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State HIE leaders face uphill journey to health data interoperability

States can build national health information exchange, but interoperability must come first. State leaders discuss the current technical, legislative and economic issues they face.

The HITECH Act and meaningful use aim to promote -- and fund -- the building of a health IT infrastructure in which patient data fires across a national health information exchange (HIE). State IT leaders discussed the trials of building this national network at the 2011 State Healthcare IT Connect Summit in Washington, D.C. The main hurdle they must overcome? Health data interoperability.

"At its worst, meaningful use can appear a bureaucratic hodgepodge of hoops to jump through," said national health IT coordinator Dr. Farzad Mostashari in his keynote address, in which he confirmed that proposed Stage 2 meaningful use criteria are on schedule to be released later this year and finalized by mid-2012. "As hard as [achieving electronic health record] adoption is, exchange is that much harder because of technical reasons, because the services you need aren't there yet, because policies need to be articulated -- particularly around privacy and money."

Gregory Franklin, deputy health IT director for the state of California's Technology Agency, framed the complexity of the health data interoperability challenge in a panel discussion following Mostashari's address. Not only must state HIEs connect EHR, lab and e-prescribing data through local HIEs and regional health information organizations because of HITECH mandates, but also for the benefit of state Medicaid agencies and insurance exchanges propagated by federal health reform. On top of all that, there's administration of the Medicaid EHR Incentive Program -- yet another state-based health IT project that didn't exist prior to the HITECH Act.

Franklin said goal setting is the key for states to help prioritize the massive IT project that federal laws mandate. Taking on tasks that improve care quality, establish accountability and maintain patient privacy -- along with cost-cutting and process transparency -- top a long list of how California decides where to focus its resources.

"We wanted to capture the very essence of what was important, as we move forward," Franklin said in outlining the list, to which third-party partners such as Cal eConnect -- the nonprofit charged with building the state HIE infrastructure -- must also adhere. "At the same time we wanted to show everyone -- all of California, all of the world -- that these goals [will be] embodied in a lot, if not all, of the work that we do."

It's not about just spending money, it's really about providing better outcomes.
Ed Dollydeputy Medicaid commissioner, Medicaid CIO and state health IT coordinator, West Virginia

Ed Dolly, who serves as West Virginia's deputy Medicaid commissioner, Medicaid CIO and state health IT coordinator, also pointed out that health care reform, at least in his state, forced a top-to-bottom review of health IT systems. Out of that review came meetings with stakeholders such as the state hospital association and local mental health agencies. Dolly said his team then formed a collaborative with those stakeholders in order to "steal the best ideas" and implement them.

The meetings so far have not only found that some stakeholders were duplicating efforts, but that these same-but-parallel projects were costing different amounts. Combining efforts and contracting the cheapest third-party help has created savings, Dolly said.

"It's not about just spending money, it's really about providing better outcomes," said Dolly, whose collaborative -- like the California Technology Agency -- made a priority list and repeats it at the beginning of every meeting to remind members what they're trying to accomplish. "We invite stakeholders to bring their expertise, their opinions, their outside mindset, to help us look at things a little differently -- and that has been instrumental in helping us solve some of our large, fundamental problems about resource allocation."

Minnesota has financial issues, too, said Thomas Baden, chief enterprise architect and CIO, and director of enterprise architecture for the Minnesota Department of Human Services. Baden said the state's shrinking budget complicates upgrading aging -- in some cases, decades-old -- IT systems in health care and social agencies.

To begin with, the state laid off 15% of its technical IT staff two years ago and an additional 10% last year -- coincidentally, the years federal legislators passed the HITECH Act and health care reform, