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Surfing the HIE

May 24, 2010
by Chuck Appleby
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The Santa Cruz information exchange experience offers lessons on what works

“The computer is the network” goes the famous Sun Microsystems advertising tagline; some consider it one of the smartest marketing slogans ever conceived, because it actually has meaning. Put simply, the phrase implies that all of a network's resources are available on the user's computer to the point they appear to be part of the user's desktop. It's also a line that may outlive its company of origin-and not just because the Redwood City, Calif.-based Oracle Corporation completed its acquisition of the Santa Clara, Calif.-based Sun in January. In fact, the emergence of health information exchanges (HIEs) is making it more and more clear that the computer can be and possibly will be the network in healthcare.

Perhaps this is nowhere more evident than in Santa Cruz, Calif., which claims to have the longest-running successful HIE in the United States. Spearheaded in 1996 by Physicians Medical Group of Santa Cruz County (PMG), a large independent physician association (IPA), the Santa Cruz HIE uses a virtual clinical network to connect 80 percent of the region's physicians and staff as well as competing hospitals, labs, radiology centers, Safety Net Clinics, county health clinics and other healthcare entities.

“In 1993,” recalls Robert Keet, MD, “I was medical director of our IPA and we had so much administrative money left that we decided to use it for connectivity and electronic medical records. We took the email model for business and made a business decision to tie all the docs and providers together.”

Eventually Keet, who practices internal medicine and geriatrics at the Dominican Medical Foundation, a 35-physician multi-specialty group in Santa Cruz, and his IPA contracted with San Jose, Calif.-based Axolotl Corp. to build the software necessary to connect the laboratory services, radiology offices and hospitals with which the group contracted.

“All the providers agreed to build the network, pay for it and become data suppliers,” he says. “In 1995 we went live and started getting all the data delivered. Over the years it grew. In 1999 we added prescription writing. It grew to add automation. So people began to use EMRs.”

Not an EMR fan

Keet also serves as Axolotl's CMO, although the role is informal. “The reason I've stayed involved,” he says, “is because I totally believe in the HIE vision. I'm not an EMR [electronic medical record] fan, because the EMR and its tools tend to create silos.” In fact, Keet says, “We need a whole new nomenclature, because the ability to get the data will depend on the interoperability of the network. What you're seeing in the HIE is that some people view it as an EMR, and it meets meaningful use. Every doc participating in the Santa Cruz HIE already meets most of the anticipated HIE meaningful-use criteria.”

Dominican Medical Foundation is now owned by the San Francisco-based Catholic Healthcare West, which uses the core product from the Chicago-based Allscripts as an ambulatory EMR. “What's happening in Santa Cruz,” he says, “is that our HIE has bi-directional full interfaces. When I do a note in Allscripts it goes directly into the HIE.”


HIEs offer a new level of IT functionality. “HIEs are like the telephone system,” Keet says. “EMRs are these big fancy things you attach to them. It's all going toward electronic data exchange management. Ophthalmologists and other specialists will put whatever tool they need onto the HIE. The electronic infrastructure is the key. With ASPs [application service providers, third-party companies that provide software from a central location to customers in other locations], all you need is the Web. You'll see EMRs go away and get replaced by automation tools that support workflows and frameworks like the Medical Home,” he adds.

That's especially true because ambulatory care constitutes the bulk of care and the momentum has shifted there. When the Santa Cruz HIE was launched in the mid-1990s there were 77 separate physician practices, ranging from a top of 30 doctors down to single practitioners. Participating doctors pay a yearly fee. “I see the HIE as the system that brings them all together,” says Keet, and the Santa Cruz HIE model has worked. “I believe we're one of the few HIEs that has never gotten a grant.

Keet acknowledges that the Santa Cruz region is particularly amenable to an HIE. “There are a lot of reasons it worked. We're lucky because we're isolated and we're a very collegial community. We also made some good decisions early such as to use push technology rather than pull,” he says. Push technology is easier because a physician who sends results or other information to the HIE does it willingly by definition, whereas pull technology queries the HIE for information and raises complicated issues of data ownership and release.

“The thing that kills HIEs is they start with pull technology,” asserts Keet.

A medical group and HIE CIO with an active network

“We've used the HIE for six years as a complete EMR,” says Nicholas Abidi, M.D., FAAOS, an orthopedist at Santa Cruz Orthopaedic Institute. “I've been able to pull up patient information in Europe and at 3:00 am on a tarmac in India and facilitate on-the-spot accurate diagnosis. Santa Cruz's HIE makes it one of the most unique cities in the United States. When I've shown it to a 75-orthopedist practice with tens of millions of dollars in yearly revenue they were envious. They don't have what we have,” he says.

“I pull up websites. There are no phone calls because we do everything online. When I go to my other practice [outside the HIE] I'm calling other doctors all the time. It makes us inefficient with our practice,” says Abidi.

As CIO for the Physicians Medical Group of Santa Cruz (PMG) and the Santa Cruz HIE, Bill Beighe oversees an active network. “We have most stakeholders connected in Santa Cruz,” including 18 major data feeds and almost 700 electronic users, 400 of whom are doctors. Eighty of those physicians, like Keet, are on EMRs, which means that the rest are using Axolotl's web product to use the HIE.

“We see a huge growth in true EMRs, because of meaningful use,” Beighe says. “The real bang for the buck comes when you have a real robust exchange of data related to referrals, consult letters, ED visit summaries, discharge summaries, lab and radiology reports. What's next for us getting to true interoperability and seamless exchange of the CCD [Continuity of Care Document] record between connected EMRs,” says Beighe, who serves on the board of Cal eConnect, the State Governing Entity for Health Information Exchange services in California.

Clearly, the future of the Santa Cruz HIE is built upon a history the rest of the country is rediscovering because of new emphasis by the federal government's stimulus program. Dawn Mackey, whose job it is to provide EMR support for the Santa Cruz HIE and who has worked for IT-early-adopter physicians in the community over the years, put it in perspective: “We've been grinding along for 10 years and we didn't even know what we had.”

Chuck Appleby is a Benicia, Calif.-based freelance healthcare journalist. Healthcare Informatics 2010 June;27(6):68-69

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