• Meaningful Health Information Exchange

    Lola Butcher

    Spurred in part by Stage 2 meaningful use rules that require information exchange, healthcare providers are testing many approaches for electronically sharing information among hospitals, physicians, patients, and others in the continuum. 

    meaningful hieHealth information exchange means different things to different stakeholders. To a solo practitioner in Pasadena, Calif., it means having ready access to information about the treatment her patients have received in the local hospital and from other physicians—even though she does not have an electronic health record (EHR). 

    To a skilled nursing facility in Boulder, Colo., it means an end to 50-page faxes when patients are transferred from the local hospital. “This new portal allows us to grab information that is important to us and not be inundated with irrelevant stuff we do not need,” says Patrick McAteer, CFO, Frasier Meadows Retirement Community.

    To an emergency physician in Milwaukee, information exchange means fewer duplicate imaging tests for emergency department (ED) patients—and faster throughput for those ED patients who have had many previous visits. “We can assess the medical behavior of patients before we make decisions about their workups or their treatments,” says Cory Wilson, MD, emergency medicine physician, Wheaton Franciscan Healthcare. “Knowledge is really powerful, and in our field, it’s gold.”

    Seeking Ways to Exchange

    Health systems are engaging in three distinct forms of electronic information exchange:

    • Directed exchange, in which they send and receive secure information between care providers to support coordinated care
    • Query-based exchange, which allows providers to request specific information about a patient from other providers
    • Consumer-mediated exchange, in which patients access their health records and share the records with providers of their choosing

    Some health systems are building their own electronic health information exchanges (HIEs) or creating ways to give patients direct access to their medical record information, while others are linking to regional or statewide HIEs—and a few are pursuing multiple approaches.

    One motivation is the federal government’s final Stage 2 meaningful use rule, which requires hospitals and physicians to provide an electronic summary of care for more than 10 percent of patients who are transferred or referred to another care setting. Equally important, though, is the necessity of information exchange for improving care and coordination. 

    Huntington Memorial Hospital in Pasadena, Calif., built a communitywide HIE of clinical information and images to improve patient care—and to help ensure the financial viability of the more than 2,500 physicians providing care in the community. “We’re not going just for meaningful use. We’re going for meaningful value by improving the quality and cost of care. So we are out ahead of the mandates and requirements,” says Rebecca Armato, executive director for physician and interoperability services. 

    “Some of the EHR vendors have said, ‘Look, we don’t have to exchange data until Stage 2.’ We respond with, ‘This isn’t about Stage 2; this is about patients who need care and physicians who need access to information that is necessary for care collaboration and to provide the best quality of care now.’”

    Engaging Patients with Information

    Providers who give patients access to their health information achieve two important goals: They increase patient engagement and facilitate information sharing among providers.

    Access to clinicians’ notes. By this time next year, all patients treated by clinicians at Beth Israel Deaconness Medical Center will be able to click into PatientSite, the Beth Israel Deaconness patient portal, to read their clinicians’ notes. This decision came after a year-long OpenNotes pilot involving 39 physicians and 10,000 of their patients. When the pilot ended, 99 percent of participating patients said they wanted continued access to physicians’ notes, and no physician elected to turn off his or her patient’s access to notes (see the exhibit below). 


    “We honestly did not know whether patients would read them,” says Janice Walker, RN, MBA, who helped conduct the study. “Boy, did they.” Indeed, 84 percent of the Beth Israel Deaconness patient participants who had access to notes read at least one. Patients surveyed after the trial said that reading the notes helped them understand their health conditions better and remember their care plans. 

    What’s more, 20 percent of patients reported that they shared a physician’s note with others, and 60 percent said that reading the notes prompted them to take their medications as prescribed. Patient-reported data is often overstated, says Walker who discounts this finding but still finds it encouraging. “It would be a huge improvement even if just 10 percent of patients become more diligent about taking their medications because getting patients to do that is really hard,” she says. “The bottom line is that this is a win for everybody if patients become more engaged.”

