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Micky Tripathi Explains the Second Phase of Mass HIway

February 4, 2014
by Gabriel Perna
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Micky Tripathi

Micky Tripathi is a perpetually busy man.

When the president and CEO of the Massachusetts eHealth Collaborative (MAeHC) is not busy strategically leading a nonprofit organization that has helped multiple organizations, including several regional extension centers (RECs), deploy electronic health records (EHRs) and achieve meaningful use, he is serving on an array of boards and committees, including the Information Exchange Workgroup of the HIT Policy Committee.

Recently, Tripathi was in attendance when the second phase of the Massachusetts health information exchange (HIE), the Mass HIway, was demonstrated at Beth Israel Deaconess Medical Center in Boston. The event was attended by Massachusetts Governor Deval Patrick.  The Massachusetts Executive Office of Health and Human Services (EOHHS) and Massachusetts eHealth Institute (MeHI) selected MAeHC to provide advisory services for the design and launch of the Mass HIway.

The second phase involved the release of a query feature that allows providers to locate, request, and retrieve medical records from other participants on an interconnected system. Tripathi recently spoke with Healthcare Informatics’ Senior Editor, Gabriel Perna, on the second phase of the Mass HIway, what it entails, how it’s different from other query technologies, the question of HIE sustainability, and what’s next for the Massachusetts HIE.

Below are excerpts from that interview.

Explain the new developments with the Massachusetts HIE?

The first phase went live in October 2012, and it enabled the Direct-based push of messages and documents among participants. There are 57 participants who are live on that Phase 1 service. They are able to send documents, data, whatever they want, over the HIway to another provider. What Phase 2 enables is kind of the reverse, which is a query – the ability to identify where a patient’s records are with the patient’s permission, and then being able to retrieve those records from other providers.

How does this retrieval system work?

It’s got two layers. One is the creation of a statewide relationship listing service, and what that will do,   with your permission, is it will list where you have records. That’s the first layer, and it’ll create that on an ongoing basis, based on the permission you’ve given to each of the legal entities that has records on you. If you give them permission to publish on this secure website that you have records with them, then it will publish that. It’s a master-patient index, with a listing of where records are available.

The second layer is the ability to query those organizations that have records and be able to get something back. That’s a separate layer. The first part is just where those records are. That on its own is valuable. If we didn’t even have the second piece, it’s still valuable that if you show up in emergency room, they can look up your name and find your records in three places, and be able to call up, say, your primary care physician. That still provides value to the market that isn’t there today.

With the point-to-point query, it doesn’t necessarily invoke the Mass HIway, because the provider that is making the request knows where the records are if they want to generate a request.  There is no repository, unlike other HIEs, of clinical medical information. The only repository is the listing of the patient and where the patient has records. The queries are done directly to the organization that holds the record and that organization has the ability to determine how they are going to respond.  

Without the repository, how is that information going from one provider to another?

One thing we’ve tried to do is have as much flexibility in the process as possible and not dictate, say, in order for an organization to use this service they have to do it according to [various] standards. Right now, there are no federally sanctioned standards for query and retrieve. We’re hoping in Stage 3 of meaningful use we get there, but we’re not there.

So what we showed, for example, in that demo is that Atrius Health (an alliance of medical groups based in Newton, Mass.) has a tight relationship with Beth Israel. They have a clinical affiliation with Beth Israel and they refer their patients there. Because they have built a lot of trust between those organizations, in that case, because they know it’s Beth Israel that’s asking, and they know it is a Mass HIway participant, they have a high degree of trust, and will allow Beth Israel a single sign onto its EHR. So Beth Israel is actually looking at the patient’s record in the Atrius EMR. In that case, no data actually flows, what flows is the credential to enable single sign on.

We also showed for Tufts Medical Center (Boston.) and Holyoke Medical Center (Holyoke, Mass.), they don’t have tight relationship with Beth Israel. In that case, Beth Israel actually sent a Direct message on the “patient,” with his consent, and a request to get his medical information. The medical centers reviewed it and sent it back. That query and response can be flexible according to the relationship that the requesting and the data holding organizations have with each other.  

How is this different than how most HIEs do query and retrieve?

The HIEs that have enable query and retrieve, I think the vast majority and all of the ones I can think of, have a clinical data repository to enable it. In Massachusetts, we’ve had the longstanding view, going back a decade, we don’t want to have a statewide clinical data repository. It’s a policy choice we as a community decided. In some ways, it’s taken us longer to do a query and retrieve, but now we feel technology business processes and market demand is appropriate to allow this creation of point-to-point query and retrieve, rather than force everyone to have a federal data repository.

Why is this the best route for an HIE?

When you look at federal data repositories, what we’ve seen in the market is participation is really slow going. Maybe a couple of organizations are contributing data, but the vast majorities aren’t. They feel discomfort with a model where they are supposed to send their data to a repository that’s controlled by someone else. And now as we’ve seen with the Omnibus rule, the penalties for breaches have gotten so much higher, people are more and more concerned about that kind of model.

 When it comes to sustainability, how do you sell the value of this HIE to providers?

I don’t want to overlook the fact we’re fortunate to garner Medicaid HIE funding to help with sustainability. We were the first state to get the 90/10 funding from federal Medicaid (as part of the Health Information Technology for Economic and Clinical Health Act, 90/10 provides core funding every year). Medicaid saw what we’re doing would benefit Medicaid from a business perspective. For the increment we have to fund, because the way technology works and how we’ve made it flexible to various technical and policy approaches, we think that gives it much higher prospect for sustainability over the long run.

What are the next developments for the Mass HIE?

Adoption, adoption, and adoption, and execution.  What we did (recently) at the demo was show everyone that the technology is in place at the HIway for organizations that are ready to do this. As we tried to be clear at the demo, now we to get need to get provider organizations to want to do it. It’s one thing for them to be interested, it’s another thing for them to pay dues and get their technical and business people to make it a priority. That’s the next phase of work. That will take a 1-3 year trajectory.  

What we’ve tried to be careful about is not overreaching and trying to do too many things. There is a huge temptation to do that. With the way the federal funds were structured, because of the time limitation, there was a temptation for a lot of places to cram in as much stuff as they can. We’ve tried to say, “the simple stuff is hard enough, let’s just focus on the simple stuff and really make sure that’s working before we get fancy.” That’s why we only had two announced phases. There are no more phases in the Mass HIway.

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