Philadelphia, not unlike many other major cities, is a metropolis with several overlapping health systems. Richard Snyder, M.D., senior vice president and chief medical officer at Independence Blue Cross (IBC), refers to it as a “virtual Venn diagram of health systems on top of each other.”
What’s more, unlike some cities where there is a predominant health system that encompasses a big portion of the population and can build its own health information exchange (HIE), Philadelphia does not resemble that, Snyder says. “It has a lot of health systems, so you have that issue which makes it complicated since they all compete for doctors. They are working on an electronic medical record (EMR) that the hospital uses and in some cases acts like a little like an HIE, but only for that system—not for others in the region,” he says.
Additionally, as physicians continue to take on more and more risk in the new healthcare, they are starting to now realize that half of all admissions occur in a different hospital than the original incident’s hospital, Snyder says. “So if I drive to Penn Medicine for surgery, then late at night I am 20 miles from home but still in Philadelphia, they will take me to the nearest hospital, rather than to Penn,” he says. “Also, if you have a couple of chronic conditions, chances are you’re getting care in more than one system. The systems don’t talk to each other so the records don’t get transported back and forth routinely. There is a recognition that we have to work together, but there is no way for each of us to build a robust HIE that fit sour needs and our patients’ needs since they’re going to different systems.”
Richard Snyder, M.D.
As such, several years ago, Snyder’s peers at IBC, along with other payers in the area, knew something needed to be done. “We’re not cutting down on readmissions or complications, and we need to share information with each other. We knew we had to build an HIE. All of a sudden, it’s very important for us to have real information available at the point of care. There is no way to get that in the EMR unless you have an HIE,” he says.
As a payer, of course, IBC has exact information on which physicians patients are seeing, as they get a claim for every occurrence. “We know where patients are getting care,” says Snyder. “What are the chances that when a patient walks into the ER, that he or she will tell the person helping them at registration all of the physicians and all of the facilities he or she has been to? They will say one name; it’s all you have time for. Now when it’s time for a discharge summary to those doctors who will care for that patient, they have no idea where to send it to or where to get the records from. We as a payer know that information,” he says.
All of this was the impetus behind the creation of HealthShare Exchange (HSX) of Southeastern Pennsylvania, incorporated in May 2012, with its board and bylaws put into place in January 2013. Snyder, who is also chair of the HSX board, says that it’s the nation’s only exchange in a major metro area built on collaboration between insurers and hospitals.
State and federal grants were instrumental in the launch of HSX, which is now primarily funded by participation dues from hospitals representing more than 90 percent of admissions in the Philadelphia region and several major insurers. Currently, 15 hospitals are signed on, though Snyder says that 37 health systems in southeast Pennsylvania have signed a letter of commitment documenting their desire to participate in HSX. Further, he notes, two mental health facilities are signed on as well as a few federally-qualified health centers (FQHCs).
A Unique Business Model
Snyder says HSX is providing a master patient index that links patients to all their physicians and places they get services, so that whenever a patient leaves the ER or a specialist, at the press of a button, a discharge summary comes to HealthShare. “We will look it up and attach copies to all the doctors so everyone is in the know and has all the information. That just doesn’t happen in most places,” he says.
The idea was to get the knowledge of where to ask for records and send records to, Snyder continues. “We also collect lab results, we know claims history, so we know what physicians they see, what diagnoses there are, and what procedures have been done. We summarize that into a clinical care report, which is all we know about you, and can include up to four years of history on a patient. We make them into individual PDFs that are readily available,” he says. What’s more, if a patient goes to the hospital or ER, the registration person will put the patient’s information into a form, and an admission, discharge, or transfer (ADT) message is sent to HSX, which looks it up, and then sends a report back to the ER or the hospital’s admitting doctor. “It’s a powerful tool for the physician to take care of the patient,” Snyder says.
In April, the first month in which ADT messages were live, Snyder notes, some 480,000 such messages were passed through the system. However, he adds, not all physicians are pleased with the influx of information. “The early adopters, those who have been using it the longest, are very much interested in the value of the exchange,” Snyder says. But there is another generation of physicians that say, ‘Wait a minute, you’re telling me that when I turn on the phone in the morning, there could be 50 messages for me? Who will be responsible for them?’ But this means there is more information flowing through the system, and it’s our job to turn the data into actionable information for doctors. We will continue to do that,” he says.
Snyder says that while sustainability is the biggest barrier to health information exchange, HSX has a model that is indeed sustainable. Although most HIEs start out with query-based exchange, where there is a database full of data and you can look into it or ask for information from it when you need it, Snyder says that was not preferable in the case of HSX as it would be hard to build and maintain an accurate database in a big metro area—as well as very expensive. “We also didn’t think it would grow as quickly. If I am feeling nervous about treating a patient I know nothing about who’s in the ER unconscious, and I can receive clinical information about that patient to help me help inform me about how to care for [him or her], that would be just awesome. Physicians value that,” Snyder says.
Currently, HSX serves the five counties of Southeastern Pennsylvania, and that’s the primary goal, says Snyder. But 25 percent of admissions to the city’s academic centers are coming from South Jersey or Delaware, outside the region, he says. As such, HSX has been getting inquiries from providers in those areas to be connected, as they want access to that information that’s generated in the Philadelphia market and could go back to them, Snyder notes. “We have discussions going on and I think you will see that we’ll connect to other HIEs so information can flow better to and from,” he says.