With the help of the American Recovery and Reinvestment Act (ARRA), Oklahoma got a jumpstart to create its own statewide health information exchange (HIE) called the Oklahoma Health Information Exchange. John Calabro, CIO of Oklahoma City-based Oklahoma Health Care Authority, spoke to HCI Associate Editor Jennifer Prestigiacomo on how Oklahoma decided to structure and govern its HIE.
Healthcare Informatics: Can you tell me a little about how the Oklahoma Health Information Exchange (HIE) got started and what the overarching goals were in setting it up?
John Calabro: Two years ago the Oklahoma Health Care Authority felt the need to have health information exchange to improve the quality of medical care for the SoonerCare [Oklahoma’s Medicaid program] population. About two years ago we ended up sending a request to the legislature to give us funding to do it. The government’s budget started to decline, and it [our request] did not get funded. But right around the same time, February 2009, the Recovery Act [The American Recovery and Reinvestment Act] passed, and there were grants from the State Health Information Exchange Cooperative Agreement Program [administrated through the Office of the National Coordinator for Health Information Technology].
Originally, we were only looking at the SoonerCare population when we did it, but the Recovery Act grant provided funding to develop a statewide health information exchange. The Governor’s Office of Oklahoma designated the Health Care Authority to be the lead agency to apply for the grant. So by fall we put together a team of about 40 different medical institutions to help write the grant and submit it October 16. Oklahoma was awarded $8.8 million on February 12, spread over a four-year period of time. We are currently in the planning phase and are putting together our strategic plan and long-term sustainability plan, called an operations plan. Those are due August 31 of this year.
Our Legislature meets February through May, and we introduced legislation in our section to create a public trust for health information exchange. So its long-term life will exist in the public trust. The legislation for our health information exchange passed the House and Senate unanimously, and the governor signed it and it went into law July 1. We’re now in the process of taking nominations for the trustees of the public trust, and we’re hoping that we’ll have it [the trust] created at the end of August when our operations plan is due, so it can vote on the plan and submit it. There will be a total of seven trustees, three from the governor’s office, two of them nominated by the speaker of the House, and two of them nominated by the speaker pro tem of the Senate. At the same time, the governor’s office will name the first Obama health information technology coordinator. So the coordinator will make sure all these grants act as a uniform program for Oklahoma.
HCI: What is the purpose of the Health Information Infrastructure Advisory Board?
Calabro: In Oklahoma, we have our own commissions, our own boards, our own budgets. So one of our objectives we had passed in the 2009 legislative session [was that] we created the [Health Information Infrastructure Advisory] Board. [The issue is] how do all the state purchasers of health participate in this statewide HIE and not look like 10 different agencies doing 10 different things? How do we help the Health and Human Services agencies that are purchasing healthcare using state dollars look and operate like one entity, so that the public trust doesn’t have to navigate, ‘Well here’s how the health department does something, here’s how the department of mental health does something.’ [The challenge is] to break down those barriers and agree on the approaches. That would make it easier for the public trust to enable the statewide HIE to operate more smoothly. So, [the purpose of] that board is to keep all 10 of the state agencies moving in a common direction.
HCI: How did the Oklahoma HIE grow out of the Oklahoma Health Care Authority?
Calabro: When the Recovery Act came out, the governor’s office took different sections of the act and asked the cabinet secretaries to look at what impact the different sections have on Oklahoma, and if there is an impact or deficit to Oklahoma, [and then] put together workgroups or teams to work on the. And if there were grants in that area, go for them. The secretary of health in Oklahoma was assigned the HITECH [Health Information Technology for Economic and Clinical Health] portion of the Recovery Act to take responsibility to look at how it impacts Oklahoma. Secretary [of Health and commissioner for the Oklahoma Department of Mental Health and Substance Abuse Services] Terri White asked me to look at all of the health information technology pieces of the Recovery Act to act as a chair of workgroups to study it and make recommendations. And if grants come out then I put together workgroups to work on the grants.
HCI: Why was the Oklahoma HIE created as a public trust rather than another type of entity?
