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The CEO of Indiana’s Statewide HIE Sees Complexity in the Push for Interoperability

October 10, 2017
by Mark Hagland
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IHIE’s John Kansky shares his perspectives on the broad complexity involved in the push towards interoperability

The leaders of health information exchange (HIE) organizations are developing a wide variety of strategies, at a moment redolent with both challenge and opportunity. With the shift towards value-based healthcare delivery and payment accelerating, the need for effective data exchange between and among all the stakeholder groups—physicians, physician groups, hospitals, health systems, health plans, public health agencies, and state health departments—is growing by the day.

In that context, the need for interoperability is accelerating apace as well. Yet creating true interoperability is far more difficult in practice than in theory, particularly given that there is no “magic bullet” or easy approach that can fast-track a path to near-universal interoperability and data exchange. So what are the leaders of some of the most successful statewide HIEs doing to create successful strategies, and to help support their colleagues in moving forward?

One HIE leader who has been thoughtfully pondering these questions is John Kansky, president and CEO of the Indianapolis-based Indiana Health Information Exchange (IHIE). IHIE was founded in 2004; Kansky has been its CEO for nearly 11 years. IHIE’s network connects 117 hospitals, representing 38 health systems; 14,592 physician practices, representing 42, 215 providers; and 13,221,125 patients, and 10, 916,592,344 data elements, according to information on its website. Kansky spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding his perspectives on the current moment in health information exchange, and the potential for breakthroughs in interoperability in the next few years. Below are excerpts from their interview.

What are your organization’s top goals in the coming months?

We’ve got a strategic plan that we’re in the middle of executing, that has three basic tenets to it. One is integrating our data within the EHR [electronic health record]. I’m sure you’re familiar with the general theme that many have expressed, that having a physician have to leave the general medical record is suboptimal. In that regard, we’re one of the nation-leading HIEs willing to do the heavy lifting around that. Number two, in the context of the patient-centered data home, we have to share data beyond state lines and in different markets. We have to figure out how to increase interstate health information exchange. And the third theme is helping our participants in terms of supporting them around population health.

John Kansky

You’re the statewide HIE, of course. Are there also local HIEs operating in Indiana?

Yes, there are; there is one in Bloomington, and there is one in South Bend, called Michiana Health Information Network, with South Bend being near the Indiana-Michigan border. And that relates to another theme: we’re very collaborative and cooperative in our approach. And both of those HIEs are connected with us and are exchanging data, in the context of our patient-centered data home. It’s important for HIEs to take the perspective that if your state needs data in another HIE, you need to help get the data for them. My joke is, if you can’t make a long-distance call from South Bend to Indianapolis, something’s wrong with the phone system; and the data shouldn’t be any different [in terms of its connectivity].

So what would you say about the state of interoperability right now across U.S. healthcare, in this context?

I was on an ONC [Office of the National Coordinator for Health IT] panel last week Tuesday in Washington, and it was interesting discussion. Right now, most healthcare IT professionals have a very superficial understanding of the different interoperability approaches; and because their understanding is still rather superficial, there’s this idea that there’s a single best approach. And the federal government wants to know who’s got this interoperability thing figured out, and what’s best for the country? And obviously, healthcare IT professionals want an answer that’s no more complicated than it needs to be. But it’s wrong to try to simplify it down to one interoperability approach, because the various approaches do different things, focus on different things. And we often say here at IHIE that interoperability is not one “thing.”

There’s massive confusion around that in the field, right?

Yes, there is absolutely massive confusion around that in the field. And unfortunately, humans always try to go to the simplest solution to any problem. And at the DC panel, we were talking about what it’s like to move things around within any organization—physical logistics. It ends up being a rather complex effort involving trucks, cars, and planes, for example. And at times, we need to focus on making sure those different modalities work well together. And that’s a good way of thinking about data—why should moving data around be less complicated than moving stuff? And how HIEs, and Carequality, and the eHealth Exchange might collaborate together. There’s a tendency—whether you’re SHIEC or CommonWell or The Sequoia Project—there’s a tendency to think that your solution will solve everything. And so my stump speech is basically that you shouldn’t believe that, or want that for your organization, because that’s like saying, we’re going to move everything via train, so no trucks, cars, or planes, and then you’ll twist yourself into a pretzel trying to achieve that [limited vision].

