Health Affairs, 24, no. 5 (2005): 1190-1196 doi: 10.1377/hlthaff.24.5.1190 © 2005 by Project HOPE	New Online   McAllen, TX & Beyond: An Expert Roundtable   Geography & Reform   Medicaid or Insurance Exchange?   Siren Song of New GME   Public Plan Option: Pro & Con

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Implementation

PERSPECTIVE

State And Community-Based Efforts To Foster Interoperability

Abstract

 
The MidSouth eHealth Alliance is developing a comprehensive health information infrastructure supporting providers in three Tennessee counties. Success in the alliance’s first year is the result of sustained leadership, a systematic assessment of regional needs and capabilities, a flexible technical architecture, and a critical review of best practices from four different data exchange models already operating in other states. Long-term evolution to a truly interoperable health information infrastructure will depend on the extent to which the alliance demonstrates value to consumers and practitioners.

In parallel with these efforts, the governor announced a regional health information technology (HIT) demonstration project in the southwest region of the state, the MidSouth eHealth Alliance. This project’s goal is to create a health information infrastructure improving the care of people in three urban and rural southwest counties.

Planning for the demonstration project began in the summer of 2004. During a six-month period, planners assessed the region’s needs, examined technical capabilities within the state, and reviewed four different models for information exchange operating in other states. From these analyses they developed a governance model, an organizational structure, an initial technology architecture, and a formal evaluation framework. This paper documents how these early decisions were made and how they have affected the MidSouth eHealth Alliance during its first year.

Models For Interoperability

Top Models For Interoperability Tennessee: The MidSouth eHealth... Roles And Responsibilities NOTES

 
The Tennessee planning teams studied four prominent models implemented in other regions and states. Sharing many common goals, the models differ in their initial objectives, early guiding coalitions, governance, technologies, assessment frameworks, business models, and evolution.

Santa Barbara. The Santa Barbara County Care Data Exchange is among the earliest community-based approaches to connectivity.² This effort, begun in 1998 and funded by the California HealthCare Foundation (CHCF), is designed to coordinate the care of county residents across a broad range of care settings. It is led by a public-private community coalition. The technology architecture is based on a distributed, point-to-point transaction system supporting individual and community health needs. More recent initiatives often base some of their governance and business planning on the Santa Barbara model.

Massachusetts. A second community-based approach began in 1978 when the Massachusetts Health Data Consortium built the state’s first all-hospital, all-payer centralized inpatient database for public reporting on use and market share. This effort created an atmosphere of collaboration among traditionally competing organizations and helped information technology (IT) leaders from these institutions approach common challenges in a consistent way.

The Massachusetts experience demonstrates how collaborations can evolve. In 1995 the consortium created the CIO Forum to set strategies and projects for the region’s health information infrastructure. This group addressed common issues of security, privacy, clinical encounter data sets, and Health Insurance Portability and Accountability Act (HIPAA) compliance. In 1997 the New England Healthcare EDI Network (NEHEN) was spun off by three provider organizations and two payer organizations to share HIPAA-mandated administrative transmission development costs. The financial savings incurred through this approach have increased participation. Four-fifths of the administrative health care transactions in Massachusetts are now conducted through this network.

In 2003 the consortium formed MA-SHARE (Massachusetts Simplifying Health-care Among Regional Entities) to accelerate clinical data exchange. Initial MA-SHARE projects focus on e-prescribing and real-time access of medication histories from health plans to hospital emergency departments.³ MA-SHARE also works with the Markle Foundation to test generalized approaches to identifying and retrieving medical information from multiple sources.

In 2004 MA-SHARE joined thirty-four other state organizations to create the Massachusetts eHealth Collaborative. The collaborative will sponsor three communitywide pilot programs to accelerate adoption of electronic health records (EHRs). As part of the pilot, participants will develop operational and financial models that will guide statewide adoption of EHRs. Leadership for this effort includes the governor of Massachusetts. Funding includes a $50 million contribution by Blue Cross Blue Shield of Massachusetts.⁴

New York. The Taconic IPA (independent practice association) in New York uses its physician base as a core for a comprehensive, practice-oriented health information infrastructure that includes clinical information systems and secure networks.⁵ Hospitals, clinical laboratories, health plans, and pharmacies subscribe to its network to communicate more effectively with practitioners. IPAs in Colorado, Oregon, and other states are adopting similar models. Often they combine these collaboration networks with organized means of capitalizing and maintaining ambulatory care information systems. These approaches are relatively inexpensive; create immediate value to physicians; require low degrees of standardization; and do not require broad consensus among hospitals, health plans, or other traditional sources of concentrated capital and power.

