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Market Profile: San Diego Healthcare Leaders Find Togetherness Comes Naturally

December 6, 2017
by Mark Hagland
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What’s behind the cooperative spirit in San Diego? A history of collaboration—with some unique geographical features

All U.S. healthcare markets have localized features, and the San Diego healthcare market is no different. In fact, as some have noted, there is an odd, almost “island-like” quality to the geography of the San Diego metropolitan area, in that it is bordered by the Mexican border on the south, the Mojave Desert on the east, the Pacific Ocean on the west, and Camp Pendleton on the north. At the same time, it’s also true that some of its nearly 3 million residents do seek patient care to the north, on the edges of the sprawling Los Angeles/Riverside/San Bernardino metro market. So in that sense, perhaps the metro San Diego market is most like a geographic/demographic peninsula of sorts.

Meanwhile, though it shares much in common with the large metro markets of San Francisco and Los Angeles to the north, the San Diego healthcare market also has differences, particularly with the L.A. healthcare market, particularly in two areas: the levels of inter-healthcare-organization collaboration present, and the levels of risk achieved in risk-based contracting.

Daniel Chavez, executive director of San Diego Health Connect, the metro area’s highly advanced health information exchange (HIE), attributes the level of collaboration to the fact that “We have no dominant players, we have all dominant players. We have a very active public health agency—our health and human services agency is the largest in the United States,” he says. And when it comes to payers and providers cooperating, Chavez says, “They get along as well here as anywhere I’ve worked, and I’ve worked on both the provider and health plan sides. I’ve lived up and down the state, and in Austin, Texas, and Tampa and Jacksonville, Florida, and this is the most collaborative community I’ve ever had the opportunity to work in. In balance, this is the most collaborative place.” He cites Blue Shield of California and Anthem Blue Cross as being particularly willing to work closely with providers. And of course, Health plan and provider leaders work very closely together inside the organizational structure of the local Kaiser Permanente organization, which also has a strong presence.

Speaking from the health plan perspective, Joseph Garcia agrees strongly with Chavez. Garcia is COO of Community Health Group (CHG), a local health plan with 290,000 members, 280,000 of whom are MediCal (California’s version of Medicaid) members. Community Health Plan actually started out as a federally qualified health center (FQHC) decades ago, and its leaders remain committed to sticking close to their community. Garcia’s perspective is also enriched by the fact that “We work with practically every primary care physician in San Diego County” outside the Kaiser and Sharp HealthCare organizations, as he notes.

“This is the only county we’re in; and every provider knows our corporate headquarters is right here, and they can meet with the CEO, COO, CMO—they can come over or call,” Garcia emphasizes, about CHG. “We have 30-year relationships. We were born out of a community health center, San Isidro Health Center. We were a provider, then a provider and health plan together, and then 20 years ago, we separated. And I and others have worked at both.” And that core attitude of cooperation, he says, extends to all of the plan’s interactions with providers.

Both CHG and SHC have been participating in a county-wide effort, led by the county’s health department, to control and end an outbreak of hepatitis A that has caused many problems and been difficult to control, especially given a very large homeless and transient problem in the county.

As an Oct. 31 report in the San Diego Union-Tribune noted, “The county Health and Human Services Agency published new weekly totals Tuesday, which add one to the number of deaths recorded since the health crisis started in November 2016. The running tally of confirmed cases also continues to increase, reaching 536 from a previous total of 516.”

As Chavez notes, “We’re going through a hepatitis A outbreak, and we’re coming together to solve that. We have the fourth-largest homeless population in the U.S.—about 10,000 people—and this is largely a result of that. We’re working hard on homelessness, and this involves the entire community.”

Indeed, Chavez notes, the broad reach of his HIE is turning out to be extremely helpful during this public health crisis. With 23 hospitals, 18 federally qualified health centers, and hundreds of physician practices connected, Chavez is able to boast that 99 percent of the patients living in San Diego and next-door Imperial Counties have their patient records entered into San Diego Health Connect’s core data repository, which is facilitating 20 million messages a month, encompassing everything from ADT alerts to full C-CDA (consolidated clinical documentation architecture) transfer. As a result, he reports, “With regard to hep A, we’ve done a wonderful job with public health reporting. I venture to say that in every one of those cases, that information was passed back and forth through the HIE, all automated, with no human intervention. As soon as we had any information through a diagnosis, we registered the case with public health, with no human intervention whatsoever. And people have no idea how important the HIE is, in that. What would that outbreak be, without HIE?” The response to the outbreak among providers, health plans, and public health, he says, has been terrific.

