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At the SHIEC Conference, Payers and Social Service Providers Highlight Collaboration Plans with HIEs

September 1, 2017
by Mark Hagland
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Health plan and social service organizations agreed on the need to collaborate with HIEs, this week in Indianapolis

At the SHIEC Annual Conference held this week at the Crowne Plaza Union Station Downtown Indianapolis, and sponsored by SHIEC, the Strategic Health Information Exchange Collaborative, leaders from a wide range of stakeholder groups led presentations and panel discussions that articulated why they’re collaborating with health information exchanges (HIEs) on a variety of emerging and ongoing initiatives, with the dominant theme that of community health enhancement.

On Wednesday morning, August 30, two panels in particular shed light on some of those collaborative efforts. First came “Linking Social Factors to Health and Community Information Exchanges: 2-1-1 Connects the Dots,” which was presented by John Ohanian, president and CEO of 2-1-1 San Diego, and William York, executive vice president of that organization. That panel was followed by “HIE Payer Use Cases,” in which the panelists were Susan Beaton, R.N., M.S.N., vice president, provider services, care management & risk, at BlueCross BlueShield of Nebraska (BCBSNE; Omaha); Michael Heidenreich, HIE program manager, at PacificSource Health Plans (Bend, Ore.), and Teresa Rivera, president and CEO, Utah Health Information Network (UHIN; San Diego).

As the first speaker on the payer panel, BCBSNE’s Beaton told the audience of HIE leaders that she continues to be very excited by all the innovative work that her organization has been able to do collaboratively with Deb Bass, CEO of the Nebraska Health Information Collaborative (NeHII), and her colleagues there, and with local provider groups.

“We at BlueCross BlueShield of Nebraska serve over 700,000 members—two of every three Nebraskans carry our card,” Beaton noted. “Physicians and payers working together to utilize NeHII-facilitated data helps provide a path forward” to improving patient/plan member health status and better managing costs, she said. “So it’s very important to participate in health information exchange. And it’s important to make sure we can help NeHII work smarter.”

The key strategic goals at BCBSNE, in the context of working with NeHII and with local providers? Aligning on quality metrics, working with providers to improve care management, enhancing the use of data as a tool, and improving community health status overall. With regard to the alignment on metrics, Beaton told the audience, “The fact is that 300,000 of our 700,000 members are in patient-centered medical homes or ACOs”—accountable care organizations. “We want providers to work from harmonized sets of measures; we understand that they are very frustrated over having to work with so many different sets of quality measures. So we’ve partnered with the Nebraska Medical Association to work on CPC+”—the federal Comprehensive Primary Care Plus patient-centered medical home model initiative—“in order to create the same metrics and measures for physicians.” More broadly, per leveraging available data, she said, “We actually send or case management nurses into clinics when they participate in ACOs and case management. We want to make sure our providers not only use the HIE but push their data into the HIE.” That’s exactly where NeHII fits in, she said. “Community betterment is the key. Physicians are our members’ most trusted resource. We are an advocate for them, and provide tools for them.”

In that regard, Beaton shared with the audience five key goals in their collaboration with NeHII and with providers. “First,” she said, “is reducing barriers. We’re so often seen as yet ‘one more thing to do.’ We want to reduce barriers” in order to ease practice burdens for physicians contracting with the insurer. Second, she said, is “whole-person care. How do you bring everything together? We have the claims data; physicians have the EMR data; the HIE has other data. How to bring that together?” That is both the challenge and opportunity, she noted. Third, she cited “connectivity of clinicians that ensures actionable and sharable data. Trying to figure out how we can deliver that information, even though it’s claims-based,” she said, remains an enormous challenge, but one that she and her colleagues are determined to overcome. “You often hear about providers having to wait 90 days to receive claims-based data. In fact, we’re able to work to deliver that claims information within 30 days on a care management platform, via a dashboard, to give physicians actionable information in as close to real time as possible.” Ultimately, she said, the goal is to improve on that 30-day timeframe, to bring clinicians closer to receiving claims-based data that can further enhance their ability to care for patients. Indeed, “adherence to care plans and medication programs” was the next major objective she cited; and the final one she referenced was “security and HIPAA compliance around data-sharing.”

