Healthcare Informatics has been closely following the pace of change at regional and state health information exchanges over the past few years as they seek to become increasingly relevant to hospitals, clinics and physicians.
In September our editor-in-chief, Mark Hagland, did some excellent reporting from annual conference of the Strategic Health Information Exchange Collaborative.
From Mark’s news story:
“At a time when some in U.S. healthcare are prematurely writing a collective obituary for HIEs, the reality behind the scenes is both brighter and far more complex than the announcements of HIEs forming and breaking apart. And that complexity and nuance were on full display at the SHIEC annual conference. On the one hand, no one attempted to gloss over the fact that HIEs face challenges going forward — challenges around funding, policy issues, and above all, sustainability. On the other hand, the leaders of numerous HIEs are developing strategies that are putting them on more and more solid ground.
For instance, many HIEs are building on the trust they have established to help physicians with their MIPS reporting under the Center for Medicare & Medicaid Services' Quality Payment Program (QPP), under the Medicare Access and CHIP Reauthorization Act (MACRA).
In a recent interview, Deb Bass, executive director of the Nebraska Health Information Initiative (NeHII), told me: "When the MACRA legislation first rolled out, I thought, here is our opportunity to step up to the plate." The HIE set out to become a qualified clinical data registry (QCDR) and offer MIPS calculator tools to allow providers to report to the QPP through NeHII in 2018.
I was reminded of all this when I came across the new strategic plan for the Statewide Health Information Network for New York (SHIN-NY). Its SHIN-NY 2020 Roadmap echoed many of the things people at the SHIEC conference told us about how they were aligning with stakeholders in the shift to value-based care.
The decade-old SHIN-NY is comprised of eight regional health information networks connected together to share patient information. The ultimate vision, according to Valerie Grey, executive director of the New York eHealth Collaborative, is that the SHIN-NY will create a 360-view of a patient’s health, empowering them and their care team to create a treatment plan that addresses not only an illness or injury, but underlying conditions, medical history, and social determinants of health.
The roadmap stressed that organizations using the SHIN-NY are already seeing a significant impact: fewer hospital readmissions and emergency department visits and reductions in unnecessary lab tests and x-rays.
But the roadmap also acknowledges the financial pressure SHIN-NY is under. It notes that virtually all Affordable Care Act (ACA)-related proposals at the federal level would have negative fiscal implications for providers and create immense challenges for New York State's Budget. “New York will likely face reductions in federal Health Information Technology for Economic and Clinical Health (HITECH) funding in the near future and the enhanced HITECH match expires in 2021. While all stakeholders will strongly advocate for maximum funding, the SHIN-NY will potentially face a perfect storm of reduced support over the next several years.”
• Other Headwinds HIEs Are Facing? New and potential advancements such as Fast Healthcare Interoperability Resources (FHIR), Blockchain, machine learning, and natural language processing could have significant impacts on the traditional forms of HIE, the strategic plan notes. In addition, “some argue there are alternatives to state HIEs given several EHR vendors’ eﬀorts to connect diﬀerent systems through private exchanges and the availability of national HIEs.”
The roadmap identifies several key strategies to address the challenges it faces, including:
• Ensuring a Strong HIE Foundation Across the State: Partly due to initial design and rollout, statewide SHIN-NY participation is strong for hospitals, federally qualified health centers, and public health departments, but not as robust for physician practices (especially small ones), home care agencies, nursing homes, behavioral health providers, and others. There is also wide variation across the regions in terms of participation, data completeness, consent, and usage of core services. As more community-based organizations are involved in care teams and population health eﬀorts, it will be necessary to develop additional participation targets and determine appropriate levels of data viewing and data contribution.
• Supporting Value-Based Care: An independent statewide assessment of provider input is underway to further inform prioritization of potential enhancements. Based on earlier stakeholder discussions, some functionality enhancements that could be undertaken to improve workflows and help providers include, but are not limited to:
• Single sign-on for DOH’s Health Commerce System (e.g. prescription drug monitoring, immunization registry, etc.)
• Advanced alerts with action-oriented information or results delivery with flags for abnormal results
• Documentation of upload and view/download of summaries of care to demonstrate compliance for MACRA/MIPS
• Increased integration with EHRs
• Ability to exchange care plans among teams
• Potential expansion of available data related to national patient centered data home
The statewide assessment will also seek to better understand provider interest in the types of data currently not available through the network.
Based on stakeholder feedback, examples of additional data and services that could help support value-based care and initiatives such as Medicaid’s DSRIP value-based payment, Medicare’s alternative payment models (APMs) & MIPS, include but are not limited to:
• Medication fill data
• Quality measurement reporting
• Claims data (potentially via the All Payer Database and eventually inclusive of ICD-10 z-codes, i.e. social determinants of health)
• eMOLST (Electronic Medical Orders for Life-sustaining Treatment in New York State)
• Variety of registries (cancer, electronic death registration system, etc.)
• Housing, hunger, and other social determinants of health indicators
NYeC estimates that about half of adult New Yorkers have provided the necessary written aﬀirmative consent to allow their clinical data to flow to at least one provider. Recommended changes to consent policy to facilitate the use of HIE to improve healthcare delivery include:
• Patient alerts without written consent to those with treating relationships, and
• SHIN-NY consent incorporated into other consents (such as health insurance enrollment forms).
• Promoting Efficiency and Affordability. Given the financial pressures that are likely on the horizon, SHIN-NY operations will need to be re-examined and value-engineered with an eye toward improved eﬀiciency and affordability. “This is especially true when considering the stress that will be placed on the system through the increased number of SHIN-NY participants and demands for additional services and data,” the report notes. The effciency opportunities can take many forms
• Group purchasing
• Specialization by regional HIEs
• Shared services
• Potential mergers between the regional HIEs
The report notes that the pressure will become more intense if total funding is reduced and underscores the need for market analyses to inform sustainability discussions.
The current system sometimes supports duplication and non-standardized approaches (e.g. high-cost EHR interfaces). Moving forward, a new “wire once/pay once” strategy will be employed. Given that the SHIN-NY network allows the regional HIEs to provide information statewide, payments will be made only once rather than multiple times for connections to multiple HIEs or NYeC. This strategy would apply to various statewide data, certain services, and provider / EHR connections.
Clearly, the SHIN-NY stakeholders have a lot to keep them busy over the next three years! And perhaps other states can learn some lessons from the things SHIN-NY has chosen to prioritize. We’ll keep an eye on their progress.