Today's Health Information Exchanges 2

When Dr. Mark Sandock's medical practice signed up to share data using the Michiana Health Information Network, five doctors in the internal medicine part of the group saved $1 million in transcription costs in the first year alone. Doctors at the South Bend, Ind., practice no longer have to dictate reports on lab and other medical tests for the hundreds of patients who are tested at outside facilities each week and whose results were previously sent back on paper. Instead, the MHIN network sends the doctor an e-mail alert when a patient's lab results are available, and it automatically feeds the results into the patient's electronic health record. " Quality of care is improved, and you're saving money at the same time," says Sandock, who's since retired from the medical practice and works as a consultant.

Doctors should compete on the effective use of data, not on its availability, CRISP's Afzal says

Besides eliminating the need to transcribe lab and other reports, health information exchanges, or HIEs, ensure that all doctors providing care to a patient have the most up-to-date and comprehensive information on the patient's condition. They also speed decision-making by providing faster access to information; cut down redundant testing by providing results of all tests a patient has had; and ensure patient safety by letting all caregivers know medications a patient is taking and allergies he or she has.

Many HIEs let healthcare providers share patient data only with other practitioners and institutions in their local communities. Others connect providers across a region and, more recently, are developing connections across entire states and among neighboring states. The federal government is establishing standards to link HIEs into a national network (see story, "A Network For Everyone").

Some HIEs focus on sharing a specific kind of data, such as problem and allergy lists, drug histories, hospital discharge summaries, and radiology and lab reports. Others are more comprehensive.

There are about 200 HIEs in the United States, according to the eHealth Initiative, a nonprofit group that advocates using IT to drive quality, safety, and efficiency in healthcare. That number is growing rapidly, particularly now that the federal government is expected to make exchanging patient data electronically part of the "meaningful use" criteria that physicians and hospitals must comply with to get funds under the American Recovery and Reinvestment Act. Besides the EHR incentive money, the feds also are providing $564 million in ARRA funds to help states deploy exchanges and expand existing ones. Earlier this year, the Department of Health and Human Services awarded grants to states ranging from $4.6 million to $38.8 million (see sidebar, "Statewide Networks", below).

While there's great enthusiasm for these networks, everyone isn't comfortable with them. Some doctors don't want to give up paper-based processes for digital ones, Sandock says, noting that, as with EHRs, there's going to be a steep learning curve.

Physicians also worry that sharing data makes it easier for colleagues to steal patients and for patients to easily switch doctors. But those fears are fading as doctors start using the HIEs. "People are recognizing that it's not as much a competitive issue. It's a convenience issue," says Tom Liddell, executive director of the Michiana network. With the meaningful use criteria now expected to include HIE use, "it will be more difficult for a provider not to participate in a data exchange," he says.

HIEs aren't new. Over the last decade, regional organizations were launched with data sharing as core to their missions. Many were funded by public and private grants and fell apart when money ran out and participating healthcare providers didn't want to invest in them.

Now, with big money behind getting healthcare providers to install and use EHR systems, it's possible that health information exchanges will have a much better chance of surviving. What follows is a look at four HIEs in different parts of the country, each with different goals but all of them very promising efforts.

Rural-Urban Link

The Louisiana Rural Health Information Exchange, or LaRHIX, is a state-funded initiative that serves 1.3 million patients in north central Louisiana, a poor, rural area underserved by primary care doctors. It was formed three years ago by the Rural Hospital Coalition, a statewide nonprofit that works with Louisiana's rural hospitals.

Because of the shortage of doctors, patients frequently wait three months or more for appointments with specialists like cardiologists and pulmonologists. They often have to travel great distances to get to those doctors, a significant hardship for low-income patients who don't always have cars and can't afford other transportation, says LaRHIX CIO Jamie Welch. Many patients end up not seeing specialists, and that can result in "a domino effect" of serious, sometimes deadly complications, Welch says.

IBM's Websphere and Carefx's Fusion provide the infrastructure for LaRHIX's Web portal, which gives healthcare professionals real-time access to medical records from any provider database connected to the network. Doctors associated with the 24 participating hospitals are able to share patient information with each other and with the Louisiana State University Medical Center in Shreveport. Specialists at the medical center can review patients' records and tests without requiring them to travel to the city.

Authentication and single sign-on capabilities, policy-based authorization, identity federation, and auditing access are being provided by CA's Identity and Access Management products. Telemedicine technology, including Webcams, are used to examine patients remotely. The ultimate goal is for LaRHIX to serve the entire state, though a specific timeline hasn't been established for that, Welch says.

Hospitals in the exchange can use any EHR system they want, Welch says, since its federated data model stores patient data at the source. The exchange's services include mobile digital mammography, where radiology equipment and technicians are sent to rural hospitals to conduct exams and images are sent to specialists for analysis.

The state of Louisiana has provided LaRHIX's $40 million in funding so far. It wasn't difficult to convince state legislators that there was a need for this type of service, Welch says. "The majority of the state is rural, and the legislators come from rural areas," she says. "The hard sell was the money."

Many of the rural hospitals that are part of LaRHIX have been able to deploy EHR systems with funds from the program and are already at HIMSS stage 6 or 7, the highest stages of EHR adoption, Welch says. Now with the federal government's $20 billion-plus EHR incentive program under way, more hospitals will likely begin rolling out the EHR systems, and that will make it easier to expand the network statewide, she says.

Small But Profitable

There have been two basic models for health data exchanges. Regional ones like LaRHIX, and smaller ones that serve a more-defined community.