    At the end of the study, BIDMC leaders decided to expand OpenNotes across the institution.

    Reducing needless images. Meanwhile, the ongoing battle to reduce unnecessary medical imaging is just about to get a big weapon, courtesy of direct-to-patient information exchange. RSNA Image Share—an initiative of the Radiological Society of North America—is a network that allows radiologists to share medical images with patients using personal health record (PHR) accounts. Patients, in turn, can share those images with other physicians, reducing the need for duplicate images.

    Redundant images are often cited as a culprit of America’s high healthcare costs. In 2008, 19 percent of surveyed patients reported that their physician had ordered a test that had already been done in the past two years (Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, The Commonwealth Fund, 2011). 

    Radiologist David S. Mendelson, MD, senior associate for clinical informatics at The Mount Sinai Medical Center, gives the example of a patient who has a magnetic resonance imaging (MRI) of a knee and goes shopping for an orthopedic surgeon. If the patient is connected to RSNA Image Share, he could log on to his PHR at the surgeon’s office to show what the knee looks like on the inside.

    David Mendelson

    “Better yet, the patient can send an email link credentialing the surgeon to look at his images in the personal health record account whenever the surgeon wants to,” says Mendelson, principal investigator of the RSNA Image Share project.

    Currently, images are most often shared on compact discs (CDs), a technology that seemed terrific at first but has proven problematic. For one thing, CDs are easy for patients—and physician offices—to lose. For another, CDs are not standardized so physicians are not always able to access the images they need. 

    To address this problem, Mount Sinai and four other health systems—Mayo Clinic, University of California- San Francisco, University of Chicago Medical Center, and University of Maryland Medical Center—received funding from the National Institute of Biomedical Imaging and Bioengineering (NIBIB) to create and test the technology that supports the Internet-based network. So far, about 2,000 patients are enrolled.

    Recently awarded another $10.5 million from the NIBIB, the RSNA Image Share creators plan to expand the network rapidly. “We are aggressively extending this service throughout the nation,” Mendelson says. “We have a plan over the next two years to target different parts of the country and try to extend this to hundreds of imaging centers and hospitals.”

    Improving Care Transitions

    In Colorado, a statewide HIE system that uses both query-based and directed exchange is improving coordination of patient care. The 14-hospital Centura Health system in Colorado and Kansas had started building a private HIE before the Colorado Health Information Organization (CORHIO) started. Even though it costs more, Centura Health CIO Dana Moore calls switching to the statewide exchange a “no-brainer.”

    For one thing, it helps reduce duplicate testing. For another, it improves care when patients move from one care setting to another. “We believe that, as the largest provider in Colorado, we have a responsibility to the citizens of this state to lower healthcare costs and deliver excellent care,” he says. “We think the HIE is one way to do that.”

    caregive corhio

    As of January, there were 28 hospitals, two large commercial laboratories, nearly two dozen long-term care and home health providers, and two behavioral healthcare providers connected via CORHIO. In addition, more than 1,000 physicians are connected or in the process of connecting.

    “All told, we’re up to about 1.7 million unique patients whose information is now being exchanged within CORHIO—that’s about 25 percent of the state population,” says CORHIO CEO Larry Wolk, MD, who points out that the number grows weekly.

    CORHIO provides a real-time data feed of admission/discharge/transfer data, laboratory reports, imaging data, and transcriptions from hospitals. Currently, the larger hospitals are primarily senders of data while critical access hospitals, physician offices, and long-term care providers are receivers; however, some hospitals receive data from other providers through portal access in their EDs.

    Of course, the plan is for data to eventually flow among all entities connected to CORHIO. Four physician practices are starting a pilot to send their information via a continuity of care document (CCD) to hospitals. A CCD is a standardized HIE feature that contains a core data set of administrative, demographic, and clinical information facts about a patient’s health care; the CCD has been deemed an acceptable format for meaningful use. “I emphasize the word ‘pilot’ because the technology is not quite there, despite what EHR vendors might say,” Wolk says. 