From the health system perspective, a mature market—with alignment

Some of what makes collaboration possible, say those in the trenches, is the very maturity of the San Diego metro healthcare market. One executive who shares that viewpoint is Dan Gross, executive vice president, hospital operations, for the seven-hospital (four acute-care hospitals, three specialty hospitals), 1,836-bed Sharp HealthCare, one of the largest and most market-moving of the area’s large integrated health systems. Gross, who has witness a lot of health system change in the 38 years he’s been with Sharp (11 years in his current position), says that “I would describe San Diego as being a very mature, consolidated healthcare market. It is a market that embraced integrated healthcare delivery system design and risk-based reimbursement, very early on, going back to the 1980s.”

Meanwhile, Gross says, “When I look at where we’re at and where we came from, it is that one truly has to have an integrated healthcare delivery model, and a very close affiliation and alignment with physicians, to be able to address risk-based reimbursement and capitated managed care, so that there’s an alignment between physicians and having common beliefs around care coordination, commitment to being a high-quality, low-cost provider with a very keen sense of service orientation, to a population served. The ‘magic,’ if you will, or the key to success, is that provider alignment; because without having physicians committed to the same outcomes, it doesn’t work. And you have to create an economic model so that everyone is incentivized to work towards the same outcomes and goals. It really requires that one think through how to ensure that everyone is winning, how you define winning. And also embedded, you have to have some great flexibility and knowledge around, how do you work with different patient populations, as it relates to the economic model behind them?”

The physician group perspective, even within the integrated Sharp system, can be different, even as it is consonant with the hospital executive perspective. Collaboration has flourished among physicians and physician groups, for a number of reasons, says Vicki DeBaca, R.N., vice president of health and provider services, at Sharp Rees-Stealy Medical Centers, the 500-physician employed medical group that is a component of the integrated Sharp health system. “Working at the medical group level, I find that most of the medical groups are dealing with the same issues, the same populations,” DeBaca says. “I think the groups try to be collaborative, per medication shortages” and similar issues. For example, she notes, “We’ve just recently worked on a hypertension collaborative with all the major medical groups. So we’re collaborative overall as a community. We pull together.”

Indeed, DeBaca says, perhaps one element in the collaborative element of the market has been the very isolation of San Diego from the rest of the state, and its relatively advanced work in risk-based contracting over a period of years. “We’ve been a highly capitated market for some time, unlike the case in Los Angeles,” she says. “So I think over time, the organizations in San Diego, because they’ve had a bit more flexibility with the dollars, have been able to focus and decide on how best to spend those dollars. So we might fund special diabetes programs, or special end-of-life programs, we have flexibility in terms of how we utilize resources.”

And, with regard to the physician culture, DeBaca says, “I feel that the physicians here are very engaged. There’s that the collaborative spirit here is about. They’re coming together to address the health of the population. We started the community health information exchange, which was highly advocated for by physicians. So they’re very caring and concerned, because they want to help patients.

And health information exchange, as facilitated by San Diego Health Connect, has clearly been a part of that equation, DeBaca says. “Many of my staff use it,” she says, referring to the HIE’s capability. “Ad our providers have a link within the EHR [electronic health record], and are able to go right into the EHR to find that information. And members of my staff, who are largely case managers, can access that information as well. It’s been excellent in terms of getting patients connected back to their primary care physicians after ED visits and hospitalizations. And the goal of our care managers is really to support the patients, in whatever they need.” So, she says, the continuous loop of information and data has proven to be very important in advancing case and care management.

In the next article in this series: where are population health management and care management headed in the San Diego market?


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Two N.Y. Regional HIEs Partner to Enhance Technology, Services

October 1, 2018
by Heather Landi, Associate Editor
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Two New York regional health information exchanges, HealthlinkNY and HealtheConnections, have formed a strategic partnership aimed at accelerating HIE use by providers. The HIE leader contend that the partnership will provide more value to providers by offering innovative technology, new capabilities, and richer data for participants in the HIE.

