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Public vs. Private HIEs (Part 3)

October 31, 2014
by Gabriel Perna
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Dan Paoletti

Health information exchanges (HIEs) are at a crossroads in 2014. A recent survey revealed that most HIEs are struggling with the financial costs of interoperability as well as building a sustainable operational model. Less than half of HIEs surveyed by the eHealth Exchange said that dues or fees were their greatest source of funding. Forty-nine percent of all HIEs surveyed said they were sustainable.

The end of federal funding into state-designated HIEs has shifted the landscape. Many public HIEs have been forced to shut down or dramatically shift gears, while others have succeeded in connecting major healthcare providers within and even across state lines. Meanwhile, some are turning to private HIEs for data exchange.

Healthcare Informatics Senior Editor Gabriel Perna spoke with four leading HIE executives –in both public and private organizations – who shared their thoughts on the challenges of running an HIE, the advantages of being public or private, where they’ve succeeded, and where they see the market headed.

Part 1 of this four-part series was an interview with Doug Dietzman, executive director at Great Lakes Health Connect

Part 2 was with Michael Matthews, CEO of MedVirginia, a regional HIE in central and eastern Virginia.

Part 3 is with Dan Paoletti, CEO of the Ohio Health Information Partnership (OHIP), which operates the Clinisync HIE. Clinisync is the statewide HIE for Ohio, funded from the HITECH Act in 2009. OHIP, also formed in 2009 from a collaborative effort among the state of Ohio and various other stakeholders, is an independent nonprofit. The HIE has been successful thus far, attracting 141 hospitals, contracts for 215 long-term and acute care facilities, and well over 3,000 independent physicians.

Below are excerpts from HCI's conversation with Paoletti.

How have you been able to recruit to the HIE?

We had many champions, it included large hospital systems but also many rural hospitals that saw this as a way of using technology to reach out into community and do things they wouldn’t be able to do on their own. We had a lot of early adopters that helped bring other stakeholders to the table. It was a grassroots effort. The hospitals were the original grassroots members. We tried to focus on solving problems they had and accomplishing goals they had for using health information technology to communicate into the community and other providers. As long as we could solve problems that the hospitals had in an efficient and cost-effective way, they have been and continue to be, good supporters of what we're trying to do.

[The hospitals] have helped us reach out to other providers in community. Now it's taken a life of its own. The long-term care community is coming on board in large volumes. Now we're engaging home health and EMS. Pharmacy is another place we’re starting conversations. It's the whole continuum of care.

Was your strategy from the beginning or is it something you kind of stumbled into?

There was a little bit of luck involved;, I'm the first to admit that. But I think we realized from day one, if the hospitals did not join in large volumes that this wasn’t going to be successful. As we looked across the country at previous efforts to developed exchanges, if they didn’t have the vast majority of hospitals, they struggled to bring value and sustainability. We had to have a critical mass. Our critical mass was 80 and we reached that.

How did OHIP also being a regional extension center help out the HIE?

Because we were regional extension center and the state-designated HIE, having large scale electronic medical record (EMR) adoption was crucial in bringing value to the HIE. Stage 2 of meaningful use is where transitions of care have become very important. We’re helping quite a few of our stakeholders meet that measure. That has had a large effect in making the HIE successful.

Where are you guys at in terms of sustainability – the HITECH funds are running out, do you have a plan going forward?

The vast majority of the HIE grants closed down last spring; we shut ours down a few months early. We anticipated that since most of the dollars in the beginning were coming from hospitals, 80 hospitals was the tipping point for some form of sustainability. Because we've surpassed that, we're able to distribute the costs among all the hospitals, which has pushed us to the point where sustainability is achievable. Going forward, we'd like to spread the cost even more to the long-term care and the ambulatory provider communities. We’re getting them engaged. Now, we've reached out to the payer community. Even though we don't have any financial contributions from payers yet, we are working on projects that will show value and return on their investment. At some point, we think payers will contribute.

The idea of spreading cost out is important and will become even more important as money gets tighter. We do think that as healthcare transformation and reform happens, whatever that is, it’s going to mean payment reform. We think information exchange will be a huge factor in that healthcare reform model. As long as we can help stakeholders be successful in that regard, we can continue to bring value and sustainability to the market.

The marketplace is changing so fast; we’re having to be fairly flexible and adapt to its growing and ever-changing needs. I think that’s key whenever you talk about sustainability and health information exchanges:How fast can they react to the changing needs of the marketplace?

It's like you are running a business and you have to respond to what your customers need, which changes every single day.

Amen to that. I think the one thing that’s key and hasn’t changed is data. The important thing to remember is whether you can you create a way for the data to flow with the proper governance and privacy aspects in a way that makes everyone comfortable. Facilitating the movement of data is the key to all of this. It’s not about technology. It’s about developing a neutral third-party that people trust.

Have you encountered challenges as a public HIE that you feel private HIEs do not face?

There are three categories of HIEs. There are enterprise-wide private HIEs, which is brought to bear by a provider organization. There are the public state HIEs, which are really propped by the state government. Whether they are inside or outside the state government, the government uses a lot of mechanisms to try to propel HIE and it provides oversight. Then there are public HIEs like us, which are privately run in a nonprofit.

In my mind, there are benefits to all three. What we bring is benefits the others can’t have. We’re more flexible and we can react more to the market needs and focus more on the stakeholders than the governmental type of HIE can. There is a trust factor there that sometimes people get nervous about giving too much data to governmental entities that we've been able to overcome.  On the private side, it can be a challenge because providers that compete with each other can be nervous and it’s difficult to get an entire community on board.

What we're trying to do is be that trusted third party that people can feel comfortable with and data governance and privacy is going to be maintained. Trust is the underlying factor of our success we’ve had so far. Ensuring that trust continues is at the forefront of what we want to do. That's the big benefit of our model.

The governance is represented by our stakeholders. We have groups that represent our  stakeholders that oversee what we're doing on data governance and policy. For the most part, those stakeholders dictate what we do and ensure we are serving the broader community.

Sounds like you feel that your HIE is kind of the best of both worlds.

It goes back to the grassroots movement. The people that felt this was important and the champions early on felt they have ownership in what we’re doing. That's part of the benefit of the best of both worlds. In a private HIE, the ownership is there but not spread among multiple stakeholders. And in the governmental framework, having that ownership can be difficult to accomplish.

How do you think HIEs will shape out over the next five years?

I think we are at a point where we know, because of health reform, that data is going to be key and being able to bring that data together for the care of the patient in a way that’s efficient and cost-effective. How that occurs is what we and many are chasing.

There will be consolidation of HIEs. You’ll see more enterprise HIEs come to bear that may be collaborations between different provider groups because of a lack of options in that region or the marketplace. The landscape will change. What’s going to be key in that is everyone will have to figure out information exchange occurs, wherever they are. People will have to come together to make that happen. The example I think of is in New York and California where that's being done by the state or different stakeholders.

At the end of day, if we fast forward 5-10 years, it’s about data and data governance trust and making sure that this information is used in a proper way. Ensuring that patients have rights in this and that data governance is overseen in way that makes everyone comfortable. Ultimately, that will be our important role: data governance, trust, and third-party facilitation. The technology may change but the data governance piece and trusted third-party concept is where the future is.

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