    What is possible: providing nursing homes with useful information about patients being transferred from hospitals. Incomplete data leaves nursing home caregivers unaware of diagnoses, medication regimens, and care plans that are essential to providing proper care in the facility. “It’s important for us to get the nursing homes connected so their physicians and nurses can deliver the care that is needed so the patient doesn’t end up back in the hospital,” Moore says. 

    CORHIO received a federal grant to test the hypothesis that HIE can improve transitions of care for patients between hospitals and post-acute care providers, including nursing homes, assisted living facilities, home health, and hospice agencies. More than 20 skilled nursing facilities have already connected, and Wolk expects more to join this year. The grant allows CORHIO to waive a $2,000 interface fee for the post-acute facilities that connect to the exchange. Each facility or agency pays a monthly subscription fee that ranges from $200 a month for a 50-bed facility to more than $2,000 a month for a facility with 350 beds or more.

    Frasier Meadows, a continuing care retirement community in Boulder, is proud to be the first senior facility to connect to CORHIO. Since mid-2012, its 108-bed skilled nursing facility has been using a web portal to access data about patients being admitted from the local hospital. By this spring, the connection will allow the hospital’s data to populate the nursing home’s EHR—and eventually Frasier Meadows will extend HIE to its assisted living facility as well. 

    Before linking to the HIE, Frasier Meadows suffered from too little—and sometimes too much—information from hospitals, says CFO Patrick McAteer. Discharge paperwork coming from a hospital might spill out in a 50- or 75-page fax that, instead of being comprehensive, was confusing and incomplete. In contrast, staff at skilled nursing facilities connected to CORHIO can now query the HIE to obtain specific data that are needed to understand a patient’s medical condition.

    “Oftentimes when a patient would present, we did not have the most current lab work or we didn’t necessarily know what had happened on the hospital side,” he says. “CORHIO gives us good information on the patients as they are presenting.”

    Equally important, the HIE system allows Frasier Meadows to avoid accepting patients who are ill-suited for the facility, which can often lead to hospital readmissions. “When the hospital is contemplating a discharge, we can obtain information to make sure the patient is appropriate, based on our skill level and the patient’s requirements,” McAteer says.

    Increasing ED Throughput

    Meanwhile, a different kind of query-based HIE links 15 EDs in five competitive health systems in the greater Milwaukee area, allowing physicians to see a summary of a patient’s healthcare activities for the past two years. 

    The Wisconsin Health Information Exchange is populated with real-time registration data—date, chief complaint, allergy and reaction, and primary diagnosis—for all patient encounters. The HIE also includes Medicare insurance claims data, so it shows procedures performed and prescriptions filled. The system also allows providers to post messages related to their encounters with specific patients; those messages become part of the patient’s record, available to other providers in the future.

    “For our emergency medicine group, this has dramatically changed our practice,” Wilson says. “If a patient comes in with a headache, and he has never been to an emergency department or seen anybody for a headache, I’m going to look at that case much differently than a patient who has had 30 visits for a headache in two years.”

    Although the HIE does not currently show the results of a patient’s previous CT scan, it helps physicians find out what tests the patient has had recently. Just knowing that a CT scan was performed may dissuade the physician from ordering a new one. That saves money and reduces the patient’s stay in the ED. 

    cory wilson

    “If you add that up over the course of a day for headaches, chest pain, abdominal pain, and back pain—many of the complaints that we see day-in, day-out—this enables us to reduce those length of stays significantly,” Wilson says. “It reduces bottlenecking, reduces wait times, and increases the throughput of the department. It’s wonderful.”

