The year 2014 will be a make-or-break year for the Duluth, Minn.-based Community Health Information Collaborative (CHIC), which since 2011 has been the only state-certified health information organization (HIO) in Minnesota. Like virtually all health information exchanges (HIEs), CHIC benefitted from funds from the Office of the National Coordinator for Health IT to help it establish its core services. With much of that federal and state funding coming to an end, next year will be a test-bed for the organization’s sustainability.
(In the state of Minnesota, an HIO is one of two types of state-certified HIE service providers. An HIO is an entity that provides all electronic capabilities for the transmission of clinical transactions necessary for meaningful use of electronic health records; its counterpart is a health data intermediary (HDI), which provides the infrastructure to connect computer systems or other electronic devices used by providers, laboratories, pharmacies, health plans, third-party administrators and pharmacy benefit managers to facilitate the secure transmission of health information.)
“Next year we will find out if we are sustainable or not,” says Cheryl M. Stephens, Ph.D., president and CEO of CHIC, who notes that the organization has been 70 percent to 80 percent self-funded. She is confident that CHIC will reach its sustainability goal, and that it will be able to meet its growth projections.
In an exclusive interview with Healthcare Informatics, Stephens discussed the next steps for her organization, as well as her view of the challenges confronting HIEs nationwide.
Expanding its Infrastructure
In August, CHIC selected Orion Health Inc. to power HIE-Bridge that will give providers across Minnesota access to patient information via a secure Web-based information exchange platform. Orion’s HIE services for CHIC will include clinical information, medication and immunization histories, laboratory and diagnostic test results, and, in the future, clinical data analytics. Stephens says that CHIC has a conservative growth projection and good agreements in place with its vendors, and she expects the organization to break even after five years.
Stephens notes that HIEs are still in an early growth stage, with expanding networks of providers and patients. “We are reaching that tipping point where we have enough people to make it worthwhile,” she says. One key to an HIE’s long-term prospects is perceived value by its provider members. “It’s not a barrier, but it’s a factor that people have to understand,” she says.
Fortunately for CHIC, Minnesota has a mandate requiring that by January 2015, all hospitals and healthcare providers must have in place an interoperable EHR system, and one way the mandate defines interoperability is through the requirement of connecting to a state-certified HIE service provider. Yet much of Minnesota’s population is centered on the Twin Cities of Minneapolis and St. Paul, with a high percentage of the large provider organizations using Epic as their EHR system. Part of CHIC’s growth strategy is getting more Epic users on board, by convincing those organizations to break out of their silos to communicate with rural providers in the state electronically. For that to happen the provider organizations on Epic have to “understand that there is value in the data on other systems that could assist in their patient care,” she says.
Stephens acknowledges that there is a fine line between the competitive nature of providers making up an HIE and the cooperation needed to make it function as a single organization, and she credits her organization’s governance structure as making that possible. She notes that its board of directors is comprised of all of the stakeholders, including representatives from public health, hospitals, clinics and physicians who use its businesses. Each business line has a workgroup or governing committee that handles day-to-day responsibilities, and makes recommendations to the board. “We have a representative type of governance, where if you want to get involved, it’s easy to get involved, whether it’s in a technical workgroup or a governance workgroup or a policy workgroup,” she says. In her view, communication and transparency are essential to keeping all stakeholders informed.
A Framework for Development
Stephens says that standards are a huge part of HIE development. She sees the role of the federal government as that of an enabler that brings together the industry’s stakeholders together to work out standards. “Let the standards organizations take it from there,” she says. If the federal government can “help convene the groups and the forums together to make the conversations happen, so we know what we need, that is what their job should be.”
CHIC began as an organization in 1997, and initially, it took small steps aimed at getting people to work together, such as a federal grant to test single sign-on or test hooking up a Web portal. Stephens describes those efforts as “bits and pieces, that when you pull them all together, become an HIE.” Given the absence of standards, the organization didn’t want to build something only to have to rip and replace it later on to comply with standards after implementation. While progress has been made, she says more work is needed, particularly regarding more granularity in patient consent, and the exchange of unstructured data.
Stephens also notes that if data is going to be shared among disparate organizations—for example, an HIE in Colorado sharing data with an HIE in Massachusetts—agreements have to be worked out so that each organization reaches a certain comfort level. Agreements such as the Data Use Reciprocal Support Agreement and e-certificates can help with electronic health data exchange; nonetheless, for hybrid environments, in which the organizations use a mix of standards—for example, eHealth Exchange and DirectTrust, or different digital certificates—an electronic handshake between providers can be problematic. “Working on that is going to take some heavy lifting in the next few years,” she says.
Interoperability is also still a challenge to sharing information, but progress is being made on that front as well, Stephens says. She observes that the meaningful use requirement to export a continuity of care (CCD) document helped to get vendors on board, as far as the ability to export data and accept it back. “Some are better than others,” she says, predicting that “in three years, we’ll be a lot better off than we are now.”
Supporting Accountable Care
Stephens believes that HIEs tie in with initiatives such as accountable care. “If I am looking at a patient, I can get a full picture of that patient because I am connected,” she says. That will allow better decisions on the next treatment plan, because the provider will have a better picture of the care the patient has had in the past. She says that she used to run a health maintenance organization, “and the worst thing is not knowing where the patients are who are not with you,” she says. “Now we are finally at the stage when we can know where the patients are going, if they are not coming to my house. That should help with the cost analysis and care coordination.”
Ultimately, HIEs are organizations that are built on trust. Stephens says that participating providers understand that their data is not going to be commingled, but also must realize that they will be sharing information. “Three years ago, this was more of a ‘no-no,’ whereas now it has become part of what is expected—because of the need to improve patient outcomes, they know they have to share,” she says. CHIC members sign a DirectTrust agreement for data exchange that outlines the responsibilities of participants. “That helps build the trust between the organizations, because they know their responsibility is the same as everybody else’s,” she says.
Stephens takes as an article of faith that HIEs “can do what we’ve all wanted to happen for patient care. I hope that everybody gives it the opportunity to prove itself before they go on to something new,” she concludes.