The Public HIE Dilemma: Two Viewpoints

Compiled by Health IT Outcomes staff

An executive of and a physician in CurrentCare, Rhode Island’s state HIE, share their thoughts on the challenges, benefits, and ultimate financial sustainability of their public HIE.

The public HIE model has faced a ton of scrutiny over the past year. Questions loom about provider participation, data security, and the organizational and patient care benefits that are ultimately realized as a result of leveraging public HIEs. However, the biggest concern is the long-term sustainability of these public exchanges once federal funding runs dry. CurrentCare, Rhode Island’s state HIE, which was developed and is maintained by The Rhode Island Quality Institute (RIQI), has stake in this game. I had the opportunity to speak with both an executive of CurrentCare, Gary Christensen, COO and CIO of RIQI, and a physician in the HIE, Al Kurose, MD, of Coastal Medical, Inc., regarding the current use and future outlook of their exchange platform.

Q: How many healthcare providers leverage CurrentCare?

Christensen: More than 600 healthcare facilities from across the state — including hospitals, doctors’ offices, and labs — currently share data and use CurrentCare services. Through their efforts, approximately 300,000 Rhode Island residents (about 1/3 of the state’s population) are enrolled to have their health data shared over the HIE. Patients must provide their consent to have their data transmitted via the exchange.

Q: Can you describe what technology supports CurrentCare?

Christensen: CurrentCare is based on a platform called HealthShare by InterSystems. Data sharing partners (DSPs), which are both institutional and practice-based sources of information, send us, through a secure infrastructure, healthcare transactions for patients who have consented to participate in CurrentCare.

QuadraMed Smart Identity Exchange is another component of our HIE infrastructure. This solution is a matching engine that links data input to specific patient records. The database can even track if a patient’s last name has changed because of a marriage or a divorce, as well as keep track of where a patient lives.

Finally, technology from Apelon allows us to translate unique codes to standards and keeps track of translations. This is important because one facility may use one set of codes to refer to a procedure and another hospital may have a separate set of codes, so we translate these into common standards.

Q: How is patient data shared via CurrentCare?

Christensen: Our data-sharing network is comprehensive. We’re connected to 10 of 12 major hospitals in RI, and they inform CurrentCare when patients are admitted or discharged from the hospital or emergency room. We’re connected with virtually all the major labs. We get more than 90% of lab results in the state through hospital labs, as well as local and national lab companies. We’re connected to the Surescripts network (operates the nation’s largest e-prescription network and supports a rapidly expanding ecosystem of healthcare organizations nationwide), which gives us access to medication histories for all patients who fill prescriptions in the state. And we’re connected to a number of individual practices through their EHRs; they send us data about patient encounters through this infrastructure.

CurrentCare is the hub for this complex web of health information. Sophisticated matching algorithms ensure that every record matches the right patient. Health data is normalized (i.e. put into a consistent format) because healthcare facilities use different terms for the same information. We translate hundreds of data points about a patient and make complete, current records available through a viewer function. A CurrentCare user in a hospital or practice can look up patient information as needed.

CurrentCare also generates hospital alerts. When a consented patient is admitted to or discharged from the hospital or emergency department, we notify the patient’s primary care physician (PCP). The PCP can follow up and help reduce the probability of a readmission through post-discharge attention.

Q: Are the enrollment partners charged to be part of the HIE?

Christensen: No, it’s a free service. The aim is to make sure the information is used to provide thorough care and higher value care. We’re seeing improvements happen, and charging for it would be a barrier to that.

Q: Have you been able to measure how healthcare has been improved for the individuals participating in CurrentCare?

Christensen: Physicians currently use CurrentCare to see if a patient just had a lab test before ordering a new one and to ensure there are no unsafe prescription combinations. Both are examples of patient safety being enhanced. That’s the whole aim of the HIE — to make sure that additional information is available where and when it’s needed.

We are also honing our focus on the analytics infrastructure of CurrentCare. We are looking at how to measure whether people are healthier. For example, we have been following the data on hospital alerts to see if patients have fewer readmissions to the hospital. To date, we’re seeing a double-digit reduction in readmission rates associated with the hospital alerts service.

Q: How can you make sure funding for CurrentCare doesn’t dry up? If it does, how will the HIE survive?

Christensen: For many years, CurrentCare and the community have worked on the question of long-term sustainability of this organization. We hired the Boston Consulting Group to review the ROI of having an HIE in Rhode Island. The numbers indicate a projected $108M in savings (e.g., reductions in duplicate lab tests, record duplication, and courier costs, etc.) with $6M operating cost annually. Investment returns accrue to the system, and no one entity accrues most of the benefit.