Moving Ahead in the Pacific Northwest

In a very different corner of the country, things are moving forward as well. Michael Heidenreich, the HIE program manager at PacificSource Health Plans, began by sharing some background on his organization, not one of the better-known health plans. Based in Bend, Oregon, PacificSource has 272,000 members, and contracts with 46,000 providers in Oregon, Idaho, and Montana, with a dedication to a “high-touch model of service,” as he emphasized—which, among other things, means a focus on direction personal interaction over the phone and in person. For example, he noted, “We direct our customer service calls to a live person within 20 seconds.”

With regard to health information exchange, Heidenreich told the audience that health information exchange is a central element in his organization’s strategy to improve the health status of the communities in which the health plan operates. A key goal, he said, is the collection of social-determinants-of-health data, for that purpose. “PacificSource was selected for a CMS Innovation grant called Accountable Health communities (AHC), which will survey our Medicare and Medicaid populations in Oregon,” he added, referencing the Center for Medicare and Medicaid Innovation (CMMI) within the federal Centers for Medicare and Medicaid Services (CMS). Meanwhile, he added, “A similar pilot is getting underway in one of two Medicaid regions in Oregon,” citing a planned spring 2018 launch for that initiative.

Heidenreich noted that, in both cases, there are opportunities to improve processes around screening and provider referrals, and to improve the navigation services offered to health plan members. As for working with health information exchanges, he said, “There’s a nice opportunity to take that data and use it. We’ve been talking with the Reliance eHealth Collaborative, to get the data into their database,” he said, referring to the Medford, Ore.-based HIE, with which Heidenreich and his colleagues have been discussing collaborative efforts.

What’s more, he added, collaboration with HIE partners could prove valuable along other dimensions as well. “We also see the ability to identify some markers in the clinical data, and trying to use natural language processing to trigger [social determinant and other types of] data capture,” including through appropriate access to behavioral healthcare and substance abuse data.

“Within the next 24 months, we’re trying to become live with Reliance,” Heidenreich noted. “We want to encourage that the consent [for data release] actually come through us. That means probably working with behavioral health partners and making sure the consent is going to the payer, so we can alert for care coordination. And we’d like to use the CCDA for analytic purposes. Right now in Oregon,” he added, “we have a Medicaid quality incentive around metrics for hypertension, diabetes, clinical depression and follow-up and cigarette smoking prevalence.”

In all this, Heidenreich, data coming into plans can be “problematic, and,” he added, that data “requires validation to make sure the reporting is accurate. We find that the data can be a little bit off and wrong,” he added, emphasizing that he and his colleagues want to ensure the highest level of data accuracy possible in pursuing these initiatives.

Meanwhile, Heidenreich told the audience, “We are making use of an analytic model that leverages claims data, some demographic data points, and a 12-month history” of plan members, through a solutions provider. Where he and his colleagues would like to get, within the next 18 months, he said, is a “future readmissions prediction model based on existing data, plus timely clinical transactions.” And, he said, he and his colleagues would like to be able to leverage social determinants data from clinic notes, using capabilities provided by the Reliance eHealth Collaborative capability, to help inform care management, as well as to receive alerts at the health plan, and to have the HIE alerting providers, as appropriate, to changes in status of plan members/patients.

Connecting Social Service Agencies through HIE

Ohanian and York, from 2-1-1 San Diego, a social services organization in San Diego, shared some background on what 2-1-1 organizations are, and on their organization’s expanding portfolio and initiatives. As York noted, the attacks of September 11, 2001 spurred the creation of 2-1-1 organizations, which make use of the telephone number “211” as a non-emergency number that can connect residents of particular communities with needed social services. “In 2001, the necessity for 2-1-1 being available, post-disaster, became very evident,” he said. “And as a result, over 200 emergency lines opened up in New York after 9/11. Having a single place too call was deemed important. So 2-1-1 lines were set up across the country. Fifty percent of those lines were run by United Way; the other 50 percent are standalone non-profits. We’ve created a variety of programs in San Diego. We’re working across the country for 100-percent coverage,” with “over 90 percent now” already, he noted.

What makes 2-1-1 organizations so valuable to their communities? “We’re trusted, non-profit, confidential, and stigma-free, and we operate a 24/7 service, with a 3-digit dialing code that’s easy to remember,” York said. Meanwhile, 2-1-1 San Diego is an organization that services 400,000 contacts and connections per year, and is engaged with more than 1,200 service provider organizations. It provides services in over 200 languages, via tele-interpreters, with English, Spanish and Cantonese the main internal languages available. And it prides itself on a customer satisfaction level of 92 percent, and a 98-percent referral accuracy.

