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A National HIE Leader on Patient Matching, TEFCA and the Future of Health Information Exchanges

September 6, 2018
by Rajiv Leventhal, Managing Editor
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Dan Chavez, CEO of San Diego Health Connect, checks in to discuss an array of challenges facing HIEs in this current moment

It’s no secret that healthcare and health IT experts feel that the lack of a nationwide patient matching strategy remains one of the largest unresolved issues in the safe and secure electronic exchange of medical data.

What’s especially troubling is that electronic health records (EHRs) across hospitals and health systems nationwide are riddled with duplicate records. According to a recent Black Book survey, the average duplicate rate across healthcare organizations is 18 percent.

What’s more, for health information exchanges (HIEs) across the U.S. today, matching and linking patient identities pose an enormous challenge due to the diversity and independence of the institutions they serve. As such, HIE leaders, such as Dan Chavez, CEO of San Diego Health Connect (SDHC), the metro area’s regional HIE, are tasked with finding a solution to the patient matching problem.

To this end, in 2016, San Diego Health Connected announced it would be using a patient matching platform from Virginia-based health technology company Verato. The HIE agreed to implement the Verato solution after a pilot employing Verato technology successfully increased the number of matched records in SDHC’s MPI (master patient index) by 110 percent, cutting down the time this outcome would typically take from years to a few short weeks.

The SDHC MPI manages the identifying information for millions of people across the San Diego region, aiming to ensure that the records belong to the correct patients. According to officials, due to stringent matching criteria, SDHC’s MPI matching algorithm excluded 187,000 patients because of unresolved patient identification. Once these same records were run through Verato, 75 percent of those mismatches were resolved. Verato then outperformed expectations when it found an additional 126,000 patient matches that the MPI had originally missed.

SDHC’s Chavez recently spoke with Healthcare Informatics about this patient matching issue, as well as broader HIE topics such as sustainability and TEFCA—the government’s proposed Trusted Exchange Framework and Common Agreement, a plan to spur interoperability among providers. Below are excerpts of that interview.

Can you outline the problem of providers not being able to properly match patients, and why this is a specific and unique challenge for HIEs?

What happens at the point of care is when a care provider is trying to provide care and pull up a record, depending on the EHR, the application, or the workflow—which all may be separate, distinct, or the same—whenever that happens, what’s presented may cause an interesting caregiver-patient interaction.

So, are you the Dan Chavez on 123 Main Street? Or do you live on street X? Are you born in 1975 or 1957? In this day and age, we expect that you should know who I am, regardless of the system you’re looking at. I can do that on Facebook and on Uber, so why are we having that conversation [in healthcare]? How can the doctor, nurse, or caregiver not know who I am? That’s an interesting conversation which can get uncomfortable. The provider might say that the system doesn’t allow for that information, or he or she doesn’t have the proper information on the patient. It’s usually some silly excuse.

But the doctor knows that the patient has been to provider X or Y, so how can you not have that information? So therein lies part of this challenge—why aren’t you seeing this information? And that could lead to a credibility issue, too. Why am I here for treatment and what treatment am I here for?

Dan Chavez

How is San Diego Health Connect working to solve this problem?

We involve the community. For a solution to be accurate, successful and well-implemented, it requires people, process and technology. We have a very engaged medical records workgroup and they work to make sure that our [medical records] are as streamlined, easy to use and factual as possible, through the HIE.

There might be as many as five patients [with the same name] in your [system]. Our goal is ideally to get that down to one. In our world, the worst case would be three, though we do have the anomaly of a five- or seven-name pick list. We work very hard to get it to one. And if we don’t have the information, it could be that the patient didn’t consent. So our goal is to take the gray and obscurity out of this process. When we do get that pick list of three, many times two of those three are the same person and we just have to combine those records. But we are diligent in removing duplications and feeding that back to the committee, along with problem information, names and organizations, and getting that pick list as short as possible.

What results can you speak to from using Verato?

We have an exception queue and it’s oscillating. Every time we add a new major [organization] with more than 10,000 patients to the HIE, it impacts the queue. We just added a health plan and that has added 4 million lives to the master patient index record locator service. So that will be a big bump to the queue and we have to socialize that participant into the MPI record locator service. Much of that is done automatically. That’s the beauty and also the challenge of an HIE—it’s a change management exercise and it never goes away. So even though you are achieving good results, once you add someone new, you blow up.

Going forward, it’s mostly about onboarding new participants to the process. Health plans now have patient volumes in six and seven figure numbers joining the HIE, so there are lessons learned based on the last health plan we added. We keep getting better every time we onboard. Every time we add a new player, there will be duplications, things will get gray and then adjustments will have to be made. But overall, we have about 98 or 99 percent [patient matching rate].

How you feel about TEFCA and its impact on HIEs such as your own?

TEFCA makes a lot of sense and we appreciate the intent; we support it. We hope it’s not too disruptive and takes advantage of the infrastructure, process, and lessons learned from what we have invested so far. How much will TEFCA formally incorporate—and we are all different—what we have done in San Diego, in the ultimate final ruling that is published? Our input is that you need a better scenario assessment of what’s out there, evaluate it, look at best practices, and incorporate as much of those good investments that have occurred as possible.

Are you concerned about the future viability of HIEs?

I can’t speak for the rest of the country; only California at best, and within there, San Diego. Dr. John Halamka [CIO, Boston-based Beth Israel Deaconess Medical Center] was out here recently speaking, and I was asking questions to him about HIEs, to which he said they are valuable, but immature. I thought that was very telling.

There was recently an article published by the CIO of Cedars-Sinai Medical Center in Los Angeles, Darren Dworkin, and the focus of the conversation was the return on investment for your EHR. He said that there are two things that maximize the ROI of an EHR, which takes 10 years to [achieve]. The two things that maximize that value are: interoperability, which is what HIEs are all about; and the second is data analytics and decision support. But you cannot get that data unless you have the interoperability.

So in my mind, and yes, it’s my job, but I fully believe that HIEs have tremendous value. It’s that commitment to the HIE in the community and how committed that community is that determines the evolution, maturity and the corresponding ROI. And that includes public health and the EHR—not just hospitals, doctors, and payers. The more that the entire ecosystem is involved, the greater utilization, sustainability, and value [for the HIE].

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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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