Shining the Light on Beacon Communities

In 2010, the Office of the National Coordinator FOR HEALTH IT (ONC) provided $250 million to 17 selected communities through three-year Beacon grants. The communities chosen had already made inroads in the development of secure, private and accurate systems of EHR adoption and health information exchange (HIE). Now that the three-year grants are coming to an end, it’s time to assess how the communities did. Representatives from several Beacon projects spoke to Clinical Innovation + Technology about their successes and ongoing challenges.

Tulsa

MyHealth Access Network focuses on 11 counties in greater Tulsa, Okla. MyHealth’s HIE contains 6.5 million records on more than 2 million patients with 1,600 registered physicians, far beyond its original Beacon region of approximately 1 million patients. Additional data sources in development include feeds from clinics and hospitals, claims feeds from payers and feed to and from the Oklahoma state immunization registry.

Oklahoma historically has had among the worst health outcomes in the U.S., and been at the bottom when it comes to most health quality indicators, says MyHealth Program Director David C. Kendrick, MD, MPH. “We knew we needed to do something dramatic.” First up was establishing data aggregation capabilities to identify places of health improvement. That began with an HIE.

“We started from scratch” creating the HIE, says Kendrick. Good communication and collaboration has “pulled us through and held the level of innovation pretty high.”

Stakeholder buy-in has been one of the “most important and challenging things to face,” he says. They all had to step away from their own bottom line and thinking and start to think at the community level. The participants kept their competitive interests in mind, Kendrick says, but had to think about the impact on the community an HIE could have.

Governance was very important, he says. “Everybody had representation. People felt safe enough to be willing to contribute their organizations’ gathered health information to improve the health of patients everywhere. We’ve all embraced that as organizations and it’s made a lot of things possible that weren’t before.”

Local payers were involved from the beginning, but “we did not ask that they pay for the whole network like many other communities.” They knew that improved efficiency would reduce costs for the payers. “Instead, we asked them to become partners in creating unique reimbursement models and incentive programs to get people using the exchange.”

As challenging as governance can be, “there are some technical issues that are very difficult to resolve,” such as interoperability of EHRs. MyHealth worked with vendors who volunteered to collaboratively achieve data exchange. “By working together, we were able to prove that continuity of care documents are alive and well and something we could exchange. It was more difficult than anticipated and there is a lot of work yet to be done. Many vendors didn’t participate, so I would encourage them to beef up their interoperability credentials.”

HIE was one of the first opportunities for primary care initiatives. Payer partners had a chance to implement programs that would incentivize people to use the HIE. The care management fee for primary care providers (PCPs) ranged from $2 to $28 a month. Being able to perform care management beyond the usual office fees “helps the long-suffering PCP base grow and thrive,” says Kendrick. “It’s been a really big win that could not have happened without MyHealth.” Several payers now write into their contracts that providers must be participants in good standing with MyHealth.

The group designed its own user interface as well as developed and deployed a community analytics platform. “We can perform pretty advanced analytics in the background and stakeholders can have their own analytics to work with their patient population to identify opportunities for care.” The care transitions system moves patients efficiently and with more than 110,000 completed referrals, the HIE has demonstrated significant cost savings.

Hawaii

Hawaii faces challenges regarding its HIE, specific to factors unique to an island state. The islands of Hawaii are not well connected in terms of care transfer, says William I. Park, MD, chief medical officer at North Hawaii Community Hospital, and sustainability has been challenging.

An HIE effort was underway prior to the Beacon grant. Through a grass roots process, the north side of Hawaii’s big island installed an inpatient system and then initiated an ambulatory system installation in 2007. “During the implementation, it became clear that we needed to make an effort to build a comprehensive clinical record system,” says Park.

Referred to as a community HIE, it became a regional HIE. The goal was to hook in providers in Hilo, Kona and the rest of the island. “In retrospect, it was a far-fetched idea with our limited resources.” The Beacon funding that came along shortly afterward boosted and expanded the project, says Park, who adds that it’s possible they would have been able to continue their efforts without the Beacon grant but in a much more limited way.

The three acute-care facilities on the big island’s north side are fragmented, says Park, and care coordination has been poor. The area is 25-35 miles in radius with approximately 35,000 people. Even in the relatively small area, the various providers were on four different EHR systems. “The HIE effort tried to get all the different systems to talk to each other.” At this point, they’ve been able to connect all the major entities including the inpatient care system, labs, radiology and ambulatory systems on one portal. “We have a way to go in terms of hooking other ambulatory systems into the HIE. It’s an ongoing project but, so far, the achievement is pretty impressive.”

With the different systems in use, there are concerns about connectivity, privacy and security, limited resources and sustainability. “All of those issues can be overcome if we see enough value in developing this HIE in terms of care coordination and cost savings.” Park says the biggest value is care coordination. If he discharged a hospital patient to a long-term care facility, he used to fax all the records to that facility. That would result in transmission of approximately 100 pages that “may or may not be useful. The advantage is obvious. Physicians from the long-term facility can now log on and go through the relevant record and get information that gives the best value.”

Currently, there is no concrete plan to secure the future of the HIE. Physicians always are looking for information to help take care of patients as long as it doesn’t become a huge roadblock in their workflow, Park says. They have yet to determine whether physicians would be willing to pay for the HIE and if so, how much.