Among the overall types of programs that 2-1-1 San Diego offers: food insecurity benefits and enrollment (in coordination with SNAP, Medicaid, and CoveredCalifornia programs); Courage to Call, a clinical intervention program for veterans; health navigation programs to help resident access health insurance and discharge planning, etc.; and a strong role in disaster and fire response services.

“Providers are trying to get a grasp on the social determinants of health,” York noted. “And I’ve noticed, with many of the HIEs, you layer on different services, like privacy/security aspects and identity management. So where does the social service data belong? That can be another partnership.” What is exceptionally important, he said, is “connecting the dots to create a social snapshot of a client’s situation, and matching that with a database of social service providers and referrals,” York said; and that means “connecting with a local provider and a community information exchange, and figuring out what kinds of information can be shared. Social service providers are already doing that work, and we’re already experts in connecting the dots around social services,” he said. In that regard, going forward, it will be important for organizations like 2-1-1 San Diego to collaborate with HIEs in order to help provide coordination across various environments, including for healthcare providers.

Ohanian and York were joined by Daniel Chavez, executive director of San Diego’s HealthConnect, and a 2-1-1 San Diego Board Member, in sharing perspectives on the partnership in San Diego as a model for merging social and health data and leveraging existing community infrastructures. Ohanian and York detailed what 2-1-1 organizations are, and on their organization’s expanding portfolio and initiatives.

Right now, Ohanian said, 2-1-1 San Diego’s Community Information Exchange is linked to San Diego’s HIE called San Diego Health Connect reminding health care professionals there is additional social factors and individual client information available in the Community Information Exchange. Future client data integration and referral pathways are under development.  

Meanwhile, Ohanian and York agreed, health information exchange will become increasingly important in connecting traditional healthcare providers with social service providers like the 2-1-1 organizations.

And all of those participating in both panels agreed that the kinds of social-determinants data that HIEs can appropriate share, when combined with traditional healthcare data, can accelerate the work that all the different types of organizations are engaging in, in order to improve the health status not only of individuals, but of entire communities.


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Manifest MedEx CEO on the Path Forward for HIEs, and Connecting Healthcare in California

January 14, 2019
by Heather Landi, Associate Editor
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Williams projects that every hospital and health system in the state will be connected to an HIE in the next 18 months
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In the past two years, Manifest MedEx (MX), now the largest nonprofit health data exchange in California, has rapidly grown after being formed as the result of a merger between San Francisco-based California Integrated Data Exchange (Cal INDEX) and the San Bernardino-based Inland Empire Health Information Exchange (IEHIE) back in 2017.

With offices in Northern and Southern California, the HIE facilitates the secure exchange of 11 million patient claims records and 5 million patient clinical records, and is on a mission to connect healthcare in California.

At the time of Manifest MedEx’s launch in 2017, and as reported by Healthcare Innovation Editor-in-Chief Mark Hagland, the merger combined the 11.7 million claims records from Cal INDEX founding members Blue Shield of California and Anthem Blue Cross with the 5 million clinical patient records of IEHIE and its 150 participating partners.

At the same time, it was announced that Claudia Williams, former White House technology senior advisor, was tapped to lead the new organization as CEO. At the time of the announcement, Mark Savage, chairman of the Cal INDEX Board of Directors and director of health information technology policy and programs for the National Partnership for Women & Families, said of Williams: “Claudia is the ideal candidate to lead this new entity. She is a strategic and transformational leader with national experience managing and scaling health information exchanges. With Claudia, California’s statewide HIE gets the rare combination of breadth and depth.”

The HIE has grown, and the network now has participation from more than 200 healthcare organizations, including more than 80 California hospitals, and five of the largest health plans in the state—including Blue Shield of California and Anthem Blue Cross of California. Just in the past year, Manifest MedEx has added San Diego-based Scripps Health, Stanford Health Care and AHMC Healthcare, a network of seven affiliated hospitals in the greater San Gabriel Valley, to its network, as well as Heritage California and Hill Physicians, two of the largest medical groups in the state.

