information Network.
• Washington has a thin layer translation services infrastructure approach, and provides authentication services, translation services, a provider directory and a health plan directory.
• Wisconsin has a thin layer network of networks infrastructure approach, and also has a two-phased approach for services. Phase one includes Direct and an MPI, while phase two includes a physician directory, RLS and an MPI for query/retrieval across sub-state nodes.

Heavy infrastructure typically involves building a central data repository and offering related services, while in light infrastructure, the state does not store data centrally, but facilitates data movement between entities.

State characteristics that impacted these varied approaches included geography (rural vs. urban); population characteristics; level of EHR adoption (using an EHR is a precursor to HIE, as it is difficult to have an HIE without EHRs); presence of large healthcare systems that typically have the technical capabilities to support HIEs and typically deliver the bulk of health services in a local market; pre-ponderance of large vs. small providers; and existence and influence of health information organizations and HIE vendors.

Based on their research, Dullabh and Hovey identified priority use cases, which cause demand for HIEs. Notably, the priority is tied to the type of stakeholder, as opposed to the state. For instance, ambulatory providers and health centers require electronic patient referrals and real-time access to admission, discharge and transfer information. Medicaid directors are seeking Medicaid claims data, such as patient medication history, at the point of care and data analytics for quality improvement. Meanwhile, lab providers are looking for bidirectional exchange of lab orders and results with providers.

Therefore, states need to identify the greatest need or demand in their unique settings before rolling out HIE services.

They found that incentives and grants, such as the MU program, have done much to defray the costs of enabling an HIE, but Dullabh and Hovey acknowledge that the ongoing challenge will be how to ensure sustainability.

All five states chose to decouple policy and technical roles, so states handle the government entity while the IT employees manage the technical entities. This allows the two entities “to play to their strengths.”

There were common challenges across all five states, despite the disparity of infrastructure and services. There were six that stuck out among the challenges:

1. Infrastructure cost and sustainability;
2. Engaging large health systems, including creating critical mass and making the business cases;
3. Interface cost and technical support for providers, including activating, maintaining and upgrading the technology’
4.  Provider awareness, where the familiarity is limited to certain activities such as e-prescribing;
5. Integration into provider workflow and interoperability to overcome multiple log-in screens and external data that are poorly integrated into EHRs.
6. Ongoing evolution of healthcare, including consolidation and expanding private HIEs.

Dullabh and Hovey concluded that while the states all implemented some type of technical infrastructure, the interviews suggested the need for a broader range of services to HIE stakeholders. They found that an early focus on the value proposition and sustainability planning is “essential.” Also, the practical challenges of implementing and exchanging clinical data must be addressed.

The researchers recommended that states focus on governance and establish the conditions to support the HIE, as well as harness provider interest in new care delivery models to communicate the value of HIEs.