Indiana. The Indianapolis Health Information Exchange (IHIE) has pioneered a fourth approach.⁶ Initially, the IHIE used its central database at the Regenstrief Institute to increase the value of clinical communications to a limited number of practitioners, public health agencies, and hospitals. Established primarily with grant and institutional support, the IHIE did not rely on state-level political leadership, major funding from health plans, or universal participation. With little early competition and low initial participation costs, the network’s early success was attributable to a willing critical mass of adopting entities who found value in using this technology as their primary means of communicating with community physicians.

The IHIE is now used by several thousand physicians and staff. It has demonstrated savings in hospital emergency department (ED) settings and has become a core element in the community’s approach to health care delivery and financing.⁷ A sustainable business model is suggested by the savings conferred to providers and to those organizations that must communicate with these providers. Additional revenues may come from facilitating pharmacy transactions, aggregating the collection of quality data, and coordinating pay-for-performance programs.

Tennessee: The MidSouth eHealth Alliance

Top Models For Interoperability Tennessee: The MidSouth eHealth... Roles And Responsibilities NOTES

 
In June 2004 Governor Bredesen proposed a comprehensive health information initiative for three counties in southwest Tennessee. The initiative has five major goals: to provide greater access to needed clinical information in order to improve the care provided to the community; to understand the organizational, financial, legal, and technical barriers impeding the developing of regional health information infrastructures; to study the costs and benefits of these initiatives; to implement and evaluate interoperability standards required for a national health information infrastructure; and to develop a private-public market for interoperable HIT.

The initiative evolved from an effort begun several months earlier designed to achieve interoperability among information systems used by the state’s largest public hospital and more than a dozen of the region’s ambulatory care facilities. Health data exchange technologies developed at Vanderbilt University were to be employed because of their immediate technical applicability.⁸

As awareness of this initiative grew, health care leaders recognized that the problems this technology addressed were not unique to the public hospitals and clinics identified in the governor’s original proposal. Throughout the region and the state, hospital EDs, labor and delivery wards, pediatric clinics, primary care practices, retail pharmacies, and virtually every other health care organization were limited in their ability to provide efficient care because critical information about past diagnoses, treatments, and preventive care was not available when people sought care in different hospitals and clinics. Many of these challenges could be addressed if patients and health care professionals had access to medication lists, medical problem lists, immunization records, allergies, hospital discharge summaries, and related clinical information already collected but resident in systems not accessible to those delivering care. These general needs suggested that the cost-effectiveness of an HIT infrastructure could be dramatically increased if the project initially envisioned to support a few hospitals and clinics could be expanded to address the needs of a three-county region.

To validate this hypothesis, a six-month regional planning effort began in August 2004. This effort assessed the readiness of facilities; identified common clinical data requirements; estimated benefits to every stakeholder type; and presented both an organizational and financial plan for creating a regional initiative. The planning effort was conducted in conjunction with a regional HIT demonstration project contract funded by the Agency for Health-care Research and Quality (AHRQ), the State of Tennessee, and Vanderbilt University.⁹ The contract requires demonstration of some data exchange by October 2006 and full exchange by 2008. It also requires formal evaluation of the demonstration project’s impact on the community.

Because data exchange capabilities had to be demonstrated within the first twelve months, a number of critical issues had to be addressed quickly. First, community leaders had to create a guiding coalition—emphasizing health care delivery organizations and local government—that could bring the project through its turbulent early stages. Second, the coalition had to form a governing body and organizational structure that could set priorities and allocate resources quickly. Third, the project team supporting the governing body had to develop a set of financial and clinical metrics that were consensus-driven and sufficiently compelling to sustain the collaboration. Fourth, the governing body had to ensure that the technology architecture would meet immediate needs and could evolve or be replaced in several years. Finally, the governing body had to create a management and administration structure sufficient to assure the organization’s sustainability and evolution.