In an interview with Healthcare Innovation Managing Editor Rajiv Leventhal back in March 2018, Chris Jaeger, M.D., vice president of accountable care innovation and clinical transformation at Blue Shield of California, called Manifest MedEx “a key foundational effort” leading to value-based care. “Creating an infrastructure that can be this HIE 2.0, if you will, [could be] the foundation for value-based care that can support population health efforts and drill down to the personal level as patients migrate through their life. That’s critically important,” Jaeger said.

In another recent development, the California Department of Health Care Services secured $45 million in federal funding and $5 million in state funding to invest in HIEs throughout the state and the funding will be used to help onboard providers to California information exchanges.

Recently, Williams spoke with Healthcare Innovation Associate Editor Heather Landi about the HIE’s growth in the past two years, the organization’s strategy to provide value to network participants and the path forward for HIEs.

How would characterize the growth and progress of the HIE in the past two years?

We’ve seen incredible progress on several fronts; the first is delivering valuable products and services to our participants that will help them succeed in value-based care. Over the past year we have transitioned to a new modular technology platform, integrating best of breed components from InterSystems, NextGate, Audacious Inquiry and others. We are delivering three value-added services—one is real-time notification alerts (MX Notify); second, the longitudinal health record of patients (MX Access), and in Q1 2019 we will include not just clinical data but also claims data; and third, this quarter we will be rolling out an analytics platform (MX Analyze) that will provide a tool to risk stratify patients and identify care gaps. That delivery of robust, scalable products on a solid technology base has also led to real success in growing our network. We’ve added Stanford, Scripps, Heritage, and AHMC. Those systems are leaning heavily into new forms of care and population health, and I think getting a robust stream of data, reflecting clinical as well as claims data, is incredibly appealing to them.

Claudia Williams

As a result, the network is driving measurable results reducing readmissions and ER usage. As one example, we are working with a large ACO in the Inland Empire, and they have posted measurable changes in seven-day visits after discharge, readmissions reductions, and ED visits, using our HIE services. This is an example of MX products supporting a concrete, effective workflow that succeeds in reducing ED, reducing readmissions and getting patients into care more quickly once they get back in their homes.

In building out your organization’s value proposition, what is Manifest MedEx’s strategy?

We are keeping our attention very trained on the health systems, medical groups and plans that are building out new value-based models because there is a lot of demand for information sharing in those models. Within that, we’ve evolved to focus on who the most intense users of HIEs are going to be, and in our view, it’s the senior VP of population health. On a more daily basis, it’s the care managers, care coordinators and discharge planners who are trying to build connective tissue between their clinical entity and others that are caring for that same patient. I think the average clinician in practice finds value in what we do, but it’s really in those intersections, where a group of people are trying to be accountable for that patient population where we see the deepest and most valuable use.

In March 2018, Blue Shield of California announced it would require network providers to participate in the Manifest MedEx network. What levers do you see health plans using to expand health information sharing?

I’ll cite an example in the Inland Empire, we work closely with Inland Empire Health Plan, which is a leading California health plan and the biggest Medi-Cal health plan in that area. As they look at the key challenges that they are having internally, which includes reducing readmissions, increasing care coordination, increasing their HEDIS scores, as well as doing things like improving the prior authorization experience for both patients and providers, they realize that the data that MedEx is providing is incredible and crucial to that. And, we all recognize that it’s a lift to connect to an HIE, it takes time and energy of your technology team, and your project management team, and they have many tech priorities that they are trying to juggle at once. What Inland Empire Health Plan did was they said, our pay for performance program for hospitals, we’re going to portion a piece of that to incentivizing hospitals to connect to MedEx. [Editor’s note: Inland Empire Health Plan pledged $6 million in incentives to regional hospitals that participate with MedEx and use its services in 2018.] There are actual data sharing requirements built into that incentive program, and as each hospital hooks up their system with ours and sends various types of data and results, such as ADT alerts (admit, discharge, transfer), they are eligible for a substantial financial incentive to do that. We found that helps to move the project up the list. And that’s my hope for the approach the state will take in its $50 million effort, which is really to recognize the effort and time taken, especially by hospitals, and make sure that there is money on the table for them to connect to HIEs.

