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Creating HIE Sustainability in New Hampshire

April 30, 2014
by Gabriel Perna
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For many organizations, success in creating a sustainable health information exchange (HIE) has not been easy to come by, even if leaders at the New Hampshire Health Information Organization (NHHIO) make it out to be.

The NHHIO, however, is more likely to be the exception, not the rule. While many HIE organizations are struggling to create sustainability with the loss of federal funding, NHHIO, a non-profit, state-created entity, has been able to keep the Granite State’s HIE afloat and active, with 59 organizations that cover up to 75 geographical locations actively participating. This includes hospitals, health systems, community health centers, critical-access and mental-health facilities, and a wide variety of provider organizations.

“We cover a full spectrum of healthcare in the state in terms of connectivity to the HIE,” says Jeff Loughlin, executive director of the NHHIO. According to Loughlin, the HIE has enough revenue currently to be fully self-sustaining for the next three years.

The organization’s success in HIE sustainability comes down to a basic truism: If you give someone or something a service they want and need, they will pay for it. That’s exactly what NHIIO did with the HIE. Denise Purington, vice president and CIO of Elliot Hospital in Manchester as well as Chair of the NHHIO, says the organization was able to deliver for its participants by starting simple with baseline functionality and not overspending.

“We wanted to provide a mechanism that allows healthcare providers in the state to share data between each other in a fairly simple, cost-effective way. I think in some states, the strategy may have been to try and take on too much too soon and not being able to deliver. That causes stakeholders to pull out. We started small and simple, and said, ‘Let’s become a transport mechanism so hospitals aren’t building multiple transport mechanisms between each other and we can focus on one way of transporting data,’” says Purington.

Using Direct

This strategy included not investing in a central data repository, which would have surely upped the cost of the HIE service. Instead, the organization piggy backed off the rise of the federally implemented Direct standards within electronic health record (EHR) systems.

Its standards-based technology transmits the data with end-to-end encryption. For those providers that use an EHR system that doesn’t employ Direct, NHHIO can implement a small appliance from its technical provider (Orion) that applies that standard. For instance, if a provider uses a system that has HL7 lab results, which aren’t under the Direct standards yet, the appliance can “wrap it in the Direct compliance format,” according to Loughlin.

“We’re focusing on that Direct address, either from a provider level or an organizational level, whether or not that organization has implemented that Direct standard,” says Loughlin. The end-to-end encryption is completely seamless from a technical standpoint.

The potential problems that come with this data transmission, he notes, are purely operational. “We’re struggling, as is everyone, with healthcare provider directory information and when are you ready to have data sent directly to the provider vs. the support staff vs. generalized inbox at the entity level. The technology is seamless, the workflow just needs guidance,” Loughlin adds.

Simple Pricing

The simplicity factor played into how NHHIO has conducted its operations from top to bottom, not just with technology. For instance, the organization has employed a small staff. Importantly, this mentality played into how it has priced the HIE. In the State of New Hampshire, there is a model used by the hospital association based on revenue that is used to assess fees. NHHIO adopted something similar, adding a cap amount that no healthcare provider would ever have to go over.

“Whether you are a two-doctor practice or a major health system, (this pricing system) makes it fair,” Purington says. Once the organization adds on value proposition services, she says that the pricing may change.

In terms of what those value proposition services could be, Purington says that it’s hard to tell what their members may need in the future. Patient engagement seems to be on the minds of NHHIO leaders and Purington says that the board has a consumer representative. However, they are only allowed to develop provider to provider communications under the provisions of the New Hampshire State Law which led to its existence.

“We have a bill in the (New Hampshire) House and Senate asking to expand our ability to go beyond provider to provider so that we can engage the patients. We’d like to offer them a portal if they needed it or any means to transmit the documents they have in their portals to providers either in New Hampshire or other states,” Purington says, adding that the state has a lot of “Snow Birds,” who travel frequently between the northeast and State of Florida.

 Ultimately, it’s going to come down to building up the HIE sensibly. Purington emphasizes that they don’t want to promise something and then fail to deliver. Also important to the future success of the HIE is gaining input from a variety of stakeholders.

“We devised a plan with a huge amount of collaboration across the state,” Loughlin says. “It wasn’t just a small group of individuals deciding what’s best. We took a lot of insight and perspective from across the entire healthcare spectrum to let us know what they need. Then we built out the infrastructure and laid out the plan. We’re consistently looking for collaboration and communicating with the community at large to ensure what we’re doing is working and getting feedback for what’s next.”

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