What needs to happen, in the next two years, then, to achieve true interoperability across data exchange efforts?

Let’s talk nationwide, because Genevieve Morris [the Principal Deputy National Coordinator for Health Information Technology, at ONC], who was moderating the panel, challenged us to come up with solutions. And it sounds rudimentary, but we really need HIT professionals to understand the interoperability approaches more deeply than they do; there’s no way around that. So whether that means calling on HIMSS [the Chicago-based Health Information and Management Systems Society], or the ONC, or The Sequoia Project, which is about to hold its annual conference—there’s no way to change the behavior of an HIT director or a CMIO, but it’s going to be impossible for them to make solid decisions and design the interrogability approach for their organization, if they don’t understand what’s out there.

Now, in Indiana—we’ve talked about the three things that IHIE is focused on. We’re going to do those three things. And that is at the core of our strategic plan. But as you peel that onion, there are a lot of interesting things under the surface. For example, when I said we work hard to interoperate with the EHRs, to get our data integrated into the electronic health record, not surprisingly customer organizations have different EHR vendors, which support different interoperability platforms. So we’re doing some educating. We’ve worked very, very hard to learn the nuances of the different interoperability approaches, at a deep enough level that we can help our customers understand, and get involved in their interoperability planning. We have lots of participants that are individual hospitals or systems. So we challenge them on what their interoperability plans are, where they’re at, and how we can help them, even as their EHRs’ capabilities are advancing. And use us as a consultant, because we have much more time and capability to help you address that interoperability challenge.

What has the response been from HIT leaders at patient care organizations?

It’s been well-received. Some are further along on this than others. But you have to demonstrate your knowledge of the area. A story that exemplifies where we are as an industry. I was in a conversation recently with a hospital CIO who was using Carequality, but actually meant eHealthExchange—in a conversation. Both are run by The Sequoia Project, but in some ways, their approaches are very different. So if we don’t even know the differences between different initiatives at the national level, we can’t get past that. And we’ve had members who’ve said, we want to participate in health information exchange or some other initiative, and can you get on a call with us? And we’re thrilled when they call us, because obviously, the HIE involved has to be involved. And it’s important, on a national level, to understand that HIEs can’t stand still and whine about one interoperability approach intruding on their territory; they need to find out what their territory is, and work accordingly.

Where are key officials at ONC, CMS, and HHS, on this?

TEFCA is the Trusted Exchange Framework and Common Agreement, which is an element in the 21st-Century Cures Act; ONC was required to come up with the TEFCA. That’s their focus right now, from what I can see, and it is that, of necessity. What encourages me is that, in educating themselves, and as a result, the nation, on different approaches, and on what the framework of governance should be—you have to look at what they defense as a trusted exchange framework, and a common agreement. Their report came out fa few weeks ago, where they look at Carequality, Commonwell, SHIEC’s patient-centered data home, etc., and they matrix across those approaches. Because while they’re not going to legislate that all health information exchange in the country work within a specific format, they are going to try to define a broadly common framework, and a legal agreement.  The common agreement will be a DURSA [Data Use and Reciprocal Support Agreement] of the current federal incarnation. And when you look at the eHealth Exchange, for example, they’re operating under the DURSA; it’s one of the models they’re going to look at.

Reaching a fairly common consensus vision of HIE in the next few years, is that going to happen? I often refer to the ancient Indian parable of the six blind advisers to the king, with each one touching a different part of the elephant and describing the whole elephant differently.

On the one hand, I agree with the elephant parable, with regard to the different EHR approaches, because if one of the advisers grabs the tusk, they’ll tell you about the tusk, and the tail, etc. But you need to understand the whole elephant. So there’s a prerequisite there that lots more people need to talk to more than one advisor at the time, to figure out what the elephant is. That said, I’m more optimistic, after the ONC panel—look at how much more implementation of EHRs we have in this country, and how the expectation of being more interoperable, has compelled the EHR vendors to focus on things like frameworks and legal agreements; none of that existed even three to five years ago.

