Value Drives HIE Sustainability
A study in the July issue of Health Affairs found that 74 percent of HIEs struggle with developing a sustainable business model. “There is a substantial risk that many current efforts to promote HIE will fail when public funds supporting these initiatives are depleted,” wrote Julie Adler-Milstein, assistant professor in the school of information and school of public health, University of Michigan, in Ann Arbor, and colleagues.
Reaching critical mass
Exchanges can best ensure their sustainability by heightening participation, says Chris Muir, Office of the National Coordinator for Health IT’s (ONC’s) program manager of the HIE cooperative agreement program.
“We’ve seen a large number of providers participating in HIEs, but it isn’t everyone yet,” says Muir, whose office oversees $564 million in grants to state and regional HIEs nationwide. Among grantees, he says, the total number of directed transactions jumped from 73 million in the second quarter of 2012 to 173 million in the first quarter of 2013.
Muir says reaching critical mass of users is the most critical element of sustainability. “It’s really trying to encourage the providers and the hospitals to participate in the exchange.”
While use increases, it is still far off from hitting the mainstream. Indeed, the study in Health Affairs found that only a portion of the pie—30 percent of hospitals and 10 percent of ambulatory practices—were linked to one of 119 operational HIEs across the U.S.
Increasing participation is a major priority of the Camden HIE, a regional HIE launched in New Jersey in 2010. To date, it links about 300 users, including providers and administrators, and facilitates the sharing of detailed clinical data among primary hospitals, physician practices, laboratory and radiology groups, regional hospitals and healthcare institutions.
Driving up use means active engagement with providers. “They have to have buy-in for it to sustain,” explains Abigail Fallen, RHIA, program manager at the Camden HIE.
To achieve that end, the HIE promotes various training opportunities, such as a webinar explaining functionalities and scheduled updates to the platform. That event spurred interest in other groups, including mental health facilities and hospice groups, Fallen says.
While participation is important, gaining real traction requires that users are getting the most out of their experience.
At the Camden HIE, they designate “super users” at each facility to serve as on-site experts; these users were determined by combing active user reports to find staff who tapped into the HIE most often.
“You can train everybody, but you need to know when you walk out they are able to continue to maintain what they are doing,” says Fallen. The super user encourages other staff, conducts in-house training, assists with workflow issues and notifies the Camden HIE of any hiccups in the system.
Demonstrating value
All the marketing and outreach in the world will not help if the HIE is difficult to use or does not meet users’ needs. HIEs thus must focus on offering something of real value that also fulfills the objectives of Meaningful Use, says Muir. “Instead of people thinking about HIE for the sake of HIE, how do we demonstrate that HIEs are really supporting Meaningful Use efforts?”
Many providers opt not to join an HIE because of usability barriers. For instance, if a clinician has to leave the facility EHR and go into a separate web portal to download or view an HIE’s information, it may interrupt the clinical workflow enough to discourage use. “That is a big thing we are encouraging states to address,” he says. “We’d like that data to flow into the EHR; it just makes it easier.”
Adding value need not be expensive, Muir says. “We would like them to think about the high-value and low-cost services that they can offer to the provider community, especially those services that render specific results and meet specific needs.” For example, alerts (using push technology) from hospitals to providers are a relatively inexpensive service that is of high value. “It really does help with reducing things like hospital readmissions,” he says.
At the Camden HIE, they are transitioning to a new platform to bolster value out of the service and expanding the geographic footprint of the exchange to include hospitals outside of Camden.
The exchange has found success in identifying patients for care management and care transition programs, including prescription drug monitoring programs and high utilizers of healthcare services.
Rhode Island’s funding strategy
CurrentCare, Rhode Island’s HIE administered by the Rhode Island Quality Institute (RIQI), is inching towards critical mass—slowly but surely. In part due to its forward-thinking sustainability plan, one out of every three Rhode Islanders is linked to the system, according to Laura Adams, RIQI president and CEO.
“We began talking with the community about sustainability before there was a gleam in anyone’s eye about a federal stimulus bill,” she says, noting funding was in place before the surge of federal funding. The platform accepted data in 2011 and then opened for queries in 2012.
Rhode Island has a unique strategy for funding its $8 million exchange. The state’s health insurance commissioner (the only one that exists in the U.S.) employs a public utility model, which requires insurers doing business in Rhode Island to set aside a portion of their profits to strengthen primary care. CurrentCare qualifies, and receives about $4 million each year.
That amount represents $1 per member per month for all covered Rhode Island residents covered under commercial health insurers, Adams says. “We got nothing but support from the primary care community.”
Steven Costantino, the state’s executive office of health and human services secretary, also stepped up—offering $1 per Medicaid member per month if a certain number of conditions were met. That brought in $600,000. A 90/10 federal match on that—offered for continued scalability and build out—brought the exchange $6 million, which equates to $2 million over three years. Once that ends, the state will offer a 50-50 match of what the community is putting in, Adams says.
To acquire the remaining million, Adams says the institute undertook a “door-to-door effort.” The top two employers in Rhode Island are in the healthcare industry, and as they both are represented on RIQI’s board, they agreed to ante up funds. Eight other major state employers joined them and the HIE grew another $1 million.
“We ended up with $7 million of the $8 million going in,” she says.
With that funding in hand, the institute engaged its other sustainability approaches: obtaining an outside grant for cutting-edge uses of the HIE and aligning with groups focused on accountable care. At this time, providers are not charged to access the HIE.
Partnering with payers
To achieve sustainability, Muir says it is important for HIEs to align with ACOs. The ONC, he says, helps exchanges make the technology link to other systems to help providers enhance the value of care and bend the savings curve.
HIEs can play a crucial role in ACOs, bundled payment initiatives and patient-centered medical homes. “We’re encouraging state HIEs to look at what’s going on in the state, and tell the story how they are enhancing the quality of these very specific initiatives.” For instance, if a state is looking to reduce hospitalizations, the HIE should position itself as a means to achieve that end.
RIQI’s exchange is one example of an exchange harnessing its data to support new payment models. Specifically, it has a contract with CSI Rhode Island—an all-payer patient-centered medical home initiative—to provide quality and analytics and quality reporting data.
“We are able to be part of the fabric of the new payment system when the clinical data comes into us,” says Adams.
Value & innovation
In the meantime, RIQI hopes to attract outside funding to pursue new, innovative uses of its HIE.
Adams sees the exchange as a place for patients to upload their advance directive, so they are not shuttling it around from doctor to doctor. She also sees it as a place to upload patient data, such as a scale sending data through infrared beams to CurrentCare, with a “detect and notify” function anytime a patient’s weight has increased 7 pounds in two days. That way the doctor intervenes and a patient “can be home with his or her family on Friday instead of drowning in their fluids.”
Adams sees HIEs as the ideal data hub. “The doctor can’t be taking in data from all these devices, but the HIE can,” she says. “It’s almost like we built an iPhone, and now we are putting apps on top of what we can do.”
As the first HIE to exchange behavioral health, CurrentCare remains on the cutting edge. Now that it has been in service for over a year, Adams says many providers are hooked, noting that the chairman of a major private practice group recently declared to the local Chamber of Commerce: “’I don’t know how I’d do medicine without it.’”
“Those types of stories make me believe there is no going back,” says Adams