Park says the group should have spent more time thinking about sustainability. “It’s a costly project that requires a fair amount of resources annually, particularly if you’re planning to expand.”

Rhode Island

The Rhode Island Beacon Community (RIBC) has focused its efforts on improving the quality of care administered to patients with diabetes, promoting smoking cessation, increasing depression screening and reducing preventable hospitalizations and emergency department use.

Rhode Island’s HIE, CurrentCare, is an important aspect of the project, says Darby Buroker, MPA, director of the RIBC program. “Our focus has been on the patient-centered medical home (PCMH) and the HIE is the key way we’ve supported that.” CurrentCare also serves as the foundation for building statewide data management and analytics which are “key ingredients to the PCMH.”

The HIE existed prior to the Beacon grant, and the funding was used to invest in new capabilities. RIBC started with practices that already were up and running with an EHR. “We built advanced capabilities around the infrastructure already in place. Practices that already were involved in PCMH participated in interventions designed to transform their practices even further,” he says.

Through a broad approach, “we addressed all the patients in the PCMH panels.” For example, they implemented a hospital alert service. Admission and discharge messages sent from R.I. hospitals go to the HIE, and “we pass them along to care teams that have prescribed to the service.” That allows for more coordinated care, because the PCMHs know when their patients have been to the hospital and can do early interventions and appropriate follow up.

Before an organization signs up for the service, “we’ll go out to those PCMHs and share that information. If you had been using the service, you would have received these alerts. That level of analytics alone is really important. Hospitals are beleaguered by pressures and stresses. They have to see and understand the opportunity.”
Providers frequently are surprised at the wide variety of institutions their patients visit, Buroker says. Again, that supports the value proposition of exchange and notification capabilities.

Once the three-year grant ends, “many of the capabilities we made possible through Beacon will continue through other PCMH programs.” For example, the multi-payer PCMH arrangement existed prior to Beacon, but the funding allowed the state to take advantage of the existing infrastructure and create new investment and support. “A common theme for our program was to take advantage of any existing work in this space and take it to the next level. Beacon made possible activities not funded through any other mechanism.”

R.I. providers have learned that the technology is reasonably straightforward, says Buroker. “Workflow and process change is very much a challenge and requires significant investment.”

San Diego

San Diego used its Beacon grant to focus on improving immunization rates and decreasing 30-day hospital readmissions. “We created a federated model that controls the data within the partners,” says Jim Killeen, MD, technical lead at the San Diego HIE which oversees the Beacon project. “We have a master patient index as well as a record locating service.” One of the key components of the HIE is that it receives messages whenever a patient hits the healthcare system for any reason. As a Sharp Pioneer accountable care organization (ACO), case managers know when their patients visit a facility outside of Sharp.

Part of the San Diego Beacon’s goals was getting more providers involved in Meaningful Use. That benefits providers, Killeen says, because they can get the incentive dollars and help standardize health IT across the community.

“We want to connect so that you can actually find out more about your individual patients when they come to see you," Killeen says. "We’re bringing the patients’ information to the bedside wherever the patient is."

The group believes that “messaging is a huge component for sustainability in the community itself both for providers and health systems and payers. We’ve been able to move this notification into real time.” With traditional claims data, those kinds of knowledge would be available 90 days later, and health systems wouldn’t know if patients were in different systems. Real-time notification allows entities to know within 24 hours where their patient is and help make appropriate healthcare decisions, says Killeen.

The San Diego Immunization Registry has been around for 16 years and ready to accept information but the other partners “haven’t necessarily put it on their road map,” says Eddie Castillo, PhD, who oversees the immunization effort. The HIE partnered with the registry to help improve immunization rates and documentation of immunization rates.

“We cloned the immunization registry and moved it into the HIE cloud. Any partner that connects to the HIE automatically connects to the immunization registry.” Much like the other Beacon communities, San Diego took advantage of the health IT already in place. “We leveraged processes that were done within the different health systems and translated messages so they could be forwarded," Castillo says. "We took what healthcare systems already had in place and built on top of that.”

There’s always room for improvement, says Killeen. There are many more niches to push the community on, but the project required a focus on a few key areas. “I don’t think sustainability will be an issue. The community will step forward and embrace a lot of these new changes to help the HIE run independently.”

Looking to the future

While Tulsa’s achievements may have been possible without the Beacon grant, “it’s hard to imagine this much progress without the funding,” says Kendrick. “The vision is still possible, but it would have taken a decade to get these things done.”

Rhode Island's Buroker echoes a similar sentiment. The Beacon project “allowed us to learn a great deal about how to deliver these types of programs,” he says. The important takeaway is investing in primary care practices, which need help with the challenges in a future shortage of PCPs, compensation and finding new ways of practicing, he says. “Change is difficult. We really need to align payment reform if we’re going to see delivery reform happen.”

“I am convinced that this is the kind of technology that is helpful in healthcare,” says Hawaii's Park. “There’s no question that there is value in this effort. I would like to see a concerted effort from healthcare as a whole. Whether on the federal or state level, delivery systems or payers, we need to make an effort to get them to understand that this needs to be supported over time.”

Despite the patience required for fruition of many of these efforts, “things have moved so fast in the last three years,” says San Diego's Killeen. “We’ve made such progress and huge leapfrog goals. There’s more to come.”