The state of Pennsylvania has nearly 250 hospitals with some 13 million people spread across 67 counties—statistics which lead to a significant need to make sure that when a patient sees a Pennsylvania provider or goes to the hospital, the most updated information is readily available.
To help spur health information exchange (HIE) progress in the state, the Pennsylvania eHealth Partnership Authority is responsible for the creation and maintenance of Pennsylvania’s HIE, known as the PA Patient & Provider Network, or P3N. The P3N network—composed of healthcare providers, regional health information exchanges, health insurance care coordinators, and public health agencies—helps providers find their patients’ medical records—in real time—anywhere on the P3N network, its officials say. Regional networks electronically connect healthcare providers to each other, and in turn, these HIEs connect to the P3N hub to enable statewide health information exchange.
Throughout Pennsylvania, there are five state-approved regional HIEs that operate under the eHealth Partnership Authority, of which the leaders of two of them—the Keystone Health Information Exchange (KeyHIE) and the HealthShare Exchange of Southeastern Pennsylvania (HSX)—were interviewed for this article. HSX is now five years into existence, and operates in the Philadelphia metro area connecting some 40 hospitals; KeyHIE was founded by Danville, Pa.-based Geisinger Health System in 2005, making it one of the oldest HIEs in the nation, and now connects 18 hospitals and 400 facilities overall.
The two organizations have separately, but also collaboratively, made real strides in increasing their networks and the volume of the data being exchanged. Between 2011 and 2017, the number of unique patients with health records in KeyHIE grew from 2.1 million to 4.75 million; meanwhile, HSX, which actually only started exchanging data on its network in 2013, now has more than 5 million patient records right now in its clinical data repository, up from zero just a few years back.
Indeed, the state has had some real success in being able to effectively exchange data, an area of healthcare that has had its fair share of struggles to date other than in a few pockets across the U.S. Rather, stakeholders have encountered barrier after barrier, from creating a value proposition for the provider community it serves; to getting stakeholders to agree on governance and policies; to developing standards; to determining how to exchange information with competing organizations; and more. As such, the number of skeptics who believe that HIEs can be financially sustainable has only increased in recent years.
How is PA Making it Work?
Most experts would agree that there is no one-size-fits-all approach to a successful HIE model as there are so many variables at play that could differ from one to another. In metro Philadelphia, Rakesh Mathew, program manager at HSX, says a few reasons his organization has been successful are because it gets funding from both payers and providers, and due to the collaboration that it has brought into the market.
“You have this market trend in that hospitals keep buying practices, so hospitals have their own practices as part of the larger health system,” Mathew says. “So we have over 2,000 practices that are part of health systems, some independent [practices], some long-term care organizations, behavioral health facilities, ACOs [accountable care organizations] and IDNs [integrated delivery networks] all as part of our membership. Our membership is a mix of payers and providers,” he says.
Mathew notes that in metro Philadelphia, where a patient can walk from ED to another, there is a lot of leakage happening, and the hospitals and payers all know that. As such, HSX has become a solution for patient traffic between those systems, he says. But still, like many HIEs, HSX needed to figure out a way to make sure that the data it was getting on those patients was of high quality.
To this point, HSX invested in a tool from Diameter Health, a solutions company which has a product that allows for the scoring of consolidated-clinical document architectures (C-CDAs), document standards governed by HL7. The tool, explains Mathew, is able to look at both the structure of the C-CDA and the content inside, making sure that the content is consistent. “We got the payers and providers in our community together, created a task group, and they came up with a score they agreed upon, so we started scoring the C-CDAs based on that. If they didn’t hit that score, you couldn’t send the data in,” Mathew says.
What’s more, when HSX first began to exchange data in 2015, its leaders did a mass review of other HIEs across the U.S., specifically looking at the core issues its peers were facing. Mathew recalls that it was decided internally that HSX would be stricter in the data that it would be putting in the clinical data repository. “We created an ADT [Admit, Discharge and Transfer], specification [for HSX], and we made all the hospitals [on the network] adhere to that specification, which is not something that’s normal across other HIEs—usually they just take what the hospitals give. But we were able to convince the hospitals that for the common good, it was better to put in good quality data rather than garbage. And most of the hospitals agreed; they were ready to do the work to get the ADTs to our standard,” Mathew says.
Meanwhile, in central Pennsylvania, leaders at KeyHIE point to the benefits of being a member-driven organization, so even though the HIE works under the Geisinger Health System umbrella, it is run by the community it serves, says Joe Fisne, associate CIO and vice president of IT at Geisinger. “When our members come on board, they have a vote in terms of how they operate, and that drives the business needs and the business strategy. We do an annual focus group with our members and they help set the tone,” Fisne says.