Fitting models to the community. Organizational efforts began by understanding how various other state and regional models could be applied to southwest Tennessee. Because the Vanderbilt technology platform shares many common features with the Regenstrief information system and because the initial focus was by design on a coalition of hospitals and the impact of these systems on their EDs, the IHIE served as the starting point for both technology and early cost-benefit studies focused on ED use and spending. Based only on conservative estimates of value conferred by a data exchange program on ED finances, participating hospitals in the three-county region are expected to realize a combined net present value in excess of $4 million over five years.

The alliance also adopted many aspects of the governance and evaluation framework of the Santa Barbara initiative. Although the MidSouth eHealth Alliance’s governance initially emphasizes hospitals, clinics, and government, it will be extended through additional advisory groups to include broader community participation. This will allow the organization to support regional quality initiatives and pay-for-performance programs if requested to do so.

Technology. The alliance’s technology is based on a systems architecture developed by and in use at Vanderbilt University Medical Center. It enables low-cost connectivity and fosters an evolutionary approach to interoperability.¹⁰ It can be integrated with a wide range of clinical data repositories and provider-chosen ambulatory care practice systems; organizations "publish" data in whatever format they have available.¹¹ Copies of data are stored in logically separate "vaults" controlled and updated by the publishing organization but physically housed in a single computer cluster. Processes required to integrate information are performed at the central site. Merging among "vaults" from different institutions will follow each contributor’s privacy and business rules.¹² This architecture allows for gradual evolution of common data standards as contributing institutions reach consensus over the steps required to achieve true interoperability. As consensus is reached, the alliance will pursue pilot interoperability projects with vendors. Uniquely developed Web interfaces for providers are viewed as interim measures necessary until the core system can be tightly integrated into a provider’s preferred practice information system.

Extending clinical use of the infrastructure outside of pilot projects will not take place until a consensus has been reached on systematic means of addressing all identity, security, and privacy concerns. Two-way interoperability pilots with vendors are not planned until the second year, and the pace of these collaborations will depend on vendors’ initiative.

Governance. An initial meeting of key health care leaders was convened by the governor in June 2004. At this meeting he requested that the community engage in a six-month planning process and committed $10 million in state funds to complement funding from the AHRQ contract. Three governance groups were formed in August 2004: a clinical working group, an IT working group, and an oversight group composed of chief executives. The clinical group began the process of identifying gaps in health care delivery that could be addressed by more complete clinical data exchange. The technical group began to discuss how their organizations’ systems would interact with the regional health information infrastructure. Groups to address legal issues, privacy concerns, and financial impact were formed after the clinical and IT groups began their work.

The executive oversight group quickly realized that a more formal structure would be necessary to ensure the effort’s success. To this end, they began steps to incorporate as the MidSouth eHealth Alliance. This not-for-profit mechanism allows broader community inclusion and assures that the data exchange initiatives are coordinated with other regional health care activities.

Perhaps the most interesting dialogue occurred between the clinical and technical groups. When practitioners and IT professionals discuss system implementation within an institution, their emphasis is on practice efficiency, and their focus is on often costly and highly detailed modifications to complex systems. When these parties discuss data exchange across an entire region, their emphasis is on information availability, and their focus is on simplicity. In this context, practitioners are willing to settle for less elegance in presentation if they can obtain diagnoses, discharge summaries, accurate medication lists, and other clinical information. In the regional setting, information in any format is better than no information at all. These far simpler requirements initially made by the clinical community suggest that an evolutionary approach to design and technology is acceptable in the early phases of regional connectivity efforts.

Early experience. The six-month planning effort identified many issues, concerns, and misconceptions. First, some thought that the project was designed to replace current clinical information systems in use at their institutions; they had to be shown that the regional infrastructure was designed to work behind the scenes to increase the range of clinical data present in their own systems and to foster development of interoperability with these systems. Second, some held on to the belief that institution-specific approaches to connectivity were more efficient than regional collaboration; although point-to-point connections between clinical technologies and sources of external laboratory or pharmacy information are more expedient in the short term, extending this point-to-point strategy to encompass every needed connection is neither affordable nor conducive to developing a market of interoperable health information systems. Third, time and resources spent on this initiative had to be balanced against pressing internal demands and requests from other external groups requiring connectivity for other business reasons. Projects that do not address immediate business needs cannot receive high priority. This issue was addressed by creating a technology infrastructure that could be connected to provider systems at a relatively low cost.