I’m excited by the kind of collaboration and partnerships we’re seeing, bringing together not just the clinical side of things, the providers, but also the health plans. We’re seeing those partnerships really gaining steam across the country for successful HIEs. And for me, it’s not just a question of what health plans can get from an HIE, but frankly what they’ll also give. In our case, they are providing substantial financial support and also claims data. Many HIEs have struggled with bringing in ambulatory data into the network, because it’s very time consuming and expensive to work with every single provider. So, when we have claims data that provides information—what were all the visits the patient had, what were all the hospital encounters the patient had, what medications are they on, what’s the full list of diagnoses for that patient—that provides a critical complement to the hospital clinical data that HIEs can get. The health plans being at the table, contributing financially and also contributing in terms of data, is going to be a real marker of our success and other HIEs’ success moving forward.

What makes California a unique market when it comes to HIE and interoperability efforts?

I actually think that we’re behind. It’s not surprising, given the size and the complexity of this market, but we estimate about half of all hospitals in the state participate in HIE efforts, and that compares to Maryland, where every single hospital, except the NIH clinical center, is a participant in their state effort, CRISP (the Chesapeake Regional Information System for our Patients, a regional HIE). I’m excited that the funding from the state will really set up a process and an expectation that every single hospital should come on board in 2019. Whether it’s with us or another HIE effort.

Let’s shift to policy and strategy, as you previously served as White House technology senior advisor. What does your previous experience bring to your current role at Manifest MedEx?

We really laid the policy track and the expectation track for technology to deliver on its promise of better care at lower cost. The work that I did that really dug into EHR (electronic health record) adoption, HIE programs across the country, funding, policy expectations, were the precursor tracks that were laid for our success in California.

I think one specific way my background really helped me is that I led the $500 million grant program that was aiming to accelerate HIE efforts in every single state and territory across the country. I had a front row seat to see what works and what doesn’t work. And what I saw that works is a very keen focus on delivering value to participants, and that comes from both the richness and breadth of the data network, and it also comes from a very keen eye on who should be using the services and to do what.

Also, what we’re seeing across the country is that it’s expensive and it takes a lot of expertise to effectively run the infrastructure that I’m talking about, and make it be as dependable and high quality as we all want. We’re seeing a trend towards merging of HIEs or one infrastructure supporting many communities. Maryland is one example, as that organization is now supporting HIE efforts in West Virginia, and D.C. and Virginia. I think to do this right, you need quite a sizeable, robust organization. The model we use is to share a common infrastructure across many communities but have local health information organizations, local HIOs that rally the local community, represent local needs and support participants in that community. We have three of those organizations in three communities across the state.

What are your thoughts on federal policy efforts, such as TEFCA (ONC’s Trusted Exchange Framework and Common Agreement), to spur information exchange?

We’re seeing that the federal government can play a massive role in accelerating the adoption and use of health information exchange, and TEFCA is one way to do that. But recently, CMS (the Centers for Medicare & Medicaid Services) released an RFI (request for information) asking for comment and recommendations on what could be done to accelerate information sharing, and we joined together with 50 organizations to submit comments suggesting that every hospital in the nation should be required to let community providers know when a patient leaves their doors. This is a well prescribed and well executed use case across the country; this basic idea that a primary care provider would be alerted, in real time, when their patient is seen and is discharged. There are HIEs and technology companies that can support this effort for every hospital in the nation. We recommended that become a part of Medicare, basically a requirement of participation in the Medicare program. We don’t’ know what will happen; we expect regulations on that matter. We had a great meeting with (CMS Administrator) Seema Verma, she has been making comments suggesting that is an area of interest for her, so we’d like to see efforts that are well prescribed and well adopted just become the expectation for how we deliver good care.

Looking ahead, what will the leadership team at Manifest MedEx be focused on?

I think it’s time that California come into the digital age by accelerating participation in HIEs across the state. I’d like to see MX play a lead role in making sure every hospital and health system is hooked up to us or another HIE. We have a 50 percent gap, so we have a lot of progress to make but I think with the mandate coming from value-based care, the additional funding that will be available through the state and federal government, as well as the kinds of robust, scalable services that we’re offering and that are really in high demand, I think we’ll get there over the next year to 18 months.

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Missouri Health Connection’s CEO Defends HIEs’ Value in a Competitive HIT Landscape

January 8, 2019
by Rajiv Leventhal, Managing Editor
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One HIE leader believes that health information exchanges fill a critical interoperability gap created by large EHR vendors

In Columbia Mo., Missouri Health Connection (MHC)—the state-designated health information exchange (HIE) network—has the motto of “One Connection for a Healthier Missouri,” and the organization’s senior leaders have taken to making that dictum a reality.

