In 2009, when all 50 states received grant funding from the federal government with the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the foundation was laid for the North Carolina Health Information Exchange (NC HIE).
Then in 2010, North Carolina’s governor designated NC HIE as the statewide health information exchange following the development of a strategic statewide HIE plan by a broad pool of North Carolina healthcare stakeholders that would govern the finance, legal, clinical and technical principles of NC HIE’s organizational framework.
NC HIE has seen rapid progress since its inception in 2010, including becoming part of the Community Care of North Carolina, (CCNC) suite of companies; establishing strategic partnerships with NC DHHS and technology vendors state- and nationwide (including its partnership with the Santa Monica, Calif.-based HIE vendor Orion Health); and increasing provider participation to nearly 800 ambulatory sites and 33 hospitals—up from approximately 90 sites in July 2013, says NC HIE’s president, Chris Scarboro.
Additionally, says Scarboro, NC HIE has partnered with the state to connect approximately 1,500 ambulatory practices within a three-year period that began in 2013. Now in the second year of that phase, Scarboro says they are “well ahead of schedule.” He adds, “When you add in the partnerships with the hospitals in the state, the ramp-up in the last year has been substantial, and we project that to continue.”
How has NC HIE grown so much in the past year? According to Scarboro, for one, getting ambulatory care organizations, primary care practices, long-term health facilities, home health facilities, and specialty care practices connected has been extremely beneficial. “It’s not just about hospitals,” Scarboro says.
To that end, being in North Carolina has presented a somewhat unique opportunity to connect rural providers. “Rather than a challenge, being a mostly rural state provides us with an opportunity, as rural providers don’t provide a lot of the specialty services that many larger patient care organizations might,” says Scarboro. “For instance, if you look in [our state], we have six or seven large health systems and about 130 hospitals. So we’re mainly a rural state with pockets of urban people. In these rural populations, you have to refer out for specialty care and surgical care; you may have to go to Raleigh or Durham to get surgery. Then, you get discharged, go home to your rural area, and if you have an issue in the middle of the night, where do you go?”
The answer, continues Scarboro, is not back to Raleigh or Durham, but back to the patient’s home ER. And if that facility doesn’t have access to the patient’s record, you will get redundant testing and other potential issues with treating the patient. As such, there is real value in having rural communities connected to the HIE, Scarboro says. “These communities have needs around Direct and needs around getting physician communities connected, and a lot of them don’t have enterprise-wide electronic health records (EHRs). So we have had a lot of success with our rural communities so far.”
Furthermore, just recently, NC HIE announced that the Raleigh-based UNC Health Care facilities have become the first in the “triangle” region of the state to go live on the HIE’s integrated Direct secure messaging (DSM) solution. UNC Health Care also recently went live in the triangle on the Verona, Wis-based Epic Systems EHR, which when interfaced with NC HIE’s DSM solution, allows UNC physicians to share patient health data with North Carolina providers on any EHR system, not just other facilities using the Epic software.
“This was really significant for us,” says Scarboro. “Orion Health is our partner and they have recently upgraded to being able to put in capability to integrate Direct into the EHR system. That was a big driver for UNC Health Care’s participation because they had meaningful use monies attached to their transitions of care.” Scarboro adds that NC HIE now has 12 hospitals live on NC HIE’s EHR-integrated Direct secure messaging, and hospitals and providers continue to look at the organization for a solution around Direct.
However, there is a real challenge in getting organizations to see the value in the HIE, Scarboro admits. “But that’s why we feel very strongly about connecting the entire healthcare community. Right now, one of our biggest obstacles is that most systems are at work implementing their own EHR, which obviously brings on time constraints. HIE is just another project to them. But if you demonstrate how HIE complements what they’re putting into their own systems, and how it can help them achieve reduction in emergency departments and those types of metrics that they’re already monitoring, it gives us a better chance of success for long-term sustainability,” he says.
In retrospect, says Scarboro, the timeline of EHR implementation and data exchange would be staggered differently, with EHRs getting up and running first, and once that is completed, health information exchange could begin. “But hindsight is 20/20,” he admits. A lot of hospitals and practices are still in the process of implementing their systems, but they need to think about refining workflow, which is a huge component in how you engage in a system in a new record-keeping paradigm, Scarboro says. “You can’t just shift paper workflow into an electronic one—you have to optimize it. People are still coming to grips with that, and exchange has to compete with that. But exchange will continue to grow, in our state and nationally,” he says.
Scarboro wouldn’t go as far as others in saying that HIE is currently too difficult, however. “HIE is still very adolescent virtually everywhere, and while we’re early in the game, it’s inevitable that we will have a connected health system,” he says. “A good number of exchanges were born through the federal and state funding that was put in place through the meaningful use incentive program, but the funding was just falling off as the value was just coming to be realized. And that puts a lot of exchanges in a difficult position.”
Scarboro advises HIE organizations to look towards the successful models that are mature, that have been around for some time, and that have good relationships with their provider and hospital communities. “The successful organizations have been able to figure out a way to connect those communities efficiently, and in a timely and cost-effective manner,” he says. "They usually have working relationships with their state agencies. Through those components of value and partnering with their states, they have been able to create a sustainability model moving forward that everyone is relatively comfortable with.”