Despite infusions of federal funding, numerous state-sponsored initiatives, and the development support being provided by private consulting firms, health information exchanges (HIEs) are evolving forward in a fragmented and non-uniform way at the state level.
The reasons for this ongoing fragmentation and lack of uniformity are as diverse as are statewide HIEs themselves. But one underlying reason, say industry observers, appears to be a residual conceptual framework in healthcare that derives from the Bush administration-era focus on the idea of building a national health information network (NHIN) based on the building blocks of what initially were called regional health information organizations (RHIOs). Under that thinking, the idea was that once RHIOs got up and running, they could be linked into statewide networks, which would then be linked together to form a national network.
Instead, the American Recovery and Reinvestment Act of 2009 (ARRA) has ended up putting the burden squarely on the shoulders of each state to plan, design and build its own statewide HIE - whether or not a state government chooses to incorporate existing regional networks into that HIE.
As a result, say CIOs who are involved in statewide HIEs, current efforts to build statewide HIEs are forcing all those involved in every state that is creating an HIE to essentially invent the wheel each time. For example, notes Pamela McNutt, senior vice president and CIO of Methodist Health System in Dallas, Tex., a state government can receive a grant “to hire consulting groups to help physicians - not hospitals - incorporate EMRs into their practices. But that only pays for consulting,” she notes.
Meanwhile, state governments can also can obtain grant money to assist them in building a statewide HIE- if they already have the plans in place. They can also apply for HIT workforce grants that will pay for selected schools in any state to train the workforce needed to install, build and maintain the network's infrastructure, McNutt reports.
Additionally, individual providers can get incentive dollars based on their billing volume of Medicaid or Medicare patients, but only after they have installed and can prove that they are using an EMR. “The goal is that every physician will be on an EMR by 2017 or they will be penalized by reduced reimbursements,” McNutt says.
This cash incentive was further explained in a letter dated September 1, 2009 that was sent to state Medicaid directors by the Centers for Medicare and Medicaid Services (CMS). That letter explained to providers the funding available to Medicaid healthcare providers “to purchase, implement, and operate certified electronic health record (EHR) technology. These payments, while not direct reimbursement for certified EHR technology, can be paid at up to 85 percent of the federally-determined ‘net average allowable costs’ of such EHR technology, including support and training for staff, up to statutory limits.”
Forward movement in Texas and Georgia
As a result, state governments, and some provider organizations, are beginning to move forward. Two states in which activity is proceeding are Texas and Georgia. Methodist's McNutt reports that Texas has received a $29 million grant for “planning and interstate activities” involving a statewide HIE but that these efforts are only in the planning stage.
The state does, however, have a number of regional HIEs that are also in the planning stage or operational. These include the Critical Connection Central Texas Cooperative based in Austin; the Harris County Healthcare Alliance based in Houston; Healthcare Access San Antonio; and the Integrated Care Collaboration based in Austin.
And while McNutt's own healthcare system uses the HL7 standard to connect electronic medical records (EMRs) in six hospitals and 10 clinics, she says interoperability issues need to be addressed if a statewide HIE is to succeed. “The idea is that free enterprise will reign,” she says. “But that's difficult because people are using different systems.”
Meanwhile, in Georgia, Ron Strachan, senior vice president and CIO of Wellstar Health System in the Atlanta suburb of Marietta, says the private exchange his health system currently is building - which uses HL7 wherever possible - may eventually be rolled into a statewide HIE. But he also says that Wellstar would retain some of the infrastructure for its own internal use. At any rate, it will probably take the state at least two years before it's ready to launch anything on a statewide basis, he adds.
As is typical in other states, Georgia is home to a number of regional initiatives, including an otolaryngology network based in Atlanta and the Athens-based GARHIO, which encompasses a six-county region containing over 250,000 consumers.
In addition, the Atlanta-based Georgia Office of Health IT and Transparency has launched a Health Information Exchange Pilot Program which provides matching funds to health care organizations so they can plan and implement their own HIEs; the Rx Exchange Project, which compiles medication histories on Medicaid patients as well as those served by the Department of Social Services, the Department of Corrections and the Department of Juvenile Justice; and a program designed to provide Medicaid providers with electronic health records which, in conjunction with the Georgia Medicaid Management Information System, will serve as the linchpin for the statewide HIE.