MCH was started in 2011 as an executive order by former Governor Jay Nixon as part of the HITECH Act. But once federal funding dried out, as it did for many HIEs across the country, MHC’s strategy needed to shift to remain sustainable in a competitive landscape. The organization hired Angie Bass—previously a health policy research analyst for the Missouri House of Representatives and a project analyst for the Missouri Department of Mental Health—in 2012 as program manager, but Bass quickly rose the ranks to become MHC’s president and CEO.

Under Bass’s leadership, MHC has become one of the nation’s largest health information exchanges, covering a territory of more than 69 thousand square miles and more than 22 million patients in its network. Bass recently spoke with Healthcare Innovation Managing Editor Rajiv Leventhal about MHC’s journey, the biggest challenges that exist today for HIEs, how the organization is providing value for its members, and more. Below are excerpts from that discussion.

Can you give me a brief history of MHC? How was the HIE formed?

We were started in 2011 under the original ARRA/HITECH funding. We organized as a private 501(c)(3), so we used $14 million in federal [funding] to get ourselves off the ground with the initial infrastructure and onboarding [of participants], and we’ve been a self-sustaining organization and member-funded since 2014.

We waver between being the second and third largest HIE in the country based on the size of our master patient index, which is over 22 million patients, as well as based on the sheer geography that we serve. One unique thing about Missouri is that we have several large health systems that are headquartered in the state, but we also have facilities that are outside of the state, spread throughout the Midwest. We have providers in all the states that border Missouri, up to Wisconsin and down to Louisiana. So even though we predominantly serve this state, we do have a Midwestern focus as far as the geography and territory that we do and intend to serve.

We have more than 80 hospitals and hundreds of clinics, and since we have so many integrated delivery networks and health systems, that means we have all of the ambulatory clinics and facilities that go along with them. So, that’s thousands of physicians and even more practitioners that have access to our HIE services, either through an integrated query-based interfacing, our clinical portal, our push-based alerting, or through public health. We have a variety of services, and we have thousands of [participants] who can actively receive real-time information on patient data.

What kind of data is currently being exchanged via your network?

The quality of data is our highest priority. The type of data being exchanged includes everything in ADT [admission, discharge, transfer] feeds [using HL7 standards], as well as in continuity of care documents [CCDs]. And then we have some public health interfacing for meaningful use. From an HIE perspective, we can transact anything.

The limitation is not on our ability to be interoperable between disparate systems, but [rather] the limitation is the vendors being able to export the data out of their own systems, and then allowing the customers they are serving—the healthcare providers—to be interoperable.

For instance, the meaningful use certification around what should be included in a CCD is not the entire patient record; it’s just a subset of data. The meaningful use certified version doesn’t include the critical pieces of information that most every clinician wants, such as discharge summaries, notes, and H&Ps [histories and physicals]—all the things that are very relevant and necessary for good care coordination and transitions of care.

What we have been very focused on in the last 18 months is going back to each of our data contributing participants—so everyone who is giving us an ADT and everyone who is sending us CCDs—and expanding those interfaces so that we are getting the most robust data. This [involves] going back and working with them to see about how we can extract the most data out, such as going back to a raw ADT feed and adding in those notes and other content that’s necessary. Sometimes that’s challenging, not necessarily because it’s the healthcare providers pushing back, but the vendors who are pushing back.

This speaks to the HIE’s value proposition. Can you discuss that further?

One of the things we always stress is the niche that an HIE serves is doing the data normalization of disparate systems. So, being able to extract from one EHR [electronic health record] and normalize the data in a way that makes sense for another EHR vendor to ingest. Inherently, the EHR vendors are not incentivized to do that with each other on their own, though through CommonWell and Carequality, that is what [those associated vendors] are portraying as the goal of that relationship. But it isn’t happening in the real world; it’s not happening form urban to rural, from acute to ambulatory, or between behavioral health and post-acute care. That’s why an HIE is necessary.

Meaningful use [regulations and incentives] left out post-acute and behavioral health providers, meaning none of the EHR vendors [in that space] need to be meaningful use-certified, so they are playing catch-up. That has been devastating to the industry from an interoperability perspective. Where are the vendors stepping up to help serve [these providers]? But the HIEs are; they are helping these providers with transitions of care as they move onto EHR systems.

