Very exciting things are happening these days at the Nebraska Health Information Initiative (NeHII), the statewide health information exchange (HIE) for Nebraska. Under the leadership of CEO Deb Bass, NeHII has moved ahead to embed some of NEHII’s capabilities into core, and even mandatory, state healthcare processes in the Cornhusker State.
Since January 1 of this year, all prescriptions for controlled substances in Nebraska have had to be logged into the state government-sponsored Nebraska Prescription Drug Monitoring Program (PDMP) database, which NeHII operates. And, beginning on January 1, 2018, all filled prescriptions will be required to be logged into that statewide PDMP database. Meanwhile, NeHII continues to move forward on numerous other fronts as well, particularly in terms of collaborations with payers and providers in the state.
Healthcare Informatics Editor-in-Chief Mark Hagland was able to sit down with Bass during the SHIEC Annual Conference, sponsored by SHIEC, the Strategic Health Information Exchange Collaborative, while it was being held August 27-30, at the Crowne Plaza Union Station Downtown Indianapolis. Below are excerpts from that interview.
I’m interested to hear about some of the latest developments at NeHII.
Well, we’re very excited. When I last spoke with you, we had just passed LB 471 in Nebraska. The Department of Health and Human Services is partnering with us on this. Beginning this past January 1, all controlled substances prescriptions had to be logged into our PDMP database. Now, beginning, January 1, 2018, all filled medications prescriptions in Nebraska will have to be logged into it. We are going to be able to capture all filled prescriptions in our PDMP—our prescription drug monitoring program.
The vendor we were using to get our medication history, had gaps in their data. So we got this bill passed, and that mandated the reporting of all filled prescriptions to our prescription drug monitoring program across Nebraska, and that has moved us forward very strongly in this area.
Every filled prescription must now go into a database?
Yes, that’s right—into a database set up through DoctorFirst, our vendor, through a partnership set up between the state of Nebraska and NeHII. The state owns it. LB 223 passed in May 2017, and that gives nurses access to the information. It makes possible a query directly from the clinician’s EHR [electronic health record] to the PDMP—they don’t have to go into another system. It’s minimizing the clicks so that the clinician can get to the data. Plus, it’s free to all prescribers and dispensers. So we are giving a free medication reconciliation tool to all prescribers and dispensers in our state. You know how much time it takes to do med rec. We have grants from the CDC [Centers for Disease Control and prevention], and a Harold Rogers grant from the Department of Justice.
The law specifically covers filled prescriptions. Can you explain the significance of that element of it?
Yes, many prescribers write prescriptions that aren’t filled. That’s why this is so important. This will help prescribers know which of their prescriptions are ultimately filled, and which not. Our end goal is to address adverse medical events, including the opioid crisis. Look at the dollars associated with adverse medication events, in terms of extended hospital stays, readmissions, etc.
This speaks to why health information exchange is so important in terms of improving processes in healthcare, correct?
Yes, that’s right; we are that trusted community partner. We are the neutral convener. For the most part, the HIEs in SHIEC are non-profit collaboratives, and the mission for nearly all of us has to do with patient safety, increasing quality, and reducing costs. We’ve seen real-life stories of what’s happening to people, and it just makes us all the more dedicated towards those goals, with regard to improving the quality outcomes, the cost control, and the patient, family, and community experience of healthcare delivery.
Those are all Triple Aim and Quadruple Aim goals, of course.
Yes, they absolutely are.
Meanwhile, this has been the third annual meeting for SHIEC. You must be excited by how things have progressed.
Yes, I’m very excited! Those of us who are the board members of the organization started as a little user group, and formed a trust relationship with each other. We share what we’re doing well; we call each other, we share emails. I’m viewed as something like the group’s PDMP expert, and people consult with me on that subject. And we recognize that when one of us fails, it impacts all of us. And that gives you this beautiful, no-holds-barred, trust relationship. We’re here to help each other.
One topic that might be sensitive right now is the number of HIE organizations that have failed in recent months. What I hear some healthcare IT leaders in patient care organizations expressing, is some hesitation about leading their energies to a phenomenon that seems a bit fragile or unstable right now. Could you share your thoughts on that?
We all feel the pain when one [HIE organization] goes down. But it is also a market-driven kind of initiative; so you’re seeing some mergers and consolidations. Also, we’re looking at different pricing models that are based on return on investment. And with value-based models of healthcare coming now, things are shifting. For instance, we share an admissions report with 35 hospitals in NeHII. Several hospitals have used that data to greatly reduce or almost eliminate the readmissions penalty. That is very valuable return on investment, and we are very attuned to that kind of interest. Another example involving a home health agency—they have a fleet of nurses, and the business case for them was, using our admission and discharge alerts, they knew when patients had been admitted to the hospital who had been scheduled for a nurse visit. So they knew to cancel the appointment. It’s that kind of stuff. People somehow expect it to be magical and mystical, but it’s really pretty basic ROI.