The HIEs, which are two of the state’s eight qualified entities (QE) connected by the Statewide Health Information Network for New York (SHIN-NY), together cover 43 percent of New York State. Binghamton-based HealthlinkNY and HealtheConnections, based in Syracuse, leaders said the partnership will connect providers across much of New York State, from the northern border of New York City, through the Hudson Valley, and throughout the Southern Tier and Central New York to the Canadian border. The partnership is the result of months of collaboration following HealthlinkNY’s decision to seek a strategic partner in 2017.

Staci Romeo, HealthlinkNY’s executive director, said she chose HealtheConnections because their technological platform is “exceptional,” and HealtheConnections’ “quality of services and customer engagement processes completely align with HealthlinkNY’s mission and values.”

“HealtheConnections has proven technology and associated services that create value for providers. We’re thinking progressively and looking to offer resources such as tools to measure quality and support value-based care systems,” Romeo said in a statement. “We want a partner with innovative services and an unwavering commitment to providing value to providers by enabling them to improve care and efficiency, as well as save time and money.”

The announcement came just a few days after HealthlinkNY publicly opposed another regional HIE’s plans to expand its services into HealthlinkNY’s market. In a press release issued early last week, Romeo responded to plans by Hixny, an HIE based in Albany that historically covered north and west of the Capital District, to expand into nine counties in HealthlinkNY’s territory and called Hixny’s move “a case of sour grapes after being passed over during our search for a strategic partner.”

Rob Hack, president and CEO of HealtheConnections, said the strategic partnership was inspired, in part, by a statewide effort to optimize costs and efficiencies to increase use and adoption of regional HIEs and the network that connects them all—the SHIN-NY. “HealtheConnections and HealthlinkNY have a shared vision of using health data to create healthier communities, improve healthcare delivery, and deliver value to providers. This type of progress can only be achieved through enhanced collaboration and looking beyond the status quo.,” he said. “That’s what we’re trying to do here—accelerate the great work that has already begun. The HIE works to its fullest potential when all parties, providers and HIEs alike, work together toward the common goal.”

Romeo said that HealthlinkNY will begin to migrate its current HIE interface to HealtheConnections’ platform in early 2019. With the new platform, users will be able to further filter data, set up advanced alerts and results routing, and have access to more databases, including the New York State Immunization Information System (NYSIS), Veteran’s Administration (VA), and Department of Defense (DOD), she said. Other enhancements include fully integrated analytics and reporting value-based payment support and advisory services; quality measurements; and clinical dashboards that provide usable data to identify gaps in care.

“The user experience is key,” Romeo said of the technology and services. “Both HealthlinkNY and HealtheConnections are coming from a place where we put providers first, and that includes offering providers a nimble and intuitive platform and services that support the way they deliver care and help their organizations save time and money.”

Romeo pointed out an additional benefit to providers: Both HealthlinkNY and HealtheConnections have built “hub” connections to widely-used electronic health records (EHR) systems. HealthlinkNY has 21 hubs and HealtheConnections has 13 hubs.  Combined, providers will have access to 50 different hub and custom connection options, she said.

Hack called the partnership “a game-changer” because together the two entities will be able to accelerate new participant growth, data contributions, development of new analytics, and community health improvement results. “The idea,” said Hack, “is to transform and improve patient care, improve the health of our population, and lower health care costs.”

Together, HealthlinkNY and HealtheConnections will operate a service area that covers 24 counties, more than one-third of the 62 counties in New York State, and connect all of the region’s 66 hospitals, which comprise 27 percent of all hospitals in New York State.

According to HealthlinkNY and HealtheConnections leaders, both HIEs administer collaborative population health improvement initiatives in their regions, and they are the only HIEs in New York State that administer Population Health Improvement Program (PHIP) grants.

Currently, HealthlinkNY’s HIE stretches across 13 counties, and its population health arm manages the Southern Tier Regional Addiction Resource Center. The HealthlinkNY Community Network works with partners on many additional population health efforts in 14 counties in the Hudson Valley, Catskills, and Southern Tier of New York. HealtheConnections has a strong regional presence in 11 counties in the Central and Northern New York regions, where 80 percent of physicians actively use its HIE, and 75 percent of providers contribute data.