So I would say that we’ve made tremendous progress in making the mess we have; without the mess, though—this is how we do things in America; we try a whole bunch of stuff, we let markets try things, and then in the end, we end up with something that works pretty well, even though it’s complex. So we have to get to this intermediate state of messy confusion, to have the opportunity to move forward.

How fast do you think we’ll get towards that level of advancement in the next few years?

Not fast; maybe at medium speed. I sent our marketing director a video of some individuals testifying at a Senate Committee in 2008, and it was surprising to her how much the discussion was like now. The point being that tremendous things have happened; we weren’t using the word interoperability in 2008, but nonetheless, it’s going to take a while; we’ll still be talking about this in ten years from now.

What should the CIOs, CMIOs, and other senior healthcare IT leaders reading this interview, be thinking and doing right now, then, based on everything we’ve discussed here?

They should be educating themselves more deeply about the different interoperability approaches available to them, and they should be challenging their HIEs and vendors about potential plans. Per the Indian parable, if their EHR vendor is only offering you a tusk, you need to ask why they can’t send you the tail as well.



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Regional New York HIE, Hixny, Adds Nine Counties to Its Territory

September 17, 2018
by Heather Landi, Associate Editor
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Hixny, a regional health information exchange (HIE) based in Albany, has added nine counties to its territory, committing a significant amount of funding over the next 18 months to connect local providers.

Hixny is one of the state’s eight qualified entities (QE) connected by the Statewide Health Information Network for New York (SHIN-NY) – a “network of networks” that allows the electronic exchange of clinical information and connects healthcare statewide – overseen by the New York State Department of Health.

“The success of the SHIN-NY hinges on meeting the needs of providers based on complete, accurate and up-to-date data,” Mark McKinney, CEO, Hixny, said in a statement. “At Hixny we’ve demonstrated the effectiveness of our model – and want to do the same for the providers and patients in our neighboring regions.”

The region in the Hudson Valley and Southern Tier has historically lagged in connecting providers to one another and collecting patient consent.

Hixny’s territory encompasses 28 counties north and west of the Capital District and south of Hudson Valley. In its existing region, 100 percent of hospitals and three out of every four providers are connected via Hixny. Ninety-two percent of adult patients have given consent to their physicians, a number that increases each month. Additionally, it offers the only patient portal in the state called Hixny for You, allowing patients to view their own medical history, with data that spans the entire state.

“Their reputation precedes them,” Yuk-Wah Chan, M.D., a family practitioner in Pleasant Valley, NY, part of Hixny’s new territory, who recently signed-up, said in a statement. “More than ever, physicians need to deliver higher quality and more personalized care to their patients while lowering costs – to do that, you need access to the best, most reliable data. And that’s Hixny.”

Eight total locations have already signed participation agreements with Hixny: Dialysis Clinic, Inc.’s three locations in Elmsford, Hawthorne and Yorktown; Hurley Avenue Family Medicine’s three locations in Kingston, Stone Ridge and Saugerties; Premier Dialysis Center in Goshen and Dr. Chan’s practice.

All participating organizations will have access to patient information across the state through the SHIN-NY.

“We are pleased to welcome these new providers to Hixny; their decision proves that providers who have a choice will choose better data,” McKinney stated. “Hixny is changing the game and this news is only the first of many announcements that demonstrate why Hixny is the best option.”


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The Power of Data Exchange as Disaster Strikes: How HIE Leaders Have Prepared for Hurricane Florence

September 14, 2018
by Rajiv Leventhal, Managing Editor
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The executive directors of GRAChIE and NC HIEA say building HIE-to-HIE connections throughout the region, in preparation for a natural disaster, speaks to the power of health information exchanges

As the nation—particularly the Southeast U.S.—braces for the force of Hurricane Florence, which as of the time of this publishing has made landfall in North Carolina, just a day after Georgia’s governor declared a state of emergency for every county in the state, healthcare and health IT leaders continue to work in overdrive to help those in need.

