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11/20/2013
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R.I.'s Direct Approach To Health Information Exchange

CIO Gary Christensen saw that if doctors could exchange records directly, the state's centralized HIE would also benefit.

Gary Christensen, CIO/COO of the Rhode Island Quality Institute
Gary Christensen, CIO/COO of the Rhode Island Quality Institute

As the operator of Rhode Island's centralized health information exchange, Gary Christensen could have seen the Direct Project as a threat. Instead, he became its biggest champion.

"Regardless of how you do it, the point is to get information flowing," Christensen said in an interview. As CIO and COO of the Rhode Island Quality Institute, he oversees its best-known technology initiative, CurrentCare, a hub for the exchange of patient data and medical information from hospitals and medical labs across the state. But to get more doctors participating, CurrentCare has also encouraged the creation of a parallel system in which doctors can exchange patient records without the involvement of the central HIE, using a special type of secure email that can be used to send messages with XML-formatted continuity of care documents as attachments.

Using Direct, providers can bypass state and regional HIEs entirely, with secure email replacing the exchange of faxes between provider's offices. But even without having a chokehold on this system, CurrentCare is able to take advantage of it to accept records from providers and to send them alerts -- for example, to notify a primary care physician whose patient has just been admitted to the hospital or seen by the emergency department.

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The project was started in a 2010 public/private partnership, blessed by the Office of the National Coordinator for Health Information Technology (ONC) within the U.S. Department of Health & Human Services. Essentially, its approach is to build a parallel email system in which all messages are encrypted using public key cryptography and messages are only exchanged between trusted parties, identified with digital certificates. Participating practices and institutions contract with a healthcare Internet services provider (HISP) that manages these secure email accounts. Electronic health records systems (EHRs) can be configured to connect with HISPs, and some cloud-based EHRs act as HISPs.

HIEs may also act as HISPs; for example, San Diego Health Connect has made acting as the region's premier HISP part of its business plan for remaining viable after the expiration of federal grant funding. However, Christensen has avoided getting into what he perceives as a commodity business. CurrentCare does, however, act as the certificate authority that validates Direct email accounts and issues the required digital certificates (under a reseller agreement with DigiCert). This simplifies the process of exchanging Direct messages for all certificates, since there is one common directory for authenticating the account of any other provider or hospital in Rhode Island.

Some cloud startups talk up Direct health data exchange as a simpler alternative to centralized HIE infrastructure, eliminating the need for exchanges like CurrentCare. Christensen said some of his peers at similar institutions similarly perceived Direct as a replacement -- and therefore a threat -- and some are still inclined to view it as competition. He never saw it that way.

"I jumped in right from the beginning," Christensen said. Although CareCloud was systematically enrolling hospitals throughout the state to send it HL7-formatted documents over virtual private intranet connections, he knew that approach could never work for the hundreds of individual doctor's practices across the state. And as long as the network was limited to hospitals, its usefulness was also limited, he said.

"Most of the data about patients is not in hospitals; it's in EHRs sitting in practitioner's offices," he explained. Further, the vast majority of the doctor's offices and practice groups don't have a CIO or an IT staff that can invest time in setting up VPNs and testing software. They really needed to have something as simple as email -- if only the security risks associated with ordinary email could be eliminated. And if the Direct Project could pull that off, it would open up other possibilities.

"What struck me was that if it were true that everyone could basically pass information over the Internet in a  secure way -- and everybody was going to do it that way -- then we could use it, too, to get information from a practice into the HIE," Christensen said.

Rhode Island Quality Institute (RIQI) is well-positioned to steer doctors toward EHRs that support these data-exchange scenarios because one of its other roles is acting as a federally funded extension service that advises physicians on technology purchases and implementation. "In that role, we're kind of acting as the CIO for all the practices that don't have  a CIO -- I don't want them signing up with clunkers," Christensen said.

RIQI is a state-chartered organization, founded in 2001, and governed by a board of representatives from payers, hospitals, and doctors associations, that pursues a variety of healthcare quality improvement programs. About eight years ago, Rhode Island became one of the six states to receive a $5 million grant to explore the potential of using healthcare data to improve the quality of care, which was the beginning of the RIQI's HIE project. In 2008, the state followed up with enabling legislation for the creation of CurrentCare.

At a time when the economic viability of some other HIEs is in question, following the end of the federal grant programs that got them started, CurrentCare is fortunate to be funded on a utility model where the state insurance department collects $1 for every member in a health insurance plan (and most self-insured employers contribute voluntarily). That's enough to cover the core service, Christensen said, although he continues to seek grants that would support greater innovation and expansion of the network. CurrentCare does not collect transaction fees but does earn some contract revenue with analytics services based on its repository -- which pose another opportunity for growth.

Unlike some other HIEs, CurrentCare does not limit itself to acting as an information broker. Instead, it operates a statewide repository of health data, providing a centralized data warehouse that can be queried to look up any participating patient's records. Under R.I. law, individuals must give consent before their data can be transmitted online or stored in the CurrentCare repository. About 350,000 citizens are enrolled out of a population of just over 1 million. CurrentCare currently has participation from almost every hospital in the state -- with the last holdouts scheduled to come on board soon -- but the next challenge is to get all the individual doctors and practices around the state participating.

In other words, the database does not represent all healthcare activity in the state. Meanwhile, there are signs that, where it is used, it is making a difference. An example is its system for alerting doctors when a patient is admitted to or discharged from the hospital. The goal of this program is to allow doctors to follow up more proactively to promote a full recovery. The statistics suggest an impact on the 30-day readmission rate -- a common metric showing how likely patients are to find themselves back in the hospital shortly after discharge. Those whose doctors are enrolled in the alert system are 14% to 16% less likely to be readmitted within that timeframe than those whose doctors do not participate.

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Alex Kane Rudansky
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Alex Kane Rudansky,
User Rank: Author
11/20/2013 | 12:48:07 PM
Questions
I'd love to hear how Christensen addresses two major HIE challenges I've come across: competition and privacy. I've seen practices that are hesitant to participate in an HIE because of the possibillity of losing patients (HIEs make it easier for patients to switch doctors). There's also the issue of privacy. What should be included in an HIE? How much is too much? The sharing of HIV status and psych data, among others, is a hot button issue.
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