About a year ago, I wrote a report that focused on four statewide HIEs--Maine, Michigan, Ohio and Colorado. What seems apparent now is that the leaders of successful HIEs are figuring out what their markets want, correct?
Yes. And I think each market is unique, and each of us has a different story to tell. And now as we move into value-based payment models, we’re seeing real opportunities emerging, along a number of dimensions.
What do you see as the most important trends, in the near future, in the landscape around HIE?
The leaders of any HIE looking into the future need to be clear that it’s not about moving information from point A to point B, it’s the value-added service. For us, it’s the admission and readmission alerting, the med rec [medication reconciliation]; we’re also going to be looking at providing quality data, not only clinical but claims data, helping providers to be successful. And if you don’t have an HIE in your community, you can’t do that.
Are health plans becoming more interested and engaged now with HIEs? That’s what we’re hearing.
Yes, absolutely, our Blue Cross plan has been supportive from the beginning. They get our discharge reporting, we’re working on providing the HEDIS scores, and we’ve been also doing prior authorization, disease and case management, hospital-acquired conditions.
Do you see some potential with MACRA/MIPS, in terms of the need for better exchange of data and information?
We’re perfectly positioned, in that context! First of all, we’re moving patients out of the hospital and into the community. And the leading EHR was up there—and all the white spaces, all the data critical to the future—and the EHR stops at the hospital door. You have to have that community data provider that knows where the patients are going. Are we always working on addressing the gaps? You know we are. Social services, we’re just starting to get into that.
One area that we’ve been covering more and more is the Medicaid managed care area, which involves patients/plan members with high levels of both medical needs and social-determinant factors. Their care managers could really use much more usable data and information. It seems as though areas like this are particularly fertile ones for HIE.
Yes, absolutely. We can identify the heavy utilizers. Those are the ones you want to focus on initially. But we have to also focus on that next tier, the rising-risk individuals. With those who are the highest utilizers, it’s about managing as best we can. That next tier is about prevention, and that’s where the opportunities are. Many of them are going to the ED because they don’t have a primary care physician. But until you know who they are and can talk to them, and use case management, you can’t make needed changes. But sometimes, these individuals already sometimes have five or six case managers, which is a turnoff. So many of us are working on the community care plan, tailored to these case managers.
I wrote an article years ago about dual-eligibles, and the interventions that can help them, sometimes totally non-medical ones, such as installing handrails in their houses to prevent falls. That’s just one example of how community health information could be useful, correct?
Yes, absolutely. We work with the PACE program, for dual eligibles. One recent example involved an elderly woman, who had COPD [chronic obstructive pulmonary disease] and diabetes, and her house was falling apart. And the window air conditioner had gone out of function in the middle of a heat wave with high humidity, and the food she needed was spoiling. So they [the health plan case managers] went out and got a window conditioner for $250; and much better to do that, the case manager said, than to let bad things happened.
So working with community-based data, social-determinants-of-health data, can be especially valuable, correct?
Yes, absolutely. When those patients have a community case manager, and they get our admission alerts, so that the primary care physician of a patient is alerted; he or she gets alerted right away, before the ED doctor makes any orders. So that PCP gets involved before the ED physician starts ordering tests or treatments that might be unnecessary or what the patient wants. And that data, provided in that moment of the care process, can be so valuable. It’s great to be a part of all that.
In your view, is HIE as a concept/phenomenon reaching higher level of awareness among federal and state healthcare policy leaders?
Well, advocacy is a number-one priority, for sure. That’s one of the reasons SHIEC was formed. So all of those are reasons why our voice probably has not been heard as it should be in [Washington] D.C. Plus, explaining all the things we’re doing, we’re challenged to explain this via soundbites. How do we make all of this understandable?
Yes, it’s important to be able to convey that HIE is a facilitator, simple terms.
Yes, we’re the network that supports the follow of information, but understanding the power of that information, is important—and hard to explain.
Are you optimistic about the trajectory for SHIEC over the next few years? How do you feel about the conference, in that regard?
I certainly do. Our attendance is getting bigger and bigger each time. Many speakers are from within our own ranks. Third one. And it was fascinating, wasn’t it, Dr. Rucker yesterday morning, talking about future paths and about connections? [Donald Rucker, M.D., the recently appointed National Coordinator for Health IT, was the opening keynote speaker at the conference.] We’re what the railroads were in the 1800s. And ironically, we’re in a railroad terminal here. [The conference hotel is the remodeled former Union Station of Indianapolis.] And we HIEs are neutral conveners. We can improve data quality and data standards.