Health IT

Lessons from a state at the front lines of health information exchange

How does a state that’s been consistently ranked near the bottom of every “healthiest places” list, with high prevalence of obesity, smoking, diabetes and heart disease, find itself a leader in something as new and challenging as health information exchange? According to two of the guys helping run the show, it’s lots of forward-thinking people, […]

How does a state that’s been consistently ranked near the bottom of every “healthiest places” list, with high prevalence of obesity, smoking, diabetes and heart disease, find itself a leader in something as new and challenging as health information exchange?

According to two of the guys helping run the show, it’s lots of forward-thinking people, some business strategy and a little bit of luck.

The national push for HIEs came with the 2009 HITECH Act and the Office of the National Coordinator’s designation of $564 million to the State Health Information Exchange Cooperative Agreement Program. But even before that Indiana, Massachusetts, Delaware and a few other states already had HIEs up and running. While other states like California and Kansas have made slow progress in this endeavor, Indiana reports that 101 of its 123 acute hospitals are connected to a health information organization (HIO).

Five private, nonprofit regional HIOs provide interoperability services to Indiana health systems for exchange of test results, images and reports within their region. The largest of the HIOs, Indiana Health Information Exchange (IHIE), connects more than 90 hospitals and health systems. In 2009, IHIE and two of the other HIOs operating in the state — HealthBridge in the greater Cincinnati, Ohio area and HealthLinc in Bloomington — began sharing their information with each other. (The other two HIOs are Med-Web in northeast Indiana and Michiana Health Information Network in South Bend.)

That spirit of collaboration among competitors in an effort to provide more efficient, patient-centered care is what has put Indiana at the forefront of health IT, said IHIE CEO Harold Apple.

Improving data flow across the state’s providers started as a grassroots effort by forward-thinking CEOs from several of central Indiana’s major health systems in the early 2000s. They partnered with Indiana University’s Regenstrief Institute, BioCrossroads and state and local governments to form IHIE in 2004.

“Make no mistake, they are intense competitors in the delivery of healthcare, but they were farsighted enough to see that it would improve care overall,” Apple said.

Andrew Vanzee, the statewide health IT director, said the reason Indiana’s system works is because the market wasn’t developed from a top-down approach. “The major systems and hospitals came together and decided they weren’t going to compete on data,” he said. “Data was not going to be held hostage from one organization to another.”

Vanzee heads up Indiana Health Information Technology Inc. (IHIT), the state’s designated entity for the State HIE Cooperative Agreement Program. IHIT funnels and oversees federal dollars to the HIOs, and works to create investments in areas of common interest. Of the $10.3 million in federal dollars that Indiana received, about one-quarter of it is allocated to the HIOs for up-front implementation and another quarter is used as incentive for them to work together and drive the providers they serve toward using EMRs.

But that funding isn’t going to keep coming, Vanzee said, so long-term sustainability has to be achieved at a state or regional level. That’s the big challenge facing other states that are trying to do in a two- to three-year period what Indiana has been doing over the last 10 years.

IHIE operates with funding from IHIT but also generates revenue from user fees that are charged to the providers it serves. That private sector-driven approach is another key to the state’s success, Apple said.

According to a 2012 Brookings Institute report, only 10 percent of the country’s 255 HIE initiatives said they had a sustainable business model and many of them are trying a handful of different approaches. Vermont, for example, instituted a health IT fund that collects tax dollars from commercial health insurance claims in order to generate revenue for its HIE networks. New York has relied heavily on state money to build its infrastructure. Others have physician-payer collaboratives or for-profit HIEs that are privately funded.

Part of the problem with getting HIEs funded is lingering resistance from some providers who have concerns that range from privacy and security to competition. According to the 2011 HIMSS Leadership Survey, one-third of senior IT executives polled said their organizations hadn’t even begun to plan to participate in an HIE.

Creating additional value in HIEs by not only translating and transferring medical records but also storing, consolidating and analyzing that data to provide a longitudinal view of trends and outcomes in care, is another way Indiana has been successful, Apple said.

But in this area, the state still has some hurdles to jump. “HIE is often seen as that last-mile effort, so many of these organizations are busy going through EMR implementations and other IT projects, and it’s something that they see themselves doing in a year or two,” Vanzee said. Particularly, long-term care and behavioral health providers have typically been left on the outside, he said, and other stakeholders like insurers and employers could be pulled into the equation too.

According to Vanzee, the state’s next goal is to be able to use information from the HIEs to populate personal health records for consumers. In the fall, Indiana received $3 million in supplemental funding in the form of State HIE Challenge Grants, some of which is being used to work with a Fort Wayne-based personal health record company, NoMoreClipboard, to do just that at 12 pilot sites across the state.