HIE Profile | Bridging the Clinical Exchange Gap
Since 1993, Utah has been honing its statewide health information exchange (HIE). All of the state's hospitals, national laboratories and approximately 90 percent of providers currently exchange administrative claims data through the Utah Health Information Network (UHIN), but now the state is beginning to navigate an unfamiliar landscape: clinical health information exchange (cHIE).
"UHIN has successfully operated for many years, exchanging administrative data, like a post office routing packages," says HealthInsight's Vice President of Strategic Development Sharon Donnelly, MS. "Since 2004, they've been working on exchanging clinical data, but this is a different model for them. The post office model wasn't as robust."
As an executive employee of the regional extension center (REC) for Utah and Nevada, Donnelly has worked closely with UHIN on clinical exchange efforts. While the REC has faced challenges in achieving successful clinical data exchange, she says the past success in administrative exchange keeps her from worrying about cHIE's future.
Rather than allowing private clearinghouses to take control of the state's market for administrative exchange services in the early 1990s, stakeholders got together to create their own exchange, Probst says. "They had a really clear business model, and that's worked well for Utah because it brought all of the big players together—the hospitals, the government, the physician groups and the payors."
Donnelly agreed that UHIN's administrative exchange's success is due to a coordinated community effort. Strong leadership from private payors drove an effort to focus on what was best for the community, she says. "In some communities, people come to the table to protect their personal agendas, but, in Utah, we've generally been able to work for the betterment of the whole community."
However, UHIN's CEO Jan Root, PhD, doesn't paint a portrait of seamless cooperation. The expanses between provider and payor sometimes seemed unbridgeable, she says, but their ability to work out an agreement was an impressive accomplishment.
The result was state legislation to create a nonprofit, private-public entity to facilitate administrative exchange. That entity became UHIN, which currently charges payors 17 cents per claim to participate and offers an annual fee schedule for providers starting at $240 per year for solo physician practices.
UHIN's low fees, according to Root, have allowed UHIN to survive among and compete with larger, for-profit, national clearinghouses.
"We've been successful," Root says, "mostly because we're inexpensive and because we meet our members' needs."
Now, UHIN is working to deploy a patient record inquiry service, which will allow participating providers to access their consenting patients' longitudinal clinical records from anywhere in the state. Providers can use these functionalities to pursue meaningful use incentive payments.
UHIN's strategy has been to "first fill the wells and then collect consents," Root says. To accomplish this, UHIN has worked to identify providers willing to participate and patients willing to share data.
Utah's four major hospital networks have begun putting data into cHIE and paying membership fees and more "rural hospitals are coming on board," Root says. Patient data from their EHRs is in cHIE, but the major challenge to clinical exchange has been collecting patient consents.
The UHIN board had initially hoped to avoid collecting patient consents by requiring patients to opt out if they don't want their data shared, but the UHIN board of directors chose an opt-in model, which Root agrees is "the right way to do it."
While easing some patients' privacy concerns, the drawback to an opt-in model is that it requires a tremendous amount of time to collect a state population's worth of consent forms.
"There are about 2.7 million people in the state. We have less than a million identities in the EHRs and fewer than 25,000 consents," Root says. "That's our bottleneck."
Consents make patient data available, which is necessary to make fees worthwhile to provider participants. According to UHIN's fee schedule, cHIE costs range from $600 annually for solo provider practices to $28,189 for healthcare networks with more than 200 providers. Those fees, along with the cost of making a recently implemented EHR system interoperable with cHIE, may be fair prices to pay for the service. But, Root, Donnelly and Probst all agree that providers won't pay for the cHIE if patients' data are not available.
Donnelly notes several differences. "There's a long successful history of moving packets, but never opening them. It's also been very payor oriented. When they were beginning clinical exchange, they had to change their board because they needed more provider representation, and they had to deal with data risk issues they've never had to deal with before."
UHIN also had gone into the clinical exchange business assuming an opt-out model, preventing the scramble for consents.
"The change in the cHIE consent model poses a serious and significant delay in implementation, provider adoption and utilization thereby jeopardizing the potential to demonstrate value and generate a sustaining business case," a 2011 UHIN legislative report reads.
In an attempt to achieve sustainability by the end of 2013, UHIN has been using federal and state grant money to implement cHIE and to conduct public outreach, adding to the sense of urgency.
Despite that urgency, Root, Donnelly and Probst all believe that Utah can achieve clinical exchange just like it achieved administrative exchange many years ago.
Outreach efforts have been successful so far, Root says, and she's pleased with the opt-in model. "People appreciate being asked, and they appreciate being educated," she says. "The education effort is extremely important."
In addition to outreach, Root says UHIN is working on developing an electronic consent procedure that can authorize identities. Probst says the 23-hospital-strong Intermountain Healthcare is devoting IT resources to consent collection and Donnelly says the REC is working with providers on cHIE interoperability.
"It takes a long time to get all of the patients signed up," Root says. "We're pushing that rock up the hill, but it will get done."
Things may be moving slowly, but Utah is getting there. According to Root, more than 90 percent of patients are providing consent when asked and UHIN is "getting buried with consent forms from clinics."
Donnelly says that perhaps the people of Utah proceed cautiously to ensure that things are done right. "We move very slowly in Utah," she says. "We tend to produce a good product, but it is a slow community process."
"UHIN has successfully operated for many years, exchanging administrative data, like a post office routing packages," says HealthInsight's Vice President of Strategic Development Sharon Donnelly, MS. "Since 2004, they've been working on exchanging clinical data, but this is a different model for them. The post office model wasn't as robust."
As an executive employee of the regional extension center (REC) for Utah and Nevada, Donnelly has worked closely with UHIN on clinical exchange efforts. While the REC has faced challenges in achieving successful clinical data exchange, she says the past success in administrative exchange keeps her from worrying about cHIE's future.
Early administrative exchange
Marc Probst, MBA, CIO of Salt Lake City-based Intermountain Healthcare and previous UHIN board member, says that administrative exchange became successful in Utah because the various healthcare stakeholders realized they would all benefit by working together to make it happen.Rather than allowing private clearinghouses to take control of the state's market for administrative exchange services in the early 1990s, stakeholders got together to create their own exchange, Probst says. "They had a really clear business model, and that's worked well for Utah because it brought all of the big players together—the hospitals, the government, the physician groups and the payors."
Donnelly agreed that UHIN's administrative exchange's success is due to a coordinated community effort. Strong leadership from private payors drove an effort to focus on what was best for the community, she says. "In some communities, people come to the table to protect their personal agendas, but, in Utah, we've generally been able to work for the betterment of the whole community."
However, UHIN's CEO Jan Root, PhD, doesn't paint a portrait of seamless cooperation. The expanses between provider and payor sometimes seemed unbridgeable, she says, but their ability to work out an agreement was an impressive accomplishment.
The result was state legislation to create a nonprofit, private-public entity to facilitate administrative exchange. That entity became UHIN, which currently charges payors 17 cents per claim to participate and offers an annual fee schedule for providers starting at $240 per year for solo physician practices.
UHIN's low fees, according to Root, have allowed UHIN to survive among and compete with larger, for-profit, national clearinghouses.
"We've been successful," Root says, "mostly because we're inexpensive and because we meet our members' needs."
Clinical bottleneck
According to an annual legislative report dated October 2010, UHIN has been working on cHIE since 2004. The service currently allows participating providers to electronically prescribe medications and order reports from data sources, such as hospitals and laboratories.Now, UHIN is working to deploy a patient record inquiry service, which will allow participating providers to access their consenting patients' longitudinal clinical records from anywhere in the state. Providers can use these functionalities to pursue meaningful use incentive payments.
UHIN's strategy has been to "first fill the wells and then collect consents," Root says. To accomplish this, UHIN has worked to identify providers willing to participate and patients willing to share data.
Utah's four major hospital networks have begun putting data into cHIE and paying membership fees and more "rural hospitals are coming on board," Root says. Patient data from their EHRs is in cHIE, but the major challenge to clinical exchange has been collecting patient consents.
The UHIN board had initially hoped to avoid collecting patient consents by requiring patients to opt out if they don't want their data shared, but the UHIN board of directors chose an opt-in model, which Root agrees is "the right way to do it."
While easing some patients' privacy concerns, the drawback to an opt-in model is that it requires a tremendous amount of time to collect a state population's worth of consent forms.
"There are about 2.7 million people in the state. We have less than a million identities in the EHRs and fewer than 25,000 consents," Root says. "That's our bottleneck."
Consents make patient data available, which is necessary to make fees worthwhile to provider participants. According to UHIN's fee schedule, cHIE costs range from $600 annually for solo provider practices to $28,189 for healthcare networks with more than 200 providers. Those fees, along with the cost of making a recently implemented EHR system interoperable with cHIE, may be fair prices to pay for the service. But, Root, Donnelly and Probst all agree that providers won't pay for the cHIE if patients' data are not available.
A different kind of business
Exchanging patient data is "a very different business from exchanging claims," Root says. "It's not the same business model at all."Donnelly notes several differences. "There's a long successful history of moving packets, but never opening them. It's also been very payor oriented. When they were beginning clinical exchange, they had to change their board because they needed more provider representation, and they had to deal with data risk issues they've never had to deal with before."
UHIN also had gone into the clinical exchange business assuming an opt-out model, preventing the scramble for consents.
"The change in the cHIE consent model poses a serious and significant delay in implementation, provider adoption and utilization thereby jeopardizing the potential to demonstrate value and generate a sustaining business case," a 2011 UHIN legislative report reads.
In an attempt to achieve sustainability by the end of 2013, UHIN has been using federal and state grant money to implement cHIE and to conduct public outreach, adding to the sense of urgency.
Despite that urgency, Root, Donnelly and Probst all believe that Utah can achieve clinical exchange just like it achieved administrative exchange many years ago.
Outreach efforts have been successful so far, Root says, and she's pleased with the opt-in model. "People appreciate being asked, and they appreciate being educated," she says. "The education effort is extremely important."
In addition to outreach, Root says UHIN is working on developing an electronic consent procedure that can authorize identities. Probst says the 23-hospital-strong Intermountain Healthcare is devoting IT resources to consent collection and Donnelly says the REC is working with providers on cHIE interoperability.
"It takes a long time to get all of the patients signed up," Root says. "We're pushing that rock up the hill, but it will get done."
Things may be moving slowly, but Utah is getting there. According to Root, more than 90 percent of patients are providing consent when asked and UHIN is "getting buried with consent forms from clinics."
Donnelly says that perhaps the people of Utah proceed cautiously to ensure that things are done right. "We move very slowly in Utah," she says. "We tend to produce a good product, but it is a slow community process."