    Indeed, preliminary results of a physician survey show that physicians using the HIE altered their workup or treatment of the patients 42 percent of the time. Additionally, the time they spent gathering data decreased by 42 percent, and the time to an ED disposition decision decreased in about half the cases (Tzeel, A., et al, “The Business Case for Payer Support of a Community-Based Health Information Exchange,” American Health & Drug Benefits, vol. 4, no. 4, July/August 2011, pp. 207-215).

    Supporting Independent Physicians

    In Pasadena, Huntington Memorial Hospital is building a communitywide HIE with a virtual patient record that will eventually allow more than 2,500 independent physicians in the San Gabriel Valley to securely collaborate and coordinate patient care. The HIE facilitates secure information exchange irrespective of the technology the caregiver, hospital, nursing home, or other providers use.

    “Only 1,000 of those 2,500 physicians are on our medical staff, yet we are opening this up to all the physicians and connecting all of them,” Armato says. “To improve the health of our community, all physicians providing patient care need to be connected.”

    Currently, about 500 physicians are connected to Huntington Health eConnect. By the end of 2013, Armato intends to have all physicians connected. Physicians who do not have an EHR system—or whose system does not accommodate information exchange—are able to access the HIE through a secure web portal. If a physician’s EHR does allow information exchange, Health eConnect pushes the information that the physician requests (for example, imaging reports or discharge summaries) from the hospital or other providers directly into that physician’s EHR.

    Huntington decided to build the communitywide HIE back in 2009 to support improved patient care, greater efficiency through enhanced care coordination, and a better environment for physicians. The Pasadena market features a high cost of living but relatively low pay rates for physicians, Armato says.

    “We made a decision that we have to improve the financial viability of the practices in our marketplace, and this kind of technology supports that,” she says. “We knew we had to work in partnership with our physicians to provide care to our community, and we knew that this was the kind of infrastructure that we needed to do that.” 



    Thinking about ROI 

    Early EHR adopters worried about ROI, but HIE pioneers are much less focused on it. For one thing, many HIE initiatives are being subsidized by grants; for another, the ability to exchange information is seen as a cost of doing business for any health system trying to meet the federal government’s requirements.

    Direct-to-patient information exchange. For a hospital that already has a patient portal, the expense associated with giving patients access to physician notes may be nominal. Beth Israel Deaconness’ Walker said programmers needed a few weeks to make notes available to the pilot group of patients and then a few more weeks to expand access after the medical center decided to implement OpenNotes throughout the institution.

    In addition to patient engagement, she believes the big payoff may be in patient safety. Both physicians and patients in the OpenNotes pilot reported situations in which the note referred to a test or prescription that the physician forgot to order—until the patient read the note and noticed the oversight.

    All costs for the RSNA Image Share are currently covered by grant funding but that will eventually end. Over the next two years, RSNA will test various business models with the goal of making the service affordable for radiology departments or possibly even patients. “Or maybe the payers will pick up the cost because they stand to save a lot of money if we reduce redundant inappropriate imaging,” Mendelson says.

    Information exchange between providers. In the fee-for-service world, if health information exchange helps avoid a duplicate image or inpatient admission, the hospital suffers financially because of it. But emerging payment models will change that dynamic. “In a bundled payment world, if I don’t have to do that test again, that is going to help me financially,” says Moore, the Centura CIO.

    Huntington Hospital’s Armato says the cost of sending information to physicians via its direct exchange HIE is less than the cost of faxing and mailing the information—sometimes repeatedly because reports sometimes get lost in physician offices and are not available when the patient shows up for an appointment. 

    “We base-lined all of our costs and said, 'You know what? This is a smarter way to do business,'” she says. “So why would we make it a hurdle for physician offices to adopt this when this is our preferred method—and a more cost-effective method of getting information to them? Plus, the information is there where they need it, when they need it.” 

    Payer access to patient information. CORHIO intends to ask private insurers to help sustain the HIE. “Payers need to come to the table because they are all asking hospitals for point-to-point interfaces that tell them when their patients are in the hospital,” Moore says. “The reality is, in a fee-for-service world, insurers receive the biggest financial benefit from an HIE.”