 

 

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One New York Regional HIE Opposes Expansion of Another, Highlighting Issues with Competition Among HIEs

September 24, 2018
by Heather Landi, Associate Editor
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In a 2015 report, 84 percent of HIE leaders cited competition among HIEs as a barrier to development
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A New York regional health information exchange (HIE), HealthlinkNY, based in Binghamton, has publicly come out against another regional HIE’s plans to expand its services into HealthlinkNY’s market, saying it creates “confusion and uncertainty” in the marketplace.

Last week, Hixny, an HIE based in Albany that historically covered north and west of the Capital District, announced that it had added nine counties to its territory, specifically Chenango, Broome, Sullivan, Ulster, Dutchess, Orange, Putnam, Westchester and Rockland counties in southern New York. These nine counties are already covered by HealthlinkNY’s network, which covers a 13-county service area spanning the Hudson Valley, Catskills, and the Southern Tier of New York (the Southern Tier encompasses counties of New York west of the Catskill Mountains along the northern border of Pennsylvania).

With the expansion, Hixny now serves 28 counties and the HIE already has updated its website to state that it serves communities from Westchester to the Canadian border and Binghamton to Vermont. Hixny CEO Mark McKinney claims that this area, the Hudson Valley and Southern Tier region, has "historically lagged in connecting providers to one another and collecting patient consent.”

Staci Romeo, executive director of HealthlinkNY, notes that all 35 hospitals in the Hudson Valley and Catskill regions are HealthlinkNY participants. In those nine counties, Hixny has 21 sites and no hospitals, according to Romeo.

Both HIEs are two among 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 and managed by the New York eHealth Collaborative (NYeC). According to the NYeC website, participating healthcare organizations can connect with the QE that best aligns with their business, operational, and service delivery needs. 

HealthlinkNY issued a strongly worded press release late last week in response to Hixny’s expansion plans. “The truth is that an unnecessary expansion into this service area compromises the effectiveness of the Health Information Exchange [HIE],” Romeo said in the press release. Romeo also stated, "While others seek to confuse the marketplace for their own professional gain, our focus is pure: to help providers improve the continuum of care."

During interviews Romeo and Hixny's McKinney both addressed the expansion plans. Romeo says Hixny’s expansion into its territory creates competition between the HIEs and says the competition is a “distraction, it’s confusing for participants and it’s completely unnecessary.”

McKinney says, “The primary reason for us to consider expansion is because patients and providers really are not bound by county borders. We have long been a trail blazer as an HIE both in the state and around the country. From our perspective, reaching into those regions helps to meet the needs of those patients.” McKinney says Hixny officials recognized that there was an overlap of patients seeing providers both in Hixny’s service area and in neighboring counties.

“We looked at data for patients already inside our master patient index, and we saw significant percentages of patients already had records inside our systems, so for those providers and those patients, getting a more accurate and complete record and making that system available to providers seemed like a valuable exercise to bring all that information to one place,” he says. “This gives providers a choice in terms of what they value with regard to the services that are provided.”

According to Hixny’s website, 1 in 5 residents of the Hudson Valley and Southern Tier already have Hixny records, and that figure increases to more than 1 in 2 in counties neighboring Hixny's established service area, the website states.

HealthlinkNY's service area

Hixny's service area

McKinney also notes that it is not uncommon for multiple HIEs to serve multiple markets and he believes its beneficial to have two HIEs serving the same counties. “I think what’s most important is to meet the needs of patients and providers. Ultimately, it’s about patients and providers and making sure they have access to the information that they need,” he says.

And in response to Romeo’s statement that Hixny’s expansion creates “confusion and uncertainty in the marketplace.” McKinney says, “I can’t comment on her response; what I can say it that we’re very committed to our expansion and delivering the data and the information that will improve care and lower costs for patients and providers in the region.”

Hixny (formerly known as the Health Information Xchange of New York) launched in 1999 as a collaboration between Iroquois Health Care Alliance, which represents upstate hospitals, and the New York Health Plan Association. The HIE currently serves 1.7 million patients.