Organizational leaders point to a recent partnership with CitiusTech and Orion Health that enables KeyHIE’s Information Delivery Service (IDS) to provide alerts, notifications and critical patient information to its participating providers so they know when and where their patients receive care within the network. With IDS, providers can decide the quantity of information they wish to receive, including inpatient admission and discharge notifications, emergency admission and discharge notifications, and lab results/clinical documents delivery. In addition, a subscription management portal allows doctors and healthcare providers to update their subscription preferences when it’s convenient for them.
Kim Chaundry, an IT director at Geisinger, and KeyHIE’s operations director, says that the IDS is a rules-based engine that sits in front of and also behind orders and results. It allows KeyHIE to structure its delivery service so that it can read the metadata and move clinical data amongst its member community quickly and easily either via Direct or via an HL7 message. “If the participant we’re sending the information to is a participating organization, we also help out by adding a header to give them the direct medial record number that they have tied to that patient,” she says. “So when it goes into their EHR [electronic health record] system, into a holding area, we do the auto-matching for the facilities, and we have found that it saves them time and effort. We did a study on one of our participants, and we found that in one month, we saved 312 manpower hours just by using this automated service. We estimated that it would have saved them $56,000 per year.”
Both HIE organizations have also understood how important it is to create a value proposition for its provider members. HSX has worked to make this happen by simply making life easier for its clinicians. Mathew notes that many HIEs will provide a portal to the hospitals where doctors log in, do a query and get the patient information. But for the HSX community, says Mathew, “We engaged them early on, and 90 percent of our physicians told us they don’t want another portal to log into, and don’t want to look at anything other than their EHR in their workflow.”
As such, when a patient enters the hospital, HSX provides a C-CDA of the patient’s longitudinal record back to the EHR, and it attaches right to the patient’s chart in the medical record, Mathew explains. “By the time a physician comes in to examine the patient, the data from the clinical repository is already in the EHR. It might be an external document or on a separate tab, but the key component here is that it’s in the EHR and within the doctor’s workflow. They are getting one consolidated document,” Mathew says.
KeyHIE management similarly wanted to make sure the physician’s workflow wouldn’t get disrupted. They created what Fisne calls a “beachhead” in which they went and demonstrated how the HIE would work to one or two providers to show them the value proposition, and that they wouldn’t have to create “50 million interfaces,” he says. “Once one or two get on board, more [providers] see the value in it. In the community, they start to pull together to take advantage of things like transitions in care.”
Part of proving the value of the HIE to its members was done by co-developing a tool with solutions vendor VorroHealth that converts standard clinical reports into easier-to-read clinical summaries. The tool specifically helps the part of the community that doesn’t have EHRs, so long-term care facilities for instance, by helping them transmit resident health information directly to an HIE. Says Chaundry, “We worked collaboratively with that spectrum and built a tool that allows us to take the already-entered data they have to send to CMS for billing requirements, and we converted it into a standard HL7 message which converts into a C32 file. So now it gives folks the ability to make their information available even if they are still on paper.” Fisne adds that the tool enables the organization that can’t afford the high-level EHR to connect into the HIE, “so the sharing of the information is there when and where it’s needed.”
Competition and Collaboration
Mathew feels that HSX does experience competition challenges, given the four other approved health information organizations in the state, noting that since Pennsylvania is so big, 50 percent of the state’s hospitals are still not connected to any HIE. This means that there is much more work to be done for the HIEs in the area to get those providers on board, he says.
But KeyHIE leaders have a different perspective when it comes to collaboration amongst HIEs. Fisne says that the first thing his team does when it reaches out to providers getting on board is tell them that if it makes more sense to connect to another HIE in the area, then that’s what the organization should do, since that’s where the community is. “We just want you to connect to the HIE; we don’t care which one,” he says.
Chaundry notes that the state currently has an initiative right now to connect HIEs to HIEs, and that KeyHIE is working with HSX and others to take that to the next level. “So if a patient ends up in our ER and is an HSX patient, we can identify that and send that primary care physician a notification so they are still getting that feature functionality no matter where the patient goes in the state,” she says. “The state is really doing what’s best for [everyone], and is pushing us to collaboratively work together. I don’t see much competition; we want to work together to make sure everyone gets the best clinical information that they need.”
Adds Fisne, “We see ourselves as complementary, from a competitive standpoint. We always say that we don’t care if you connect to another HIE, since the purpose we want to reach is the higher level of getting the community connected so the patient is cared for all the way through. Saturation is key; the more information that’s out there, the more it can be shared appropriately and accordingly, and this will help advance the ideas of population health. You have to keep the patient at the highest level of your goals,” he says.