Those tasked with implementing a statewide health information exchange (HIE) in New York recognize they face a tall order. When a state has the third largest population in the country, piecing together everyone’s electronic medical information is not destined to be a walk in the park under any circumstances.
When you add in the challenges of federal incentive programs from the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA/HITECH) Act and the transformation of healthcare from fee-for-service to an outcomes-based care model, it gets even more complex. Once the federal government released the multi-billion incentive program, things became chaotic with standards committees trying to catch up with a fast-growing industry, says David Whitlinger, executive director of the New York eHealth Collaborative (NYeC).
NYeC launched the first version of SHIN-NY (Statewide Health Information Network for New York), New York’s statewide HIE, in this fast-moving context. NYeC, a public-private partnership between several HIE stakeholders, has served as the leader of New York’s SHIN-NY effort since its establishment in 2006.
With the establishment of 12 regional health information organizations (RHIOs), each self-governing the HIE within a certain area, SHIN-NY got off to a quick start. The establishment of several features, such as patient-record look-up added to the network.
However, it wasn’t perfect. For one thing, the HIE wasn’t stitched together as well as NYeC would have liked. While upstate RHIOs for the most part didn’t consider patients going to medical facilities in different regions a problem, downstate RHIOs did. Many patients overlapped RHIOs, going to medical facilities in Westchester, Long Island and New York City. Workflow issues also became the major source of feedback for users of SHIN-NY 1.0. The HIE wasn’t in a good location for physicians to access it at the point of use, forcing the clinicians to switch between HIE and EHR screens.
For the second iteration of SHIN-NY, NYeC attempts to fix those issues while adding new features. The biggest thing to come out of SHIN-NY 2.0 is EHR/HIE interoperability, which NYeC, other states and vendors collaborated on to create a standardized single interface that addresses the aforementioned workflow issues.
Healthcare Informatics Assistant Editor Gabe Perna sat down with Whitlinger for an exclusive interview to discuss some of these issues, solutions and the lessons they learned from SHIN-NY 1.0, as well as what the future holds.
What were some of the lessons you learned from the first iteration of SHIN-NY?
SHIN-NY 1.0 was really ‘New York,’ with some really forward-thinking legislators who took taxpayer dollars to get started on HIE and HIT, because they really felt it would be transformational. What happened after that was the federal government, through CMS [Center for Medicare and Medicaid Services] and the ONC [Office of the National Coordinator for Health IT], put out a multi-billion dollar health IT ARRA program.
That really changed the whole set of market dynamics around SHIN-NY 1.0. SHIN-NY 1.0 was trying to slog it out with a set of rudimentary vendors, without a lot of interest from the vendor market to collaborate or build interfaces. Here comes a $50 billion-dollar injection into the marketplace with meaningful use dynamics, ACOs [Accountable Care Organizations] and a whole set of other things. It’s almost as if they are night and day problems.
The things we were able to take out of SHIN-NY 1.0 were the workflow issues and the integrated issue, that New York isn’t a big enough state to move a vendor market. Those are two key principles that we are applying in 2.0. To be frank, we’re really trying to harness all of the great creativity and opportunity that healthcare IT innovation is now exploring for the new care delivery models and harness that rather than try recreate the wheel with taxpayer dollars.
How have you been able to get healthcare organizations on board with the HIE thus far?
It really depends on the organizations, and it depends on really a couple of factors. One is size of the organization, depending on the resources they have to provide.Second is where they sit in the healthcare eco system. If they’re really affected by the lack of data, such as those in primary care, they’re a lot more receptive to wanting to receive or share data. Hospitals are receptive. Those that benefit from it are leading the way. The ultimate driver is when the payment reform system, when the fee-for-service model is the minority, and outcomes/collaborative based healthcare is the majority, that’s when it’s a given. That’s when it becomes like a public utility, like your gas or electric bill, a necessity for you to do your job.
Talk about the challenges of piecing together an HIE for New York, because it really can be divided into two states: upstate and downstate. How difficult is that challenge?
There are two different New Yorks, and you can throw in New Jersey as the third as well. We had to acknowledge and embrace early on that one size does not fit all. We were not going to build a network that had complete solutions for all, because healthcare is different upstate and downstate, and the communities are different. We believe we’ve created a technical architecture that not only supports autonomy for those upstate who want that, but still supports participation in the statewide network and then consolidation, the ability to maximize a set of infrastructures in the downstate region. We think we’ve created the flexible model. Obviously, time will tell. A lot of thought went into that.
Were there any other HIEs that you could learn from and use as inspiration?
Not really. We are probably forging new territory here. Of the states that have (developed statewide HIEs) they’re all very small. In Vermont there are 800,000 people. That’s not even half of a borough in New York City. With Rhode Island, it’s similar. They don’t have the same kind of problem. You could almost get all of the hospital CIOs from Vermont in the same room. You couldn’t do that in New York, of course. The other states that have similar characteristics as New York – California, Texas and Florida – and those states aren’t at the same place as New York. That’s largely because of the prior investment New York has made.
Where do you see SHIN-NY going forward in the long-term?
We really make it something that the healthcare community doesn’t consider a cost or expense but just as something that is the cost of doing business and that the data liquidity is a given.
Is a nationwide HIE a possibility?
There are too many differences in healthcare delivery, too much difference in state laws.