Fourth, providers had to determine the financial impact to their own organizations of reducing overall community spending for services; a "duplicate test" from the financial perspective of the community may be either a source of revenue or a source of financial loss to the facility performing this test. For hospitals in the three-county region, a conservative analysis showed that the use of regional HIT in EDs alone would save both payers and providers amounts far in excess of their participation costs. Both the degree of unfunded care and the payer mix influenced this result. As reimbursement declines, an institution’s aggregate loss as a result of redundant testing increases.

Fifth, some coalitions were planning efforts that required technologies similar to those under development by the alliance. Each group had to find a compromise between collaboration and competition. This dilemma is best demonstrated by both the opportunities and possible conflicts introduced if health plans or other groups pursue selective initiatives that work around rather than through regional governance. Such selective participation destabilizes guiding coalitions. As is the case with any participant having large market power, their desire to sustain market influence must be tempered with a region’s need to control overall health care resources and spending.

Early challenges. Obtaining data feeds from participating hospitals and plans required several months of discussion and legal effort. Because the technology can accommodate a wide range of data formats, the only initial technical challenge was to establish secure data transmissions consistent with each organization’s technical capabilities and privacy rules. Most of the dozen participating organizations expect to be contributing live data by August 2005.

Obtaining information from national clinical laboratories and prescription drug sources has been challenging from both a legal and a technical perspective but should be resolved as these large data sources develop national policies for participating in regional initiatives.

Developing a comprehensive legal framework—especially inter-institutional data-sharing agreements—has been far more challenging and time-consuming than expected. Many of the most daunting legal and technical challenges can best be addressed through collective national effort.

Lessons learned. Many lessons were learned in the first year of the MidSouth eHealth Alliance’s operations. First, as enthusiasm for health information infrastructures grows, it becomes increasingly difficult to create a broad community-based coalition without impinging on or competing with more limited but effective data-sharing initiatives already in operation. Second, a neutral guiding coalition and organizational home is difficult to create and has been possible in Tennessee only because of the strong oversight and commitment of state and regional governments. Third, some coalitions may attempt to accelerate their own point-to-point connectivity efforts to place their organizations or vendor partners in a stronger bargaining position when technical and organizational decisions are made by the region.

Fourth, the internal technology demands placed on institutions allow little time or resources for collaboration with regional data-sharing initiatives; this problem is magnified exponentially if these same taxed individuals are pressed to participate in more than one similar initiative. Fifth, projects with ambitious long-term interoperability goals must still identify "quick wins" by supporting e-prescribing programs, expanded use of data warehouses and public health databases, access in remote practice settings, or other similar efforts. Finally, changes in health care financing and regulation seem essential if our health care future is to be characterized by harmonization rather than fragmentation. For this reason, some form of regional health information organization (RHIO) must be formally defined and made a focal point for regional and national efforts.

Roles And Responsibilities

Top Models For Interoperability Tennessee: The MidSouth eHealth... Roles And Responsibilities NOTES

 
If not-for-profit regional efforts are transformed into formal RHIOs with some statutory or regulatory authority, it will be important to clarify the roles and responsibilities of states; RHIOs; and those who participate in RHIOs as providers, payers, or consumers.

States. The Tennessee experience suggests that states will play many critical roles. Tennessee has made HIT a priority; it serves as a liaison to the federal government and to neighboring states; and it plays a prominent role in negotiating access to information from health plans and national data sources providing services statewide. As commitment to regional initiatives grows, the state will have to assume a greater role in setting and adopting guidelines for RHIOs and establishing standards for interoperability. Changes to current policies and laws may also be required.

Regions. If the MidSouth eHealth Alliance is to function as an RHIO, it will have to continue its oversight of the technical infrastructure and continue setting and later enforcing regional policies on security, identity management, authorization, authentication, and privacy. It must also have the authority to serve as the single point of negotiation for technology initiatives and health programs deemed by the state to be within scope of the RHIO’s responsibility.