Calabro: There are three [available] models. There’s a public trust, a state agency, and a 501(c)(3). We created a matrix with three columns [with the three models], and we had a team of lawyers go through all of the Oklahoma statutes that would be germane to this type of enterprise. [We]actually delineated what were the characteristics of the three based on Oklahoma law and went through maybe 40 different characteristics for these three entities. So we had a pretty clear [list of] disadvantages and advantages of the three entities. We had a task force go through with the team of lawyers. We walked away feeling that based on Oklahoma law a public trust just stood out. There are some things with a public trust, like its autonomy. A public trust is not a state agency, so it has some of that autonomy. At the same time a public trust carries with it some court protection, probably the item that swayed people most. One major lawsuit could bring a 501(c)(3) down. And some of that protection of being able to operate under Oklahoma court protection swayed people that it was a more survivable kind of enterprise in this state.
HCI: What kind of hospital and provider support have you gotten so far for the Oklahoma HIE?
Calabro: The hospitals are very engaged to get all of their members up to speed to meet meaningful use. The provider community is very confused. There are a little under 7,000 physicians in Oklahoma, and it’s a lot harder to get that group educated and up to speed. There are quite a number that are very active, they’re realists. They know it will take five to 10 years for this to mature.
HCI: What kind of consulting/education will you be doing to help participating doctors implement EHRs?
Calabro: There are two things that are in the works for this. On the State Health Information Exchange Cooperative Agreement Program grant, we have a communications workgroup that will develop an outreach and marketing plan for the statewide health information exchange network. There’s also another grant that came out of the Recovery Act that creates a regional extension center. Oklahoma made the decision with the number of hospitals and physicians we had, we only wanted one regional extension center. The Oklahoma Foundation for Medical Quality was asked to lead that effort. They applied for and were awarded the $5.5 million grant. Their grant mission is to reach out to 1,000 physicians by 2012 and convert their offices to electronic health records. We also have another 1,000 [physicians] who already have electronic health records. And then the other remaining 5,000 we really want to initiate the communication. We know the docs have their own social network, and we think the first 2,000 or 3,000 physicians who are really enthusiastic, and then the rest will follow their fellow doctors.
HCI: Are there any other state HIEs that you are looking to as a model of what you want to achieve?
Calabro: What a lot of the states [including] Oklahoma did, is to look at the strategic plans that are approved [by the ONC]. So, if you look at the first one that was approved; that was New Mexico. Obviously, we studied the New Mexico one very thoroughly. A lot of time when you’re working in grants of this size, there might be a lot of gray areas; so the states that have their strategic plans approved—they’ve answered a lot of the questions that you’re asking. And there are a number of states that have shared their draft strategic plans, and you look at them. AHIMA [American Health Information Management Association] has put together a website where a lot of that stuff gets posted as a resource for the coordinators for all 56 state cooperative agreement plans.
HCI: What have been the biggest challenges so far?
Calabro: The number-one challenge was governance. We probably spent a year talking about how governance should look and operate to get to where we are today with the public trust. It is without a doubt the largest challenge. I can’t tell you how many hours we spent in stakeholder meetings getting to where we had consensus on how to approach it and how we wanted the structure of the advisory board. The No. 2 obstacle is privacy, the various laws and rules wrapped around what you can share, can’t share, how you can share it. After that it turns into a technology project, ‘what are you going to build, what it’s going to look like, what are your standards?’
HCI: What will your role be moving forward with the Oklahoma HIE?
Calabro: There are five major grants. In Oklahoma we are a very rural state and a very large state. We have a broadband grant [ARRA’s Broadband Technology Opportunities Grants] that’s going to fall under the state CIO. We were also awarded a Beacon [Beacon Community Cooperative Agreement Program] grant. We have the regional extension center [Regional Extension Center grant to the Oklahoma Foundation for Medical Quality], we have the Medicaid electronic health record incentives, and we have the State Health Information Exchange Cooperative Agreement Program Grant. Those are the five main grants that the head coordinator obviously wants to move all in sync. The Healthcare Authority will operate the EHR incentive program. My role once the public trust gets formed is to continue getting the electronic health record incentives grant applied for and operationalize (sic) that. We are the only entity in Oklahoma that can apply for that grant. It’s Medicaid money, so it has to go through the Medicaid agency. Our role will be [to administer] one of the five large grants out there all related to the HITECH Act.