The model that is in place and is providing a significant amount of funding to the continued expansion of the HIE is a public utility model. For everyone who is insured in the state, $1.00 per member per month is set aside by fully funded participants for the HIE. The self-funded entities have voluntarily agreed to contribute $1.00 per member per month. They have a real incentive to see this work, because for every duplicate lab test that isn’t performed, those dollars drop right to their bottom line. The State and Medicaid are also participating in the funding of CurrentCare. So the costs are spread across a very large population. That’s how a big piece of our expansion activities with the HIE will move forward.

We also continue to apply for grants and to be successful there. And we have a handful of contracts by which we’re providing specific services to specific entities around quality reporting or data measurement, which makes up another piece of the money pie for the institute.

Q: What aspects of CurrentCare are you utilizing at Coastal Medical?

Dr. Kurose: The hospital alerts function is the first CurrentCare service we started using. It tells us if someone has been admitted to a hospital, discharged from a hospital, or transferred from one unit to another within a hospital. We get a real-time electronic message. Now, we have workflows in our offices where the nurse care manager or another member of the care team checks those hospital alerts daily. They thereby become aware that a hospital admission has occurred.

The primary care home office team then takes this data and uses other means to gather more detailed clinical information. For example, we have a separate connection called Lifespan eHX (electronic health exchange), that we can utilize to get into the EHR system at the hospital and gather more information about what’s going on with the admitted patient. eHX provides a means for providers to share health information with other caregivers, as allowed by HIPAA and state law. For instance, if a child sees an affiliated specialist, we can access the results of that appointment. Or, in an emergency, we can instantly share lifesaving information with the Lifespan Hospital treating the child. This kind of shared information system allows all of a family’s physicians to work together to better care for a family’s health.

Another component of CurrentCare we use is the viewer function. This allows us to look at all the data that is being fed into the system by the data sharing partners. So let’s say a doctor has a patient who tells them the cardiologist sent them for a chest x-ray last week. If the patient has been enrolled in CurrentCare, the doctor can go to CurrentCare and find that report and look at any other data in there. There might be blood test reports, hospital discharge summaries, imaging data, etc. and it’s all formatted nicely. So, when CurrentCare receives lab data on a patient over time, it presents it in table form that shows sequential test results over time. So, if you look up a CBC (complete blood count) on a patient in CurrentCare, and they’ve had six CBCs over the last year, a doctor can examine the trend of the test results.

Q: What is the benefit of RIQI to your patients and to Coastal Medical?

Dr. Kurose: There are both quality and cost implications. At Coastal, we’re taking on the challenge of population health management, and we have a portfolio of shared savings contracts. So, we’re trying to sequentially move away from a strictly fee-for-service payment model to an ACO (accountable care organization) model. As a Medicare shared-savings ACO, we have a commercial contract with Blue Cross, so we’re managing patient population health, and we also have a stake in trying to reduce the total cost of care for populations. We’re both trying to improve quality as well as efficiency, and so knowing what’s happening with patients becomes crucial on multiple levels.

The coordination of patient care across different settings is a really important aspect of what patientcentered medical homes do to improve the health of their patients and improve outcomes. It’s essential that the primary care office knows when patients are having specialty care and hospital care. So at the most important and basic level, this is about taking better care of patients by having better information about what’s going on with them, particularly for the primary care office, which plays an important role of coordinating the care and being the one place where all the information is brought together in a holistic way.

Q: How easy is the HIE platform to use?

Dr. Kurose: Currently, for us to use CurrentCare, a separate portal is required. One of the things we worry about is how many different portals medical home offices and providers are going to have to use. If CurrentCare were fully integrated with our EMR, it would be much more efficient. This is a challenge that the RIQI is well aware of. The Institute is currently in the process of getting each EMR vendor to support a more integrated connection between CurrentCare and the EMR, but that’s a labor- and resource-intensive process.

Q: Is there a downside to a statewide HIE?

Dr. Kurose: With public HIEs, people worry about confidentiality and misuse of a patient’s medical information. However, I would argue that more risk exists when making a clinical decision at the point of care based on incomplete information. Compared to how often that occurs, the probability of somebody misusing medical information is probably 1% or 1/10 of 1%. I really feel strongly that the upside far outweighs the downside in terms of trying to make this information available. We’ve got a really robust consent model. There are a lot of safeguards in the system. The problem is not one of putting people at risk because their medical information is made more available. The problem is really what happens to medical care when insufficient information is available. If you’re trying to weigh the pros and cons and make a value judgment, I stand strongly on the side of establishing an HIE and encouraging patients to enroll.