With a dense population that swells to twice its size every day of the week, Manhattan is an especially tough proving ground for the health information exchange concept. Yet the New York Clinical Health Information Exchange has succeeded in building a viable provider network that ties major Manhattan hospitals to those in surrounding areas, as well as ambulatory and homecare agencies, a health plan and nursing homes.
Following the historic Hudson River Valley south takes the traveler out of the Catskill Mountains and into the tunnels and streets of Manhattan-and the New York Clinical Information Exchange or NYCLIX. Many people travel this commute daily, which is one of the challenges in building a health information exchange (HIE) in the country's densest urban area.
“Manhattan has some unique qualities,” says Gil Kuperman, M.D., board chair and executive director of the NYCLIX, in a clear understatement. “It has a population of 1.3 million people and the number of daytime commuters who come in from outside is 1.4 million people. The flux in and out of Manhattan is mind-boggling. Having a RHIO [regional health information organization] that covers just Manhattan doesn't begin to cover the needs of the people who may receive some portion of their care here.”
Despite the challenges, NYCLIX, which emerged from conversations that began at the Greater New York Hospital Association in 2004, is beginning to exchange clinical information. NYCLIX is significantly driven by the Health Care Efficiency and Affordability Law of New York State (HEAL NY), from which it received half its total $4.7 million funding in 2005. The goals of NYCLIX's HEAL project are:
Build a technical infrastructure interconnecting the participants;
Implement data exchange in the emergency department (ED) setting;
Support public health activities, such as reporting;
Evaluate the impact on cost, quality, and safety; and
Create an extensibility plan.
Current participants include six hospitals in Manhattan: Bellevue Hospital Center, Beth Israel Medical Center, The Mount Sinai Medical Center, NewYork-Presbyterian Hospital, NYU Langone Medical Center, and St. Luke's-Roosevelt Hospital Center. Hospitals outside Manhattan include Kings County Hospital Center, Staten Island University Hospital, and SUNY Downstate Medical Center. NYCLIX also includes ambulatory and homecare agencies, a health plan, and nursing homes. Allied organizations on the board of directors include the New York Business Group on Health, IPRO, Pfizer Inc., and North Shore-Long Island Jewish Health System.
A NON-TRADITIONAL COMMUNITY
Clearly, with Manhattan as the primary service area, even these big names have their work cut out for them. “We're a geographic region, but we're not exactly a community in the traditional sense,” says Kuperman. People are as likely to travel outside Manhattan for care as seek it in Manhattan. Part of the reason for the fragmented approach is that the HEAL NY program's goal was primarily to fund a variety of initiatives, with less attention given to the way they would all eventually fit together, he says. “So, there's a bit of rework to be done.”
NYCLIX's technical architecture employs a federated database with a central master patient index (MPI) that relies on a statistical algorithm to match the patient's records across the various members. Clinical data is held in “edge servers” to eliminate the need for one big database. “This is the most common infrastructure for an HIE,” notes Kuperman.
NYCLIX CAN BE VERY VALUABLE IN PRESENTING TO THE RECEIVER ALL THE UPDATED INFORMATION ON THE PATIENT.-TOM CHECK
With the technical platform running, eight organizations are contributing data involving 80 logical feeds across 42 physical interfaces. The MPI is linking patients across sites and users have access to a clinical results viewer. “We started from a blank slate, and after the registration feeds began our MPI started to fill up. We now have 2.5 million patients in the MPI,” he says. “These are very busy hospitals and the growth of the MPI reflects the movement of patients through these facilities.”
Even in its fledgling state the figures begin to reflect the HIE's scope:
160,000 or 8 percent of patients in the MPI have been to two sites;
17,600 or about 1 percent have been to three sites;
500 had been to more than three sites.
Movement among patients who visit the ED is striking: on average, nearly 20 percent of the patients who walk into an ED have data elsewhere, meaning they had been seen somewhere else. “The extent of movement is a validation of the HIE,” Kuperman says.
REAL MEDICAL HOME
On any given day, the 3,500 nurses, therapists and other staff of the Manhattan-based Visiting Nurse Service of New York (VNSNY), the largest home health agency in the United States, care for 30,000 patients in their homes, about 125,000 during a year. “As a result, we use a point-of-care EHR [electronic health record],” says Tom Check, CIO at VNSNY, which staffers access on a laptop and includes clinical guidelines for various patient conditions. “A couple of times a day, they use a cellphone connection to communicate the information they've acquired on patients,” he says, and most of that information is submitted electronically to NYCLIX.
New York State requires a patient's written consent to share his or her clinical information across such a broad spectrum, but Check says that nine out of 10 do so in VNSNY's service area that includes all of New York City, as well as Westchester and Nassau Counties. “So, we've been submitting patient information to NYCLIX whenever the patient authorized it,” says Check.
That information is run against clinical decision support software to identify any possible adverse reactions to medications based on the patient's condition. If there's risk of an adverse event, VNSNY nurses can then call to advise the patient's doctor and have the physician adjust the patient's medication accordingly.
The HIE allows homecare clinicians to see patients’ diagnoses, treatment, and medications to allow them to follow up on their care.
“We think the patient-centered medical home is really important. A lot of patients don't really have a physician, so we have to coordinate that with the physician of record,” says Check. Transitions of care such as when a patient goes from home to hospital and from hospital to home are particularly fraught with risk of losing information critical to their continuity of care. “NYCLIX can be very valuable in presenting to the receiver all the updated information on the patient,” he says.
“We extract our information daily from our systems and export a copy of relevant information-demographic, acknowledgment of their service with VNSNY, medications they're on, diagnoses, and lab results to the NYCLIX database,” notes Check.
ED CALL HOME
One of the leaders in founding NYCLIX, Paul Conocenti, CIO at Manhattan-based NYU Langone Medical Center, says a driving need among the nearly 70 brutally competitive hospitals in New York City, was the fact that any patient at any given time in the city could wind up at any one of several EDs. “If we can share data among EDs in many cases that are life threatening, that would break down the competitive wall. So we found a vendor (Mason, Ohio-based MedPlus, Inc.) and put a lot of work into areas like governance. NYU was the first to go live with patient consent forms,” he says, adding that 70 to 80 percent of the patients that walk into an ED give their written consent, a rate bolstered by the fact that desk staffers undergo a training program on what it means for patients to share data.
TO BE NOTIFIED THAT ONE OF YOUR PATIENTS WAS IN THE ED IN MANHATTAN WITH THE TYPE OF ED VOLUME HERE TURNED OUT TO BE MORE VALUABLE THAN THE ACTUAL DATA EXCHANGED BECAUSE IT ALLOWS THE PHYSICIAN TO ACTUALLY GET INVOLVED IN HELPING THE PATIENT AT THE MOMENT OF CARE.-PAUL CONOCENTI
“It's really starting to catch on,” Conocenti says. “Last week a physician called up his notes and found that data from NYCLIX was part of the record and told me, ‘That's really amazing that we're able to get that data.’ There have been a lot of scenarios on the network like that and we're really just at the tip of the iceberg,” he says.
And there are surprise benefits. While sharing patient data from ED visits throughout the city has been as valuable as expected, an unexpected benefit was that physicians were glad just to be notified that their patients were in the ED in the first place. Says Conocenti: “To be notified that one of your patients was in the ED in Manhattan with the type of ED volume here turned out to be more valuable than the actual data exchanged because it allows the physician to actually get involved in helping the patient at the moment of care.”
Healthcare Informatics 2010 October;27(10):29-31