The Texas Health Services Authority (THSA) was created by the Texas Legislature in 2007 as a public-private partnership, legally structured as a nonprofit corporation, to support the improvement of the Texas healthcare system by promoting and coordinating health information exchange (HIE) and health IT throughout the state to ensure that the right information is available to the right healthcare providers at the right times.
Healthcare Informatics is pleased to host THSA’s CEO, Tony Gilman, on its HIE panel, “Health Information Exchange at the Crossroads: Opportunity and Challenges” at the Healthcare Informatics Executive Summit, being held April 30-May 2 at the Mark Hopkins Hotel in San Francisco.
As he prepares to share his perspectives and insights with executive Summit attendees in May, Gilman spoke with HCI Assistant Editor Rajiv Leventhal regarding HIE developments in Texas and across the nation, as well as challenges and what the future holds. Below are excerpts from that interview.
How is HIE developing in Texas?
In Texas, we think we’re making good progress in implementing HIE infrastructure. We have 10 HIEs that cover all of the major urban areas in the state, and have committed to connect 85 percent of all physicians and hospitals. Over the last calendar quarter of 2013, more than 32,000 clinical and administrative staff were enabled for query-based exchange, so we feel like there has been growth. Getting final legal agreements in place and overcoming interface costs between electronic health records (EHRs) and HIEs are the biggest barriers. Sustainability is definitely a question for us, in that our HIEs are primarily operating on subscription models, and that approach works in large metropolitan areas, but concerns remain about the financial capacity of smaller communities to sustain HIE infrastructure long term. Finally, we know, through monitoring successful HIEs around the country, that success is linked to the number of users contributing data. Once an HIE achieves a critical mass of data users, that’s pretty significant, and then, HIE has shifted from being used as a verb to as a noun.
Do you think provider demands have begun to outpace vendor delivery?
I would say that vendor uncertainties—such as satisfaction—are not necessarily a bad thing, but instead says that HIE services are in high demand and the overall market is maturing. Certainly, demand is outpacing resources in the HIE world right now, but in terms of satisfaction, purchasers are more informed now than they were three to five years ago. The questions they have and their needs are different than what they once were.
What will be the keys to making HIE sustainable for long-term success?
In Texas, we’re talking more about local HIEs, with minimal infrastructure at the state level now. In terms of success at the local level, one of the things that we required of our publically-funded HIEs [that we funded in 2011 to get HIE going in Texas], was to be focused on provider engagement first. We held them accountable to getting out and communicating with physicians, hospitals, and other providers. In the community, we also required them to have a diverse governing board that included all the key stakeholders that would support a community-based HIE. We felt like that is an essential ingredient to success, and to our success to date in Texas. Focusing on provider engagement up front ensured that outcomes and use cases providers were most interested in addressing were supported by the HIE. And that drove value to the providers, which will ultimately lead to use and sustainability of the HIE. Building trust through a diverse community-based board and defining a clear governance process around how data will be exchanged and used is very important, because it alleviates many of the issues that come up when you’re working to connect organizations that compete every day within the healthcare market.
And then finally, addressing how consent and authorization will be accomplished across organizational boundaries needs to be determined early on to streamline the adoption of legal and data use agreements for an HIE. Institutions across a healthcare community may have similar approaches to how they handle consent and authorization within their organizations, but each of them have different privacy officers and compliance officers, so they may address risk differently. So across a community, identifying how you will work together to address consent and authorization, and focusing on legal agreements as soon as possible is critical to getting HIE up and going.
What are the main challenges you have overcome in Texas to get where you are today?
I think that we have overcome the challenges associated with raw connectivity and the transport of information. The next set of pressing challenges relate to content for patient summaries, patient matching, and computable consent management. Addressing these issues so the industry supports a common set of standards is critical for Texas given our federated network of networks , as well as for the nation—and I think progress is being made in all of these areas.
The EHR/HIE interoperability workgroup (a coalition of 19 states, 21 EHR vendors, and 22 HIE vendors) developed a bridge last year to further align vendors around content specification that bridges the current gap between the C32 patient care summary content specification and consolidated CDA, which is required under meaningful use. Texas is in the process of implementing a rules-based consent management system that supports patient preferences and can scale as technology advances. We’re one of the only states to really focus on that at this point.
Further, Healtheway and the Care Connectivity Consortium spent much of 2013 evaluating the minimum traits for successful patient matching across multiple organizations, and announced their recommendations at HIMSS14. Many efforts are going on to align the industry around standards, and we had a good example in 2013 of how effective this could be when ONC led an initiative to reach a consensus on an updated federated provider directory to both providers and organizations. That was critical because one of the barriers to Direct messaging efforts was a federated provider directory, so this effort represents a positive collaboration between several standards bodies—and the end result was a demonstration of updated standards at the HIMSS interoperability showcase in Orlando. So there are still challenges, but there is also focus across industry to align the industry going forward.
How far has Texas come in advancing privacy and security in health information exchange?
We take privacy and security very seriously here in Texas and one of the things the Texas legislature did in 2011—as we were ramping up our HIE efforts—was require my organization to develop a privacy and security certification program. It’s a voluntary program, but we’re the first state to really try to work with entities that handle protected health information (PHI) to create a process for these organizations to assess their current approach to managing the security of this information. It’s really an effort to allow these organizations to assess and identify gaps and best new practices, and implement them so they can continue to evolve and enhance to ensure this very sensitive patient information is protected.
Looking into your proverbial crystal ball, what do you see as the future of HIE?
I would say HIE is here and it’s here to stay primarily because it’s the cornerstone of healthcare transformation. In order to have meaningful service delivery and payment reform models, you need to have greater coordination of care. And the success of accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and bundled payments all will be reliant on interoperable HIE systems across the entire continuum of care. To support quality and efficiency initiatives, you need good data. Over the last few years, our HIEs have really focused on getting providers connected. But now, in Texas and across the nation, the focus is on more advanced forms of HIE including notifications and analytics to support better health outcomes. That’s the real value in HIE, and we’re seeing a real pivot in the market to focus on that.
And it’s also important to remember that patient engagement is a very important element for the future of HIE. It’s actually critically important because the current meaningful use requirements have really driven patient portals to be developed practice by practice. The ultimate result is we’re going to have silos of patient portal information that are really confined to an individual system or practice. Leveraging patient portals through an HIE allows the patient to have access to information that cuts across the entire care coordination team that they work with.