Although the successful exchange of health data has been a struggle in most U.S. regions, a commitment to the free flowing of information on a patient’s history—regardless of what local healthcare facility they have been at—has helped spur health information exchange (HIE) in the Midwest.
Indeed, the Lewis and Clark Information Exchange (LACIE) is one of the first fully operational, multiple-state HIEs in the country, providing patient information to healthcare systems and providers in Kansas and Missouri. Getting the HIE up and running to a point where it could successfully exchange data required a few key elements, starting with getting hospitals on board that were willing to share data. To this end, in the last 18 months, LACIE announced two major connections: first with the Kansas Health Information Network (KHIN), another major HIE in Kansas. This was a significant moment for data exchange in the Midwest, as in the past, the two organizations had failed to reach an agreement on sharing data.
A few months after that, LACIE announced that patients' electronic medical records (EMRs) were being securely shared with Tiger Institute Health Alliance (TIHA) in Columbia, Mo. In total, LACIE is now connected to 17 hospitals in two states in addition to three accountable care organizations (ACOs), the two aforementioned regional HIEs, multiple private HIEs, and the Kansas City Metropolitan Physician Association (KCMPA), a large independent physician group with 80 clinics and 350 providers. The 24 different EMRs those organizations use have been connected via a hub that has been put in place from Cerner, says Mike Dittemore, the executive director for LACIE. Dittemore says that LACIE connects to that hub so it doesn’t have to do all of the independent connections, leading to greater efficiencies and cost savings.
However, getting different provider organizations on board has not been easy, Dittemore admits. “There are always challenges with provider participation, and one of reasons we had the strategy to work with hospitals and get them on first is that we felt if we did a good job with them, that would spur participation from others. The best marketing out there as far as HIEs go is word of mouth by providers who actually use it,” he says. What’s more, LACIE’s board of directors consists of several physicians, including multiple CMIOs of organizations in the Kansas City area. “That’s really helped us, having these physicians have conversations with other providers or their clinics and talk to them about why it’s important to share this information and participate,” says Dittemore. “They can show other [providers] the value by being able to not tie up so much staff in administrative time in tracking information down that already exists in the HIE.”
Still, there are additional challenges for independent providers who have all kinds of mandates and rules they are struggling with, in addition to low reimbursement rates, Dittemore notes. “So we try to have a price point that works for them, and we also have found some grant funds through the Office of the National Coordinator for Health Information Technology (ONC). In Kansas, we used some of those funds to help folks to connect, but it’s always an uphill climb to get individual providers on board. We do think that if we can get in and meet with clinic managers, maybe not the providers themselves, but a trusted person they go to, and show them the value, getting these smaller providers on board might not be as hard,” he says.
One of these physicians on LACIE’s board is board chair, Gregory Ator, M.D. CMIO and practicing physician at the University of Kansas Hospital. Ator says that as of late, LACIE has become much more focused in getting smaller practices on board. “It’s been a great experience, it’s very refreshing to see all of these large organizations that are not competing around the ‘this is my data and you can’t have it’ concept, but rather the ‘let’s compete around quality of care and let information freely flow’ concept. That’s been quite refreshing, and moving forward we’re looking at the next tier of smaller physician practices,” Ator says.
LACIE further attempts to make the exchange process more doable by not charging organizations a fee to connect. “We have always believed in connecting to other HIEs, be it community, regional, or state. But we don’t pay other organizations to connect nor do we charge others to connect to us,” Dittemore says. “LACIE is a public type of entity. We think that’s why it’s here, for the spirit of moving information regardless of where they reside. We have been adamant about that, but not all facilities feel the same way. So that’s been a barrier,” Dittemore notes.
Making HIE Valuable
Currently, LACIE is consistently seeing 100,000 queries per month going through the HIE, and according to Dittemore, one of the things that really helps provide value to its providers is getting robust information trading rather than just checking a box. “If checking a box is what you want, our HIE won’t be for you. We’re about the meaningful trading of information,” he says.
To this end, all of LACIE’s connected providers are encouraged to share radiology reports, discharge reports, clinic visits, and any summaries, Dittemore adds. “What we have found is that when you have that type of information above and beyond the continuity of care document (CCD) or consolidated-clinical document architecture (C-CDA), it really provides a great platform for providers to go in and look at the information and find out what is really going on with patients in those last visits,” he says. “We want to try to get rid of the fax machine, or reduce its use by as much as possible. Having this robust information available does help providers to move onto other duties like taking care of patients. They become valuators rather than investigators,” says Dittemore.”
Expanding on the notion of meaningful data exchange, Ator notes that fax machines are how providers are doing HIE right now, and what’s more is that Direct also has issues with people’s addresses as well as its own technological problems. “I am an Epic customer at KU, so we have a number of Cerner operations in town as well as Epic operations, and when you log into Epic for instance, we can go out to the HIE and search for a patient, at which point a very robust matching algorithm kicks in and we get textual documents presented in reverse chronological order. Operative notes, progress notes and discharge summaries are all within Epic without a separate log-in,” Ator explains. “Our providers don’t have to dig through exchange formats such as CCDs and CCDAs to see it in a meaningful manner. And that’s Cerner shop looking at Epic and vice versa,” he says.
Value to providers is further seen in the form of impacting patient outcomes. According to Ator, the strongest use case now is in the ER. “The patients here in a big city circulate around the EDs, and it’s fabulous to have the notes as it was was signed from an organization right down the street that a person might have checked into,” he says. “So we have seen improved outcomes around the ED, and the literature backs that up. I think that it is clear there is benefit in ED world, but rest is bit too soon to call,” Ator says.
Dittemore also says that value has been seen on the care management side. Kansas City has multiple medical facilities and acute care facilities, but even more non-acute facilities, he says. Just because a patient happens to go to a provider or an urgent care clinic that they have affiliation with, they might not go there for all care, and that’s something that needs to be seen in the HIE, he says. Also with specialists, making sure to ensure patients have done the appropriate follow up and have been to specialists allows care managers to see if that has happened and if not, find out why, Dittemore says. “Was it a transportation problem, an illness or what? It gives them something to go off of when they reach back out to the patient. Care managers have seen great value in this to manage that care between multiple facilities that might not be financially related to one other. That’s been rewarding,” he says.