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HIEs Essential in Fee-for-Value Era

 |  By kminich-pourshadi@healthleadersmedia.com  
   October 02, 2012

This article appears in the September 2012 issue of HealthLeaders magazine.

The pursuit of population health and value-based care may be reviving the business case for organizations to join health information exchanges. Now more than ever providers need accurate and complete patient data to effectively manage chronic care populations and attain incentive payments; this means healthcare organizations must have the ability to capture their own data as well as that of their affiliates and competitors. Health information exchanges just became an essential for providers looking to succeed in the fee-for-value era. 

An HIE is an organized regional network that enables hospitals, physicians, and other care providers to upload and access patient health information. HIEs connect data for organizations—from affiliates to competitors—to share clinical data that can improve a patient's overall care. The HIE is generally connected through a provider portal, giving easy access to clinical applications that allow caregivers to see all of the patient's clinical information in real time while restricting access to any claims data or other financial information. Early data indicates the HIE can reduce costs for participants.

In May, the Journal of the American Medical Information Association released a study of the members of the MidSouth eHealth Alliance in Memphis, Tenn., that focused on emergency department encounters and reported that the HIE was responsible for reduced costs of  $1.9 million and a net savings of $1.07 million; reduced admissions accounted for 97.6% of the total savings. The study looked at HIE use across 12 hospitals over a 13-month period and included 15,798 HIE encounters.

Though preliminary results indicate HIEs can help healthcare organizations save money, there's still reluctance by some in healthcare to participate in these exchanges. "It's understandable," says Steve Robertson, executive vice president and CIO at Hawai'i Pacific Health, a four-hospital system with three physician groups based in Honolulu. "There's still a lot of uncertainty about the cost that hasn't been worked out, especially in these very difficult economic realities of healthcare reimbursements, like who will pay for it—the government, the insurance companies, the laboratories, the hospitals, the physicians?"

Robertson, who manages IT for HPH as well as the revenue cycle, says healthcare leaders need to look at HIEs for long-term health improvements, not short-term tactical gains. An HIE allows immediate access to a patient's medical history for all providers involved in that patient's care, which makes information gathering and analysis easier for the physician and clinical staff, he says.

HPH helped to found the nonprofit Hawai'i Health Information Exchange in 2006 and has helped it evolve. The Hawai'i HIE is governed by its participants and is funded by participants, state grants, and donations. HPH recently donated more than $100,000 to the state HIE program.

HPH and its competitor, Queens Medical Center, exchange patient clinical information so if HPH patients receive treatment at Queens Medical, the doctors are able to access their medical records. "We've been able to save lives doing this," Robertson says.

"There is a competitive advantage to having data, and many healthcare organizations may not be willing to share with others. But patients can in some cases have five or more doctors working with them. It can be more dangerous for our patients if the data is fragmented, and that puts everyone involved at risk," says Robertson. 

Moreover, having the clinical data when a patient presents for treatment can be a lifesaver, especially for patients visiting the island, Robertson says. With tourists coming from all over the country to Hawaii, health exchange enables HPH and other participants to link to critical data on the mainland, and helps reduce the likelihood of duplicate tests or other ancillary services, ultimately decreasing overutilization of services for participants. 

Participating in the HHIE is part of a larger effort by the state to encourage its healthcare providers to get involved with patient-centered medical homes, Robertson says, and the exchange will help track the results as these efforts get further along.

As the HIE in Hawaii picks up steam, in Cincinnati, HealthBridge, an HIE developed in 1997, is fully established in the healthcare community. HealthBridge, a nonprofit corporation, serves parts of the tristate area of Ohio, Kentucky, and Indiana. HealthBridge launched without any government funds, receiving its start-up money from investments by two health plans and five health systems. Each of these founding funders maintains a seat on the HealthBridge board of directors along with other community employers, physicians, and representatives of public health. The composition of the board has successfully allowed competitors to work through concerns surrounding data sharing, allowing for even greater adoption in the region.

"Whether to participate in HIE is a strategic conversation … but all the participants have to be willing put aside their individual issues and agenda and to work toward a solution that's best for the patient. If you treat participation in an HIE as a competitive advantage, then you won't get anywhere; but if providers get beyond their differences, then everyone can benefit from economies of scale from sharing information," says James Gravell, senior vice president and CFO at Catholic Health Partners based in Cincinnati. CHP is the largest health system in Ohio and one of the largest nonprofit health systems in the United States, with $5.4 billion in assets and 24 hospitals.

Gravell began working with HealthBridge more than 10 years ago as interim president and CEO of the three-hospital Community Mercy Health Partners and acted as HealthBridge's board chair when it was established. In the 15 years since it started, HealthBridge's HIE network has grown to more than 50 hospitals and 7,500 physicians in three states and transmits an estimated three million electronic messages per month, including clinical lab results, radiology reports, operative notes, discharge summaries, and other clinical information. The HIE connects more than 80% of physicians and acute care hospitals within its service area, and as of 2011, it estimates it has reduced healthcare costs to participants by over $20 million annually.

Although the American Recovery and Reinvestment Act allotted grants to encourage the establishment of HIEs, participating in an HIE still doesn't come free. Participants must have an EHR in place, and most HIEs ask participants to pay a fee to connect; that price can vary depending on an organization's size and the degree and complexity of the connectivity needed.

For instance, the fee for a hospital HealthBridge subscription includes a predetermined portion that management has allotted be covered by hospitals (a cost spread among all participating hospitals) and is based on the hospital's gross expenses. In addition to that amount, participants pay an EHR data exchange fee based on how much data a participant receives and sends.

"When HIE started in Cincinnati, it paid for itself for participants just in the elimination of fax and mail cost, but the technology has gotten better and it costs more," says Gravell. "The federal government is spending billions to digitize healthcare … and there's a renewed interest in capitation and population health. Whereas episodic care doesn't require data, population health does. HIE is the solution to community health."

As of 2010, HealthBridge began working to aggregate raw data from its participants to help its members pursue population health initiatives and related payment models. It's an effort that has led the HIE to connect to organizations beyond physician groups and hospitals, such as long-term care facilities and home-care agencies.

Gravell notes population health management is generally accompanied by incentive programs such as pay-for-performance or shared savings, which are designed to motivate doctors to make less costly treatment choices for patients and to manage the total cost and treatment of a patient beyond a single encounter.

However, these incentive programs shift a great deal of payment risk from the payers onto the providers. Reimbursement is based on data showing a patient's progress, which requires complete clinical data. Without that, physicians cannot fully and accurately treat a patient, and that can influence outcomes and decrease incentive payments. All of that makes participating in these programs less appealing to physicians. 

"There's no way to prevent patients from going outside a network, but you can't manage a population without having all the information. HIEs give providers a tool to get all the information," says Gravell.  

The Indiana Health Information Exchange, a nonprofit organization formed by the Regenstrief Institute, private hospitals, local and state health departments, BioCrossroads, and other healthcare and community organizations in that state, is making some progress with population health. IHIE links more than 93 hospitals, long-term care facilities, rehabilitation centers, community health clinics, and other healthcare providers and affects in excess of 10 million patients.

In June the Central Beacon Community Program, the IHIE, and the Office of the National Coordinator for HIT released the first-year results of a three-year study looking at the use of HIE in Central Indiana. In just one targeted area—to increase the number of colorectal cancer screenings—participants increased screenings by nearly 15%. In March 2010 (prior to the Beacon program), 57.54% of the measured population received the necessary colorectal cancer screening, but as of December 2011, more than 66% of patients were screened.

The program's goal was to drive improvements for patients and the community by "supporting better chronic disease management, better utilization of healthcare services, timely preventive care services, and to give a real-world national health IT model that achieves measurable and sustainable improvements," according to a St. Vincent Health statement. St. Vincent was among the participants in the study.

"By pooling of the clinical and financial data, and then the blinding of proprietary information allows all providers to get a truer picture of what's happening with the patients, and that's what's needed to manage a population," says Alan D. Snell, MD, chief medical informatics officer at the 22-hospital system St. Vincent Health (a member of Ascension Health) in Indiana. In June, Snell was among 82 healthcare providers in the United States to be recognized by the White House and the Department of Health and Human Services for their work with health IT.

The need for more useful population health data has the IHIE compiling health data that allows providers to track improved health outcomes for patients and is specifically focusing on areas such as cancer screenings, diabetes care, heart health, asthma care, well-child visits, and other care interventions. As the study will take three years to complete, no additional outcomes data could be released.

"As we roll toward ACOs, we're going to see more providers having to contract with some sort of entity, and there's a financial risk involved. The better the performance you have and can show proof of, the better rewarded providers will be financially," says Snell. "Over 2,500 primary care providers in Central Indiana receive reports through IHIE's Quality Health First program and they can see how they compare with their peers on prevention and chronic disease management. That also ties to the financial incentives that hospitals and payers have with providers—if they hit their quality marks, that can add up to significant dollars. And that's beginning to help us see significant improvements in the quality indicators for those participating providers. Now we have the whole medical community moving toward pay-for-value and away from
pay-for-service," explains Snell.

Snell says that Indiana has come a long way from when it started its HIE and now has five, noting that the issue of working with competitors was a very real one when it began.

"You have to work with your competitors because patients are going to expect providers to be able to access their clinical information wherever they happen to be, and not being able to do so will become a competitive disadvantage," says Snell.

With the majority of HIE organizations, governance is coming from the participants, [so] it's unlikely that the "wrong" information will get shared, Snell says. "HIE isn't a Wild West–type of business; health information is tightly regulated through HIPAA and state laws, and maintaining business security and confidentiality of that information is paramount for our participants," says John Kansky, vice president of strategy and planning for IHIE. "We have very detailed data usage agreements that reference the powers of our governance body. If we come up with an idea for how to use data, the governance body has to approve it before we can pursue it."

Though regional HIE networks are the first step for many healthcare organizations, the future of HIEs lies in eventually linking all HIE networks nationwide. But before healthcare can achieve this goal healthcare leaders must make a clinical and financial leap of faith by working with competitors, says Gravell.

"For CHP, HIE is something we are looking at for every community we're involved in," he says. "We feel strongly that from both a financial and IT perspective using HIE is a more cost-effective way to move information, and having access to that information in real-time is the right thing to do for our patients."

Reprint HLR0912-8


This article appears in the September 2012 issue of HealthLeaders magazine.

Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media.
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