HIEs are, for the most part, vendor agnostic, not-for-profit vendors that are truly doing a community good and service for providers that need to be interoperable because not everyone will be on an Epic or Cerner EHR. There are going to be those specialty and rural practices that need all the help they can get from a health IT perspective, and that’s what an HIE is there for: to be the intermediary for state agencies to interact with HIEs, and also with the federal government.  

We are very focused at the community level, while SHIEC [the Strategic Health Information Exchange Collaborative] and other organizations are doing great work in trying to work with Congress and the state governments to bring awareness about the need for HIEs and the value they serve for the public and private sectors. We are competing against those large EHR vendors that are aligning for their own self-interest needs. And that’s kind of how the game is played, but we aren’t going anywhere. I am confident about that.

How is MHC handling issues such as patient consent?

Here in Missouri, we don’t have any state mandates on the books regarding actual patient consent for HIEs one way or the other, but we have chosen to be an “opt-in” model based on certain laws that are on the books regarding specially protected information that goes above and beyond 42 CFR Part 2 data and other HIPAA requirements. So we choose to be super conservative when it comes to patient consent. But it does need to be addressed at a federal level. We need to bring technology and consent into parity. We also need to make sure that wherever that clinician lands, wherever parity exists, that the vendors can support it.

How are federal policies such as TEFCA (ONC’s Trusted Exchange Framework and Common Agreement) playing a role in your operations?

The first draft of TEFCA did not take into consideration these vendor requirement pieces. It’s all the HIEs’ responsibility to make sure they can transact every specific piece of data, but there is no teeth in requiring the EHR vendors to be able to send that data out to an HIE, without charging their customers an obscene amount of money for an additional interface cost. So I think the intention of TEFCA is good to increase interoperability on a national scope, but I think the framework on the initial release was flawed.


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Across the Care Continuum, Improving Patient Matching Capabilities Has Become Paramount

December 13, 2018
by Rajiv Leventhal, Managing Editor
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Combining its internally developed “common key” service with a big data MPI platform, MiHIN is uniquely identifying patients at a much higher rate than ever before

Patient matching—the ability to accurately link all of a patient’s health data within and across health systems—has been a challenge for the healthcare industry for decades, and 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.

In a 2014 report about the issue, the Office of the National Coordinator for Health Information Technology (ONC) found the best error rate among healthcare providers is around 7 percent, though the error rate is typically closer to 10 to 20 percent within healthcare entities, and this rises to 50 to 60 percent when entities exchange information with each other.

And for health information exchanges (HIEs), the issue is often compounded as they specifically face a significant challenge with matching and linking patient identities because of the diversity and independence of the institutions they serve.

To this end, the Michigan Health Information Network (MiHIN)—a state-designated entity that facilitates information sharing among the state's numerous HIEs and hundreds of thousands of providers—has embarked on a major project: standardizing patient matching across all these different entities in the state.

Specifically, MiHIN officials said in an August announcement that the HIN uses the big data MPI (master patient index) from California-based clinical data exchange company 4medica, along with a private patient attribute or “common key” that links individuals and their health information across systems and organizations. The combined solution enables MiHIN to match patient identities in real time, officials noted.

Shelley Mannino-Marosi, MiHIN's senior director of state and national programs, says in a recent interview that in the early stages, MiHIN’s leaders were entirely determined to only aim for exact matching. “At MiHIN, and in Michigan, our goal is to get the right information about the right patient to the right care team member or provider at the point of care in near real time,” she says.

To help reach that goal, Mannino-Marosi points to one of MiHIN’s core services, its active care relationship service, or ACRS, which enables organizations to submit data files which record the care team relationships attributing a particular patient with health professionals at that organization. As Mannino-Marosi explains, this service enables a provider or payer to “declare” a patient, so that if something happens to him or her, such as a hospital admission, ACRS can be searched to see what providers or health plans have declared that relationship with the patient, leading to that stakeholder getting a notification.

Early on in the process, MiHIN’s staff would search the service and compare the demographics on an incoming ADT (admission, discharge, transfer) notification with the data that was stored in ACRS. “And we would look for an exact match only. We were very cautious in wanting to be extremely accurate and ensure we weren’t sending the incorrect information to the wrong place,” Mannino-Marosi says.