HealthBridge, which covers a 50-mile area around Cincinnati, is an example of the latter. The 13-year-old HIE is one of the oldest in the country, and it's profitable. It wasn't created with a one-time grant and, until recently, hasn't relied on government money. Instead, HealthBridge took out loans that it's still repaying. "It's run like a business," CEO Bob Steffel says.

HealthBridge is leading the Greater Cincinnati Beacon Collaborative, which has received a $13.8 million federal Beacon Community grant that will fund its initiative to improve care for asthmatic children and diabetic adults.

HealthBridge uses Axolotl's HIE technology to connect more than 28 hospitals, 17 local health departments, 700 physician offices and clinics, as well as nursing homes, labs, radiology centers, and other healthcare providers, Steffel says. Although it covers a small geographic area, it's one of the largest community-based secure clinical messaging systems in the country, delivering about 3 million clinical messages to more than 5,500 physicians a month, he says. Doctors get free subscriptions to the service, which provides them with lab and radiology reports, hospital admission and transfer records, and electronic notifications when patients visit emergency rooms and are admitted or discharged from hospitals. Physicians can sign up for other services, such as e-prescribing, for less than $100 a month.

HealthBridge, which works with 30 EHR vendors, sends patient data directly to those systems. Physicians who don't use EHRs receive patient information via fax, e-mail, and even snail mail. HealthBridge delivers to every doctor in its region, and 96% of what it delivers is done electronically, Steffel says.

Hospitals, labs, and other large data providers pay for the services because the exchange saves them time and money. "If you faxed 20,000 reports per month, the question is whether the doctor got it. With our services, you can answer that question," Steffel says.

The idea behind HealthBridge is that "healthcare is local," Steffel says. While patients move, travel, and sometimes seek specialty care outside the region, "the bulk of healthcare is within a small radius," he says.

A Cross-State Exchange

Statewide Networks

The federal government recently awarded grants to states to develop information exchanges. Here are the 10 largest awards:

California Health and Human Services Agency
$38.8 million

Texas Health and Human Services Commission
$28.8 million

New York eHealth Collaborative
$22.4 million

Florida Health Information Network
$21 million

Illinois Department of Health Care and Family Services
$18.8 million

Pennsylvania Health Information Exchange
$17.1 million

Michigan Health Information Network
$15 million

Ohio Health Information Partnership
$14.8 million

Missouri Office of Health IT
$13.8 million

Georgia Department of Community Health
$13 million

The Michiana Health Information Network, or MHIN, covers parts of Michigan and neighboring South Bend, Ind. Like many of the successful HIEs, 10-year-old MHIN doesn't use public money and is run like a business, says executive director Liddell. Labs, hospitals, and doctors that participate in the exchange pay fees for the service, he says.

Data is stored and distributed from a central repository. Doctors pay $49 to $59 a month to have their EHR systems automatically populated. It's important for data users, like doctors, to pay even a small fee. Otherwise, Liddell says, they can easily fall into the mind-set that since it's free, "its worth is somehow devalued."

MHIN uses a Web-based real-time messaging product from Axolotl to send information to practices that don't have EHRs. Currently, the exchange has about 100 data sources, including hospital admission and discharge information, and radiology and lab results. MHIN plans to add outpatient surgical and endoscopy centers.

About 3,500 healthcare providers get information from the MHIN, including 1,000 physicians. About 140 of those doctors already use EHRs and are able to contribute patient data to the exchange. The goal for the next two years is to have 300 to 400 doctors contributing data.

From Regional To Statewide

Maryland's Chesapeake Regional Information System for our Patients, or CRISP, started in 2006. Its first phase will launch this month, letting healthcare practitioners and other providers in Montgomery County, Md., exchange patient data, including demographic information, lab and radiology results, hospital discharge summaries, and other reports.

Under a $10 million state grant and $9.3 million federal grant, CRISP is expanding statewide, bringing in hospitals and other community healthcare providers that have already set up their own HIEs. It also will set up direct links to its exchange for healthcare providers that haven't already joined an HIE. Meantime, CRISP has been chosen to help area healthcare providers deploy EHR systems.

The nonprofit is using Axolotl HIE technology to create the infrastructure for the secure exchange of data under a model where content from hospitals, such as discharge reports, is stored in edge devices either hosted by the hospitals or third parties, says Scott Afzal, CRISP's program director. This content will be automatically pushed to a patient's primary care doctor. Other authorized clinicians, like emergency room doctors, would be able to query whether data is available about a patient arriving in the ER.

Hospitals and doctors won't be charged to use the data initially. Once there's enough data in the HIE for the value to be clear, they'll have to pay a still-undetermined subscription fee that won't be based on transaction volume, Afzal says.

CRISP will work with EHR vendors and service providers, such as eClinicalWorks and AthenaHealth, to ensure that continuity-of-care data can be exchanged on the Maryland HIE, Afzal says. Such documents contain a patient's clinical, demographic, and administrative data.

CRISP's overall mission is to make it so healthcare providers don't compete based on the availability of information, Afzal says, but instead on the effective use of health IT to improve care and make practitioners more efficient. Reducing readmissions to hospitals and promoting follow-up care are among the goals, and doctors should expect that reimbursement models will shift to encourage these sorts of improvements, he says. When that happens, health information exchanges, like EHRs, will take off because everyone will benefit.

Write to Marianne Kolbasuk McGee at ([email protected]).