Regional HIEs enable provider organizations to access and exchange health information with participants in their region, and, in New York State, all eight QEs connect to SHIN-NY, which acts as a hub to provide access to patients’ health information statewide. When contacted for comment, Valerie Grey, executive director of the New York eHealth Collaborative (NYeC), stated, “Ultimately, our role is to help expand participation in the information network and support all of our partners in that process. We’re going to continue that work with each of our eight regional networks because increased participation will improve health outcomes across New York.”

Historically, HIEs separately increase their networks within their agreed-upon geographic areas, while there also is a great deal of collaboration between regional HIEs. However, one challenge for many HIE leaders is determining how to exchange information with competing organizations.

Healthcare researcher Julia Adler-Milstein, Ph.D., who has done extensive research on HIEs, says there are regions with multiple HIEs operating and competition among HIEs is a common issue, although it’s often discussed in “backroom” conversations. Adler-Milstein is an associate professor of medicine and director of the Clinical Informatics and Improvement Research Center, School of Medicine, at the University of California San Francisco.

Three years ago, Adler-Milstein was part of a team of researchers from the Mathematica Policy Research, the Harvard School of Public Health and the University of Michigan, School of Information that published research examining health IT adoption, including the advancement of community HIEs. As part of that study, the researchers surveyed HIE leaders about barriers to development, and 84 percent of respondents cited competition among HIEs as a barrier to their development.

In Opposing Hinxy's Expanion, HealthlinkNY Claims "Sour Grapes"

HealthlinkNY officials also take issue with the wording of Hixny’s press release stating that information sharing "historically lags" in the Hudson Valley and Southern Tier region, which is HealthlinkNY's territory.

McKinney says, "There has been public information that has demonstrated that the growth of SHIN-NY across the state has been uneven and so we’re basing [that] on some of that information that has demonstrated that certain areas have grown faster than others." He adds, “We think our press release stands for itself, in terms of demonstrating that there is a need for Hixny to deliver the data and the information that will improve care and lower costs for patients and providers in the region.”

In HealthlinkNY’s press release, Romeo said Hixny’s claims against HealthlinkNY’s impact and progress are "completely unfounded.”

HealthlinkNY, which launched in 2005, has all 35 hospitals in the Hudson Valley and Catskill region participating and sending data to their HIE, as well as 1,207 sites, according to Romeo. HealthlinkNY also recently hit the two million patient consent mark and has 374 participating provider organizations, up from 271 at the end of 2017, according to Romeo. HealthlinkNY also administers two Population Health Improvement Programs (PHIPs) in the Hudson Valley and Southern Tier. HealthlinkNY’s service area population is just shy of 2.9 million residents and includes nearly 1,800 participating locations.

Further, Romeo stated in the press release that Hixny’s claims “sound like a case of sour grapes after being passed over during our search for a strategic partner.” HealthlinkNY has entered into strategic partnership discussions with HealtheConnections, another HIE located in Syracuse that serves central New York, and Romeo stated, “HealthlinkNY had recently advised Hixny that they did not make the cut.”

When reached for comment on Romeo’s claim, McKinney responded, “Hixny’s strategy for expansion is solely based on getting providers data that is complete, accurate and up-to-date and supporting the success of the SHIN-NY by improving the overall health of our communities.” 

Romeo notes that HealthlinkNY has significant plans underway in the Hudson Valley and Catskill regions to increase its presence and breadth of services offered. As part of this strategy, HealthlinkNY is looking to work with a strategic partner with “innovative services and an unwavering commitment to providing value,” she says. After interviewing potential partners, HealthlinkNY decided to collaborate with HealtheConnections.

Romeo said in the press release that HealthlinkNY entered discussions with HealtheConnections because “they are in alignment with us with respect to mission, best practices, services, capabilities, and culture.” She further stated, “They also will help power a more sophisticated technology platform as well as a complementary program for population health, critical with today’s burgeoning opioid crisis and the need for increased access to mental health services. We want to take this to the next level.”

Romeo further expanded on the partnership: “The combination of services currently provided by both QE's will be expanded by this partnership. Just a few examples are: additional functionality regarding actionable analytics, HEDIS reporting, as well as alerts provided how and when participants need them. We are looking forward to synergies and shared best practices between both organizations.”

 


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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, according to Hixny officials.

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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