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In Pennsylvania, Regional HIEs are Working Competitively—and Collaboratively, Too

August 15, 2017
by Rajiv Leventhal
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Two HIEs in Pennsylvania have grown significantly in recent years. What have been their keys to success?

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.

Rakesh Mathew

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.

Joe Fisne

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.”

Kim Chaundry

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.

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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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