But over time, MiHIN’s leaders realized that there was a need to be more probabilistic. For example, Mannino-Marosi offers that if a patient’s first name is Bill and his doctor has already declared a relationship with this person as William, with the same date of birth, address and social security number, a computer can easily determine that Bill and William are in fact the same person. But with MiHIN’s early-stage patient matching system, the stakeholder who declared that patient would not receive this alert since the demographic information was not an exact match.

So what MiHIN did next was develop its in-house common key service that assigns a “key” or “ID” attribute to each patient. This information was funneled to the centralized MPI from 4medica, and then the common key, or attribute, is given back to the participating organization so that it could be stored in its system to add to any subsequent information, or to strengthen the matching that’s being done in ACRS. Essentially, explains Mannino-Marosi, “the common key becomes a shared attribute that MiHIN’s participating organizations could use to talk to the HIN or to one another.”

When used in action, 4medica’s big data MPI and the common key service can now determine with certainty that even if there’s just a bit of a difference in demographic information, the inbound ADT message is in fact talking about the same patient that the doctor cares about, Mannino-Marosi attests. Gregg Church, president of 4medica, adds, “It’s a guaranteed match even though the demographic change is in there, as we know it’s the same person based on everything that’s being looked at and scored against on the historical information.”

Notably, Mannino-Marosi contends that the common key service acts as a “gatekeeper” to the MPI and won’t automatically add information for patients when they don’t meet a certain threshold for the quality of the data. She explains that if the common key service queries the MPI and knows with certainty that a given patient is in the system, that unique attribute can be used. And at the same time, if the service knows that the person is brand new, he or she is assigned a new key and added to the MPI.

But where things can get tricky is the “middle zone” where it’s too close to call and the computer, as configured, isn’t 100 percent confident. “In that case, we will not assign a common key and will [instead] provide an error message back to the organization,” says Mannino-Marosi. That way, the cleanup of the data is also shared across the state, so the burden of data stewardship is spread out and everyone benefits from the data cleansing activities—as opposed to the person being added to the MPI and potentially pulling redundant information, she adds.

When it comes to evaluating the results of this system, Mannino-Marosi points out that some patient matching companies will boast about 100 percent or near 100 percent matching, but the criteria they are using to match is a grey area. For MiHIN, she notes, one key measure is how many unique identities they have been able to assess in Michigan. “Over a year-and-a-half, we have been able to uniquely identify nearly 8 million of the 9 million Michigan residents, and that number is of course growing,” she says.

Beyond that, another massively important metric to measure is if MiHIN can send more information to more care team members as a result of the service. “If I have three members of our care team but just one is notified, that doesn’t achieve our mission to ensure we’re getting the right information where it needs to go so that a singular patient’s care can be coordinated cost effectively and quickly,” Mannino-Marosi says. But by using the common key service with the 4Medica MPI, MiHIN has been able to send out well over a million more ADT notifications per week. “That’s very significant,” she asserts.

It’s important to note that the common key service from MiHIN is unique to Michigan, and other organizations that do not develop their own unique identifiers are using patient matching solutions—such as 4medica’s big data MPI—in a more conventional manner.

One such entity is the Nebraska Health Information Initiative (NeHII), a statewide HIE that is using the solution to assign unique patient identifiers to patient identities and to match incoming patient data to the right master patient record. According to Jamie Bland, NeHII’s CEO, because her HIE is a qualified clinical data registry for quality reporting purposes, it needed a robust solution that would be able to match patients across various complex data sets. The goal at NeHII, Bland says, “is to grow a true population health repository that matches patients. We can do better population health management and that starts with the identity matching aspect of data management.”

Currently, NeHII collects data from nearly 70 different hospital sources, and more than 200 sources in total across the state and region, says Bland. And because different hospital electronic health records (EHRs) have different matching algorithms for how they match patients, the level of complexity meant that the HIE needed to prioritize identity matching as it continued to grow in the diversity of data it was collecting.  

Bland says that the idea is to marry clinical data, along with claims data and PDMP (prescription drug monitoring program) data so that a population health utility is created. “That’s the last mile of interoperability,” she says. “We are here as a public service to assist in improving identity matching across the state so that we can build a population health infrastructure to make that a solid suite of applications that’s available through the HIE.”

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