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UPMC expert Q&A: Health information exchange grows from collaboration

Health information exchange requires standards, security and regional participation, says UPMC expert in this Q&A.

Foremost on the minds of many health care executives is health information exchange, upcoming policies that drive more exchange among providers, and protecting patient information as data becomes more liquid. The University of Pittsburgh Medical Center (UPMC) has been working with organizations throughout the region to create an exchange that meets both trust and security benchmarks while providing relevant information across medical facilities and to patients.


In this Q&A with, Tracy Crawford, program director at the ClinicalConnect health information exchange, discusses the collaboration with UPMC and how data sharing is occurring in western Pennsylvania.

Explain the genesis of the ClinicalConnect health information exchange and UPMC's decision to participate.

Tracy Crawford: The passage of the HITECH Act in 2009 to establish the meaningful use of interoperable electronic medical records{EMRs] prompted a group of senior executives from several community hospitals in western Pennsylvania to approach UPMC about forming a health information exchange. This group recognized UPMC's reputation for the advanced use of EMRs and interoperability technology, as well as its expertise in information security, and asked for UPMC's participation to help in getting the [exchange]up and running.

What interoperability problems did you have to solve to plug into it?

Crawford: The biggest challenge has been the varying degrees to which the participant EMRs can produce, trigger and transmit a Continuity of Care Document(CCD). Our model is based on the use of the CCD, as opposed to discrete [Health Level Seven International] HL7 interfaces to allow us to capture the full patient record without the complexity and expense of building and supporting multiple interfaces with each participant. This continues to be a challenge, but with meaningful use stage 2, it will now be a requirement for the EMRs to be certified, which should allow us to make progress in capturing more data.

Is it a centralized or federated model?

Crawford: We have a centralized repository for the non-UPMC participants that is federated to an extensive database of UPMC patient records, with up to 10 years of historical information in some cases. This allows us to capture data from participants as they join, and then to link this data to the UPMC records without the redundant storage of the UPMC data.

Is it a record finder or a true exchange? That is, is there electronic health record [EHR] connectivity, or is it just exchanging documents?

Crawford: It is a true exchange. A CCD is sent from the participants, and this is processed by our vendor into discrete data elements, such as problem list, medications, allergies and laboratory results. Through the use of common vocabularies, the data can then be semantically harmonized to the data from other participants.

Are labs and specialists all connected to hospitals and primary care providers, or is that a work in progress?

Crawford: Our initial focus was on connecting hospitals, but a private physician group and a pediatric rehabilitation inpatient and outpatient facility recently joined. We are actively reaching out to physician practices and other health care organizations, such as long-term care facilities and home health.

How do you deal with behavioral health data? This is a sticky issue with many health information exchanges and providers.

Crawford: At this time, it is our policy to request that our participants not send this data to the HIE. The technology to flag the data when it is sent, and to restrict access to certain elements of the data at the individual user level based on consent, is just not there yet.

A recent Ponemon survey showed that one-third of health care providers responding indicated they wouldn't join an HIE, citing data security worries (specifically, the lack of data security). Why does this perception exist?

Crawford: Data security is a critical issue, especially in health care, and it requires much ongoing effort and examination by each organization to ensure that the appropriate safeguards and controls are established and functioning to mitigate data security risks. So, this perception is a reality that needs to be addressed head-on by all HIEs and their prospective members and participants, to provide for a secure and valid data exchange.

How has participating in the HIE helped your patients? Do you have specific examples you can share?

Crawford: Our physician users have shared several examples where the HIE has eliminated the need to perform additional testing, and helped in their ability to make diagnoses.

  • An internist at one of our participant hospitals was considering ordering a stress test on a patient, but was able to review the results of a heart catheterization completed in the previous few months, eliminating the need for the stress test.
  • A hospitalist found abnormalities on an MRI that he was not certain were contributing to the patient's current condition or had been there previously. He was able to find a previous MRI performed at another participating hospital performed a year earlier, and determined the findings were not new, aiding him in a more accurate diagnosis of the current problem.
  • A patient arrived at a member emergency department requesting an MRI of his shoulder. The patient did not disclose that he had had an MRI of his shoulder at another member hospital a few weeks prior. The [emergency department] physician was able to view the previous MRI report, and determined the pain the patient was experiencing was still the same; the physician advised the patient to continue with his current treatment plan, and did not repeat the MRI.
  • A transplant patient presented to a member emergency department. The [emergency department] physician was able to view the patient's past medical history via [the] ClinicalConnect HIE and contacted the patient's transplant coordinator. Together they decided the patient did not require readmission. Had it not been for the ClinicalConnect HIE, the [emergency department] physician would have sent the patient, living in a rural community, to the city of Pittsburgh to be readmitted.

How do you measure whether the ClinicalConnect health information exchange is saving unnecessary tests and all that savings stuff that [accountable care organizations] are either requiring or eventually will require?

Crawford: So far, we see the kind of positive anecdotal evidence noted above. Our HIE has been up and running for about seven months with five participants viewing, and one sending clinical data. As it becomes more mature, we intend to carefully analyze the benefits.

How do you think the HIE network will get built across the country -- or won't it? State HIEs are either having a hard time getting built or expectations are getting scaled back in many states. Pennsylvania is leading-edge between this and KeyHIE ... Is this going to be a model that can be copied elsewhere?

Crawford: I do think the HIE network will get built eventually, but it is quite a few years away. However, real value can be obtained regionally. In our own HIE, we have anywhere from a 40% to a 60% overlap where a patient from one participant also has a record at another participant. Many more patients are referred across town than, say, to Florida, so I think it is important to keep the momentum going regionally and the wider network will eventually be there.

Pennsylvania has recently scaled back its model, and plans to offer a shared service layer to help connect the regional HIEs and eventually connect them to the Nationwide Health Information Network. I think that model makes sense. We could also connect to KeyHIE directly but don't necessarily want to build and support that model to multiple HIEs, so the state can help with that.

Explain future plans for expanding your data exchange via the ClinicalConnect health information exchange. What's next?

Crawford: We will to continue to reach out to other hospitals, physician practices, long-term care and home health agencies to encourage their participation. The meaningful use stage 2 measure around the transitions of care, while only 10% electronic in the first year, will be a real driver for people to connect. For providers, both hospitals and physicians, to all try to connect individually, even using [the Direct Project], is just not cost-effective or efficient. We can provide that avenue for them to exchange information. We are also evaluating payer participation to allow payers to access the data to improve care coordination and possibly to mine de-identified data to combine with claims data for analytics to improve outcomes or population health.

Let us know what you think about the story; email Jean DerGurahian, Editorial Director or contact @SearchHealthIT on Twitter.

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