Indeed, major disasters such as Hurricane Florence have an effect on healthcare information needs—even before they make landfall. This particular hurricane has already resulted in the evacuation of millions who have left the places where they normally receive care and where their healthcare records are housed. In these situations, electronic health records (EHRs) and health information exchanges (HIEs) can certainly play a large role in disaster relief efforts.

For instance, the Georgia Regional Academic Community Health Information Exchange (GRAChIE), which serves healthcare organizations and providers across Georgia, is currently working to connect to eHealth Exchange participants in South Carolina, North Carolina, Virginia and Florida in preparation for displaced evacuees. The idea is for GRAChIE to expand its connectivity to HIEs throughout the Southeast via the eHealth Exchange—a health data sharing network that is part of the Sequoia Project, inclusive of provider networks, hospitals, pharmacies, regional HIEs and many federal agencies, representing more than 75 percent of all U.S. hospital and 120 million patients—as quickly as possible before Hurricane Florence hits the coast, according to the organization’s officials.

Tara Cramer, GRAChIE’s executive director, says that her organization learned from what happened last year during Hurricane Irma, in that Florida was evacuating patients who ended up being displaced to Georgia. So even though GRAChIE used the eHealth Exchange to build out connections through Florida, the problem was that they had to do it so quickly, and at the time Florida was already under evacuation. As such, there weren’t HIEs on the other side of those connections to help with testing and validation, explains Cramer. “This time, we started very early to build out functional connections on both sides. This is the power of HIE, and it’s very technically possible, although it does require some magic to pull it off so quickly,” she says.

Tara Cramer

Meanwhile, in North Carolina, where the storm is hitting hardest right now, leaders at the NC Health Information Exchange Authority (NC HIEA), which is based in Raleigh, and has only been fully functional since March 2016, have also been working throughout the week to establish and build connections with other HIEs.

Christie Burris, NC HIEA’s executive director, says she owes “a debt of gratitude” to Cramer and other GRAChIE other top executives, since on Tuesday morning Cramer alerted Burris that these connections were possible via the eHealth Exchange. “Shortly after that [conversation], we got together with the East Tennessee Health Information Network (eTHIN), I got my team together and said let’s talk with our vendors, so we can figure out the feasibility in doing these out-of-state connections,” recalls Burris. “And at that time, we weren’t sure when the storm was hitting, so we spent Tuesday through Thursday working with these different HIEs, and we pulled [those connections] off successfully,” she says.

Indeed, in addition to the connection with GRAChIE, NC HIEA signed agreements with four other HIEs this week so that bi-directional exchange could occur: Coastal Connect HIE (Wilmington, N.C.); eTHIN; MedVirginia (Richmond, Va.); and SCHIEX (South Carolina Health Information Exchange). NC HIEA also already had an established connection with GaHIN (the Georgia Health Information Network, based in Atlanta) and the VA HIE (Veterans Administration). “We signed agreements with five of those HIEs last night at 9 p.m.,” Burris says.

Christie Burris

As it stands right now in North Carolina, explains Burris, more than 20 counties in the state have been evacuated, leading to numerous displaced citizens. What’s more, many pharmacies, hospitals, clinics and doctor’s offices have been closed, and prescribing patterns disrupted, leading to many patients having to reconnect with their care regimens, often in new settings.

Shelters in New Bern, a riverfront city near the North Carolina coast, are at capacity as the town flooded last night, Burris notes. And shelters in Raleigh are also at capacity, so some of those folks got moved to Winston-Salem. Thankfully, Burris says that her HIE has a central repository in which it holds onto the patient data, meaning that even if a hospital has been shut down—such as in the town of Wilmington where every hospital but one has been closed—NC HIEA has those patient records up until the time the hospital stops sending them. “So we do have that historical [view of] the patient, and at this point we have over 5 million unique patient records in our North Carolina repository,” says Burris.

Cramer notes that caring for displaced citizens has been a core reason why GRAChIE has been such an advocate for standing up these HIE connections on the fly, and quickly, during the time of a disaster. On a day-to-day basis, she says, “We know that Georgia and North Carolina residents may present at an urgent care facility or the ER, but we also know that during these times, it’s heightened. So if we can equip clinicians with a patient’s allergy list and medication history, that’s still a great starting place to take care of someone who has been evacuated and is already going through a stressful time without friends and family. It is our job to broadcast that net and gather as much information as we can for when they present for care,” Cramer says.

