At HealthShare Exchange of Southeastern Pennsylvania, executive director Martin Lupinetti has been leading the advance of a health information exchange (HIE) that is bringing numerous parties together to share clinical data in order to improve patient care. HealthShare Exchange (HSX) was incorporated in May 2012, and its board and bylaws were put into place in January 2013. By December 2013, the University of Pennsylvania Health System (Penn Medicine) and Crozer-Keystone Health System had begun to share test data; and by February 2014, HSC announced the beginning of data exchange.
By that point, Penn Medicine had directly and securely sent a patient-care clinical summary (in this case, a clinical care document, or CCD), from the office of UPHS internist Susan Day, M.D., to the office of internist Karen S. Scoles, M.D., of Crozer-Keystone Health System. With HSX facilitating the exchange, the Crozer practice also sent a test CCD electronically over the new platform.
What’s more, 37 health systems in southeast Pennsylvania have signed a letter of commitment documenting their desire to participate in HSX. Of those, between eight and 12, including Penn Medicine, Crozer-Keystone, and Children’s Hospital of Philadelphia (CHOP), have been involved in the testing of data-sharing. Lupinetti and his colleagues have been working with the Boston-based Alere Accountable Care Solutions, which has been providing the technology solution for the initiative.
And this is a very important, densely populated area in the Northeast; indeed, the five-county region that HSX is servicing represents 32 percent of all healthcare consumers and 36 percent of all hospital discharges in Pennsylvania.
In April, HCI Editor-in-Chief Mark Hagland spoke with Lupinetti about the progress of HSX’s work.
At that time, CHOP was scheduled to be moved into live production (following Penn and Crozer-Keystone) this month (May), soon to be followed by several other patient care organizations.
Below are excerpts from Hagland’s interview last month with Lupinetti.
At this point in time, which organizations are live in terms of sharing data?
Penn and Crozer, and CHOP has tested successfully, and we hope to move CHOP into production this month [April].
And then after that?
Grand View Hospital, Doylestown Hospital, Main Line Health, and Einstein Healthcare Network will be the next wave. We’re hoping to cycle through as many health systems as we can this year, but those are the ones we’re in active conversation with right now. Some kicked off in February, some in March, with testing. After the April go-live at CHOP, we’re hoping to bring those other organizations online in May and June.
What are some of the key types of data you’re focused on exchanging at first?
The two use cases we’ve focused on are really addressing the readmit challenge in this region. Surprisingly, there’s no dominant health system; they all have a slice of the pie. And there was a recognition early on that the health systems needed a better way to support one another and manage patients once they’ve been discharged from EDs. So the first use case is the discharge information use case. It’s different from a summary, because it happens sooner than a discharge summary would typically happen. We can send it out within 20 hours, whereas the discharge summary typically takes 28, 36, or 72 hours—or sometimes never. We’re sending this to the PCP, the specialist, and the care manager. And what’s interesting about this endeavor is that we have health plans that are part of this as well, and they’re not only contributing financially to making HSX possible, but are also providing data for the exchange and are receiving data as well.
Which health plans are involved?
Independence Blue Cross, AmeriHealth Caritas, and Health Partners, to start. It’s a very unusual model. I’ve not heard of it happening elsewhere in this kind of context. And again, for our opening act, it’s addressing this readmit issue. The plans are going through their development effort right now to be able to support the routing intelligence part of the use case. So they’re helping to manage the patient-PCP relationship closely; and conversely, we’re letting the plans know that their members are being discharged from EDs. And as a result, they will feed us the patient’s PCP, the specialist, and the care manager, all of whom will be made aware that their patient was just discharged from one of the member hospital EDs.
Are you also going to look at hospital discharge data?
We are going to look at that, but this was the first thing we wanted to put in play, because the health systems all recognized the readmit charges and penalties this could help reduce, and wanted to manage that in the region.
How many discharge information messages have been sent so far?
Right now, our focus is just to get the technology ready for connecting the exchange. And the health plans are preparing now to be able to provide that routing intelligence. So that will all come together in a go-live scenario in the latter half of this year. There are a lot of moving parts to make this happen; all are components of our business plan.
How many electronic medical record systems are involved?
The EMRs run the spectrum in these 37 health systems, and in the offices of the physicians affiliated with the health systems. But initially, we’re working with Epic, Allscripts, GE Centricity, eClinicalWorks, and Cerner. And some members have already established their own HISP. And in those scenarios, HSX would connect with that HISP, to be able to exchange outside their health system. And Alere has signed on initially to provide us with a Direct capability, with some custom development. And the way we’re approaching this is a little bit different. We’re using the Direct program format as the basis for initiating data exchange across the network, but we’ve tagged it as “enhanced Direct,” because we’re going to be using claims history from the plans, provided to any requesting provider connected to HealthShare Exchange.
So if I’m a doctor, and you’ve been seen at Penn, Crozer, or Einstein, I can’t get any information today on what’s been done across those organizations; tomorrow, with HealthShare Exchange, you’ll get to see the various claims histories, organized in a CCD—not with the richness of clinical notes—but the physicians would be able to see medication history, different diagnosis codes, conducted tests, and things like that. So the second application of the exchange is the activity use case, in the form of physician-to-physician CCDs, exchanged within EMR technology. Our goal is to stay within the EMR; within the workflow, as much as possible; that’s what we’re striving for, with each health system that we onboard to HSX.
What lessons have been learned so far, early in this journey?
A number of lessons come to mind. One is that some EMR vendors are still catching up to Direct-enabled capabilities within the versions of their tools running in the field in these various health systems. So in some cases, we need to wait for the health systems to upgrade, so that they can start to use that capability.
Another learning is that although we’re using Direct to start, query-based exchange is something very much of interest; and so in parallel, we’re in conversations today with our board and members around what would be required for data-sharing in a query exchange model. Some may want to stay with the Direct capability, but others will want to broaden out to query-based exchange.
This latter approach is definitely going to be another type of value that we add. We’ve also learned that while one could perceive Direct as just a conduit to get information from point A to point B, our membership is appreciate that there’s more to it. Direct can become a robust tool for exchange; and as a result, we may need to operate as a true business associate (BA) under Direct. So now we have a chief information security officer, have established a set of security policies, and are beginning to address security risks and gaps. We recognize that we need to have the ability to operate as a BA. And our board is agreeing to that, and sees how that facilitates the onboarding of members and the sharing of information.
So I’m very excited, as you can tell. This is a challenging endeavor. But we’ve got a very energized board and membership, and this is becoming real. We’re implementing our business plan 1.0, as I call it; and business plan 2.0 will include the query-based exchange.
What advice would you give to CIOs, CMIOs, and other healthcare IT leaders around the country, as they consider moving forward with health information exchange?
We’ve talked a lot about the technology and the underpinnings of the technology, but the whole other side of this is engaging the clinicians, getting them to adopt this in a meaningful way; getting them to use this as a regular part of their workflow. So as folks become aware of this and embrace it, that will be the critical next piece. And we’re starting to pay time and attention to workflows, and to engagement and adoption with the clinical user, all aimed at the value this brings to the patient. So that will be an ongoing dialogue we’ll need to focus on with our members.