At a time when the broad survival of health information exchanges (HIEs) is in question nationwide, and a number of statewide HIEs are shutting down or in danger of doing so, a small number of such organizations are actually flourishing, among them HealthInfoNet, Maine’s statewide HIE.
The Portland, Me.-based HealthInfoNet has long been known to the readers of Healthcare Informatics; indeed, the magazine named the organization one of its Innovator Awards winning organizations in February 2011, and described its successes up to that date, in this profile.
But much has happened in the past four years, under the leadership of HealthInfoNet’s executive director, Devore (Dev) Culver. Culver and has colleagues have figured out how to keep their organization relevant, even as many other statewide HIEs struggle or even fold. In that context, HCI Editor-in-Chief Mark Hagland interviewed Culver in November for his perspectives, as Hagland prepared one of the Top Ten Tech Trends for the January/February issue of HCI, on HIE sustainability. Below are excerpts from Hagland’s extended interview with Culver.
Would you agree that there is a core sustainability problem for many HIEs nationwide right now, particularly for statewide HIEs?
Yes, I would agree. My best guess, reinforced by some discussions, is that fewer than 10 HIEs will remain within about two years. What I’m talking about are the so-called statewide HIEs. Officially, there were 50, one for each state, based on the HITECH [Health Information Technology for Economic and Clinical Health] Act. And that’s part of the problem; in fact, it’s a major part of the problem. The core issue there is that they never developed a reason to exist. You can do all the nice convening you want, but if you don’t create value, you won’t last.
Was some of what was created not truly needed?
I think part of what leads to success starts with the building out of consensus among diverse stakeholders, so that there is at least the potential for value. And so you know, when I think about our history, the work started in 2004, and we didn’t have an operational health information exchange until late 2008, early 2009. A lot of that time was spent raising seed money, which took a lot more time than I’d expected; and the other part was spent building a consensus on our purpose, including developing a fairly robust economic impact study. We started with some models developed in Oregon and used those models, using Maine data running through them. Maine has had an all-payer claims database since the late 1990s. They had started managing a discharge data set as early as the mid-1990s.
So we asked questions like, what is the potential for reducing redundant testing in the state of Maine? Long story short, in 2008, the analysis coming out of that indicated a $50 million opportunity. So if you’re going to run an exchange costing $6 million, then that potential savings alone would be a huge return on investment. And you know you’re not going to get it all; but you start to build a value proposition, and you go out and get commitment from some of your larger, more data-rich organizations. And we started with a demonstration phase, one that included data from 50 percent of the providers in the state. There’s the core question of critical mass—if you don’t get to critical mass fairly quickly within two or three years, so that you have 70 to 80 percent of provider or healthcare activity in the exchange, it will be very difficult. If I as a provider go to the exchange and don’t find something the first time—maybe I’ll go back a second or third time, but that would be it. So you need critical mass that’s sufficient that people will actually use it. And right now, as of November, 96 percent of the residents of the state of Maine are in the exchange. That’s pretty damned powerful.
And then other things have to start to happen; you have to get experience and demonstrate practical value. Last month, in October, in terms of people actively clicking into the portal from within their EMR, last month was our all-time high for the number of patients whose records were accessed—23,000. That’s almost a 70-percent increase over last year. We went live in February 2009. At the beginning, a good month was a couple of hundred clicks.
And this is another problem with health exchanges. For those that are portal-based and cause you to have to go out to them, as ours is, that feature automatically creates some hesitation, when I have to take extra steps in my workflow to use them. So you’d better be pretty sure that will work. An initial assumption of ours was wrong, BTW, when we thought it would be doctors querying, but it’s actually mid-level practitioners, physician assistants and nurses.
So that is one of the big mistakes that statewide HIEs are making?
They’re making a couple of mistakes. One, because the federal government said it was a good idea, it was assumed to be a good idea. If you haven’t done the work on the ground to build a constituency for this before creating it, you’re probably in trouble. And the other thing is that even ONC [Office of the National Coordinator for Health IT] estimated just how hard it is to put one of these creatures up. It’s hard—it’s hard work, starting from the challenge of becoming a trusted entity, to actually trying to build a business case. It’s hard work.