    Learning from the Pioneers 

    The healthcare leaders interviewed for this article offer several suggestions on how to make an HIE launch successful.

    Educate and involve physicians. Many physicians are hesitant about information sharing. Although physicians have been quick to embrace Huntington Health eConnect, Armato says that is only because she and her team spent three months making presentations in their offices.

    “That conversation had to happen. You can’t just make an announcement and then not go touch everybody,” she says. “You have to look them in the eye and tell them, ‘This is what we’re doing. We are trying to help you survive and improve the patients’ quality of care and experience, and we have got to do this together.’”

    Huntington also recruited physicians to help select the HIE technology and helped coach them as they selected EHR technology that could leverage and connect to the HIE. “Electronic medical record and information exchange vendors tend to show the ‘wow’ features,” Armato says. “We educated physicians and their staffs to make sure they focused first on ensuring that the access and exchange of information was efficient and effective before the bells and whistles came into play in the decision.”

    Think carefully about pricing strategy. Centura Health’s Moore and other CIOs involved in the Colorado-wide HIE initially proposed a pricing model that physicians rejected, saying it was too much for them to afford. To lower the price for physicians, hospitals agreed to pay more. “We all agreed that that’s fine,” he says. “If we are just sharing information hospital to hospital, it’s not exactly the Bridge to Nowhere, but that’s not where most of the care takes place. It takes place in the physician’s office, and that’s who we need to get connected to CORHIO.”

    Engage consumers. Health systems need to educate patients about how information exchange can improve their health care—and encourage them to become advocates. “Hospital administrators need to acquire HIE for themselves, and they need to do it as a way to engage and be good business partners with their providers in their community,” Wolk says. “But they also need to do it for the patients because this is what’s best for patients.”

    Train operational leaders. Make sure all operational leaders—not just the IT staff—are engaged in the HIE launch and are knowledgeable enough to give status reports on the HIE rollout and address questions about functionality. Technology staff cannot do this all alone. 

    Getting Ready for Growth

    One last lesson: Once you get started with health information exchange, it will be hard to keep up with the pace. Because information exchange is so helpful to physicians, they may clamor for connectivity more quickly than expected. 

    “Be prepared and have a Plan B that you can execute quickly if you have more demand than you can fill,” Armato says. “We found out early on that we had to really get in front of a lot of people a lot faster than we expected as the word spread.”

    Lola Butcher is a freelance writer and editor based in Missouri. 

    Interviewed for this article (in order of appearance): Patrick D. McAteer is CFO, Frasier Meadows Retirement Community, Boulder, Colo. (pmcateer@frasiermeadows.org). Cory Wilson, MD, is emergency medicine physician, Wheaton Franciscan Healthcare, and president, Emergency Medicine Specialists, Milwaukee (wileyhouse1@mac.com). Rebecca Armato is executive director for physician and interoperability services, Huntington Memorial Hospital, Pasadena, Calif. (rebecca.armato@huntingtonhospital.com). Janice D. Walker, RN, MBA, is principal associate at Harvard Medical School, Boston (jwalker1@bidmc.harvard.edu). David Mendelson, MD, is senior associate- clinical informatics, The Mount Sinai Medical Center, New York City (david.mendelson@mountsinai.org). Dana Moore is senior vice president and CIO, Centura Health, Englewood, Colo. (danamoore@centura.org). Larry Wolk, MD, is CEO, Colorado Regional Health Information Organization, Denver (lwolk@corhio.org).

    Sidebar: What Physicians Want from an HIE

    • Improved practice viability
    • Reduced operating costs, inefficiencies
    • Increased value of their EHR investments
    • Control of what data flows into their EHRs
    • Something quick, easy to use within “thought flow”
    • Access from their device of choice
    • Ability to continue practicing as long as possible
    • Independence without isolation

    Source: Huntington Memorial Hospital. Reprinted with permission.