To this end, she adds that at one of GRAChIE’s participating Georgia hospitals, 14 new patients with North Carolina addresses were registered yesterday. “And we are continuing to monitor that throughout the day to see where patients are coming from. It’s our job to watch that and make sure we are delivering quality information.” She also notes that even though Georgia has escaped the major brunt of the damage from this hurricane, the state will still get plenty of evacuees, and preparations have to be in order. “We started reaching out [to HIEs] before we knew a storm may be coming so that we could build relationships. We have built connections with GRAChIE that we don’t keep active all the time, but when we need to activate them, we can. That’s been a key for us since Hurricane Irma,” she says.

Both Burris and Cramer also expressed great gratitude to the Strategic Health Information Exchange Collaborative (SHIEC), a national collaborative of HIEs, for making these connections possible. “I would have not known Tara if not for SHIEC,” admits Burris. And even though GRAChIE and NC HIEA are not yet part of SHIEC’s patient-centered data home (PCDH) project—a model based on triggering episode alerts, which notify providers that a care event has occurred outside of the patients’ “home” HIE, and confirms the availability and the specific location of the clinical data—both HIEs have plans to link up to it quite soon.

In the end, while Burris and Cramer believe in the power of HIEs when a storm hits, they also attest that providers of all types should not wait for a natural disaster to participate. “We want there to be value in the day-to-day exchange of information,” says Cramer. “In these times, you might have a more heightened awareness, but there is every-day value in health information exchanges.”

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Connecticut Receives $12.2M Grant to Build Statewide HIE

September 11, 2018
by David Raths, Contributing Editor
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Earlier effort failed because HIE was not self-sustaining

The State of Connecticut will receive a $12.2 million grant to support ongoing work that will establish Connecticut’s first statewide health information exchange.

An earlier statewide HIE effort, the Connecticut Health Information Technology Exchange, was shut down in 2014 after spending $4.3 million in federal grant money over four years. A state auditor’s report noted that the exchange was never able to provide services to stakeholders and thus, never developed a self-sustaining revenue stream. (The State of Montana also recently decided to take a second try at creating a statewide HIE.)

The grant, awarded by the Center for Medicare and Medicaid Services (CMS) to the Connecticut Office of Health Strategy (OHS), supports efforts to develop a secure, modern HIE that facilitates the sharing of health data to further patient care, improve proper efficiency, and rein in the high cost of healthcare. The HIE is expected to be operational by early 2019.

The grant follows a $5 million federal investment the state received in 2017 that facilitated HIE planning. To qualify for the additional resources, states outlined how their health technology plan would improve disease management, serve the Medicaid population (over 800,000 Connecticut residents), combat the opioid epidemic, and improve overall healthcare through the use of clinical data.

The new round of funding launches a pilot program for the health information exchange, which was one of the nine recommendations made by the Health Information Technology Advisory Council, a statutory body tasked with a comprehensive examination of Connecticut’s current health technology needs.

“The health information exchange will improve care. Providers will be able to exchange clinical and diagnostic data in real time – efficiencies that will save time and resources for healthcare systems and patients,” said OHS Health Information Technology Officer Allan Hackney, in a prepared statement. “We engaged nearly 300 providers and consumers and 75 organizations across the health sector in Connecticut to help us understand the issues and opportunities for improving care delivery and outcomes. Technology can and should be a great partner in health reform.”

Another goal is for the HIE to enable a platform for measuring clinical quality and more quickly analyzing population health – one of the keys to improving healthcare accessibility and correcting racial, ethnic, and gender health inequities. Currently, analysts most commonly use insurance claims data, which is only a proxy for real-time clinical information. This use of the HIE dovetails with the work of OHS’s State Innovation Model Office and the Health Systems Planning Unit in their efforts to better address gaps in healthcare, improve community health, and evaluate the performance of Connecticut’s healthcare providers.


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