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Industry Expert: New-Model HIEs Must Add Value

July 23, 2014
by Rajiv Leventhal
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Dignity Health’s HIE expert talks data exchange strategies, challenges
Ryan Stewart

Sharing data in the new healthcare environment is critical to taking on more risk and improving the quality of care delivered. As such, the new health information exchange (HIE) network model is more than the exchange of information. It’s about leveraging that infrastructure to use insight and data to support clinical decision-making, improve care coordination, and make processes more efficient.

In 2007, Dignity Health, the San Francisco-based health system with facilities in 21 states, started its HIE journey with a small pilot in Sacramento. Today, the health system has one of the largest private HIE networks in the country, with more than 7,500 providers across 13 separate instances of private HIEs.

On Aug. 19-20 at the Washington-based Seattle Marriott Waterfront Hotel, Ryan Stewart, director, health information exchange at Dignity Health, will discuss how to improve care coordination with data exchange during a panel session at the Health IT Summit in Seattle, sponsored by the Institute for Health Technology Transformation (iHT2). (Since December 2013, iHT2 has been in partnership with Healthcare Informatics, through its parent company, the Vendome Group, LLC.)

Separately, Stewart recently spoke with HCI Associate Editor Rajiv Leventhal to talk about Dignity Health’s HIE journey, strategies to follow for effective health information exchange, the difficulties involved with data exchange, and more. Below are excerpts of that interview.

How has Dignity Health progressed with health information exchange?

We started on our HIE journey in 2007 with a small pilot in Sacramento. Since that time, we have been deploying HIE-related services and standing up private HIEs for almost seven years. The pilot in 2007 involved delivering discrete, unsolicited results from our five acute hospitals in Sacramento to two primary care provider’s electronic health records (EHRs). Now, we distribute and share clinical data via several different methods. One of those ways is Direct—from our HIEs we build interfaces into the community doctor’s EHR, and as long as the [system] is capable of reporting unsolicited results, we will integrate with them. For those providers who have not yet implemented an EHR—and those numbers are decreasing—and for those who are not ready, we serve up those same results via a portal. And the third way we are providing access to our clinical results to outside organizations is via query-based exchange through the Healtheway eHealth Exchange.

How are you leveraging HIEs to achieve population health management?

We’re currently in the process of finalizing our selection of a population health solution and moving forward with that implementation. However, we strongly believe our HIE will serve as the foundation for acquiring the data that is transferred into that population health solution to perform analytics. At this point in time, our belief is that the HIE’s role will be in moving the data from all the different disparate platforms into the population health data warehouse and analytics package. And that’s the next step for organizations. Right now, we have been sharing information bi-directionally primarily for treatment and payment purposes. But the evolution to analytics and population health is really going to evolve into true care management.

What are Dignity Health’s strategies for data governance?

We have multiple levels of governance. Established at the local level, Dignity Health opens and operates 39 hospitals in three different states, and across the states we have geographic regions with pockets of hospitals, so that’s how we ended up with 13 instances of HIEs. At the local level, we have steering committees, responsible for prioritizing HIE implementation and effort, and providing overall governance and strategy for where they want to head with HIE. In addition, we have more of an enterprise level on top of that to focus on standards as far as how we’re deploying our HIE services. Part of that enterprise level of governance includes physician informaticists. At the local level, it includes executives such as CFOs, CMIOs, and other leaders in the market at those respective levels.

What are the biggest roadblocks to long-term HIE sustainability?

We don’t have the same sustainability challenges as local, regional, and state HIEs in regards to being dependant on participants and subscription fees to pay for the software and resource costs. Our HIEs have been funded by our hospitals as they realize the need to exchange data to provide better care for our patients.

We do run into challenges as we look to expand our HIEs and expand the level of service we provide as far as sending data into community physicians’ EHRs and extracting that data for population health purposes. Each one of those interfaces has a significant cost not only from the HIE vendor, but also from the EHR vendor. Sometimes those costs could be subsidized, but other times the community physicians have to bear some of those costs. And they’re not necessarily in a position to move forward with that.

Outside of Dignity, long term, a lot of these HIEs have been funded with state or federal level grants. As those grants have dried up and the grant money is disappearing, you need to continue to pay for ongoing maintenance and implementation. That’s dependant on participation and the HIE being able to demonstrate the value in ROI back to those participants who they are trying to get to subscribe. If they are unable to do that, they are certainly at risk of not remaining in existence.

What are other challenges you face?

We certainly see challenges with secure messaging. As most secure messaging is implemented within a portal associated with the HIE, it’s hard to sell physicians on the value of leaving the EHR and logging onto that portal to generate a secure message. Any successful implementation of secure messaging needs to be built into the EHR, and be able to correspond across EHRs. So if you have a primary care provider implement eClinicalWorks and a specialist who is on Allscripts, you need to figure out a way they can share secure messages between those two disparate EHRs rather than force the doctors to leave the EHR and log into the portal.

Additionally, we find that it’s not necessarily the providers who are the primary users of the HIE, but it’s instead their offices and support staff who are accessing it and retrieving the data on the behalf of them. I think that as technology evolves and HIEs are able to provide greater value, there will be a better opportunity to get the providers themselves using it.  

Some in the industry have said that HIE is too difficult. Do you agree with this?

Technically, the capabilities exist and have existed for several years. Certainly, there are challenges as far as funding and identifying resources with the right level of talent to continue the ongoing integration to expand HIEs and provide that value. But I don’t think it’s overly complicated. As standards exist, more and more organizations are adhering to those standards especially with the push for Stage 2 of meaningful use. It is really just a matter of resource and cost constraints, from my perspective.

So what are the essentials to getting HIEs to thrive?

HIEs need to determine where they could provide additional value beyond traditional result delivery. Organizations have figured out how to do result delivery pretty well—that has been in place for several years now. The next step is adding value to participants and subscribers. We think an opportunity is around notifications. For example, letting a patient’s primary care provider be notified or alerted when one of his or her patients show up in a hospital emergency department and also when they’re discharged.

At Dignity Health, we’re able to generate those notifications from our hospitals because we have the data required to do so. Where a local or state based exchange can really provide value is if they get the data from multiple organizations. Then they can really complete that notification service because primary care providers don’t necessarily know which hospitals their patients ended up at, and they may think they end up at the ones that their practices are most aligned with.  But of course, you can end up in the emergency department for any number of reasons, and typically you end up where the incident had occurred. That’s definitely an opportunity for HIEs to continue to provide value.


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