Participants. Participants in the current alliance retain their right to choose information technologies within their organizations; they retain responsibility for local identification of their patients and health care professionals; they must agree to participate in data exchange activities; and they must ensure that their interactions with RHIO technologies are consistent with their internal privacy and business rules. From the standpoint of participants, the greatest contribution of a formal RHIO might be to articulate and support a single, common legal and technical framework for realizing an interoperable regional health information infrastructure.

Tennessee is developing a portfolio of regional efforts designed to create a coherent, sustainable, and interoperable health information infrastructure for its citizens. In its first year, the MidSouth eHealth Alliance has learned the value of reconciling local capabilities and needs with best practices demonstrated in other states. Through these efforts, general principles on the role of states, regions, and organizations are beginning to emerge.

Leadership and capital are repeatedly emphasized as critical factors; their importance has been amply demonstrated in Tennessee. But committed leadership and ample funds cannot alone sustain a regional effort. Success can be achieved only if broad coalitions within communities make these efforts a priority and articulate how such work is essential to their collective health and economic prosperity. Since complete and sustained consensus is rare in the politics of health care, markets must be realigned to foster these efforts. If such realignment takes place, political will and capital can be harnessed within communities to develop a health system enabling greater personal choice, lower costs, and higher quality.

Editor's Notes

 
Mark Frisse (mark.frisse{at}vanderbilt.edu) is the Accenture Professor of Biomedical Informatics at Vanderbilt University in Nashville, Tennessee.

The author gratefully acknowledges the efforts of numerous participants in the MidSouth eHealth Alliance, the Office of Gov. Phil Bredesen, as well as colleagues at Accenture and Vanderbilt University. This work is supported by the State of Tennessee, Vanderbilt University, and the Agency for Healthcare Research and Quality (AHRQ), Contract no. 290-05-0006. This publication has not been approved by AHRQ. The author directs the AHRQ-funded regional demonstration project governed by the MidSouth eHealth Alliance through a subcontract from the State of Tennessee.

NOTES

Top Models For Interoperability Tennessee: The MidSouth eHealth... Roles And Responsibilities NOTES

 

1. McKinsey and Company, Achieving a Critical Mission in Difficult Times—Illustrative Strategic Options for TennCare, 11 February 2004, www.sitemason.com/page/c52CpW (25 July 2005).
2. D.J. Brailer et al., Moving toward Electronic Health Information Exchange: Interim Report on the Santa Barbara County Data Exchange (Prepared for the California HealthCare Foundation, July 2003).
3. See the MA-SHARE home page, www.mahealthdata.org/ma-share.
4. State of Massachusetts, "Romney, Healthcare Leaders Tout Medical Innovations," 6 December 2004, www.mass.gov/portal/govPR.jsp?gov_pr=gov_pr_041206_eHealth.xml (26 May 2005).
5. Taconic IPA, "Welcome to Taconic IPA," www.taconicipa.com (1 May 2005).
6. C.J. McDonald et al., "The Indiana Network for Patient Care: A Working Local Health Information Infrastructure," Health Affairs 24, no. 5 (2005): 1214–1220.[Abstract/Free Full Text]
7. J.M. Overhage et al., "A Randomized, Controlled Trial of Clinical Information Shared from Another Institution," Annals of Emergency Medicine 39, no. 1 (2002): 14–23.[CrossRef][Web of Science][Medline]
8. P. Bredesen, "Saving TennCare," Address to the Tennessee Legislature, 17 February 2004, www.sitemason.com/files/fusbvO/021704%20TennCare%20Speech%20RELEASE.pdf (26 May 2005).
9. See the Volunteer eHealth Initiative home page, www.volunteer-ehealth.org.
10. W.W. Stead et al., "Achievable Steps toward Building a National Health Information Infrastructure in the United States," Journal of the American Medical Informatics Association 12, no. 2 (2005): 113–120.[Abstract/Free Full Text]
11. W.W. Stead, B.J. Kelly, and R.M. Kolodner, "Case Study: The Vanderbilt University Information Management Architecture," in Clinical Information Systems: A Component-based Approach (Berlin: Springer-Verlag, 2003).
12. Connecting for Health, Achieving Electronic Connectivity in Healthcare: A Preliminary Roadmap from the Nation’s Public and Private-Sector Healthcare Leaders, July 2004, www.connectingforhealth.org/resources/cfh_aech_roadmap_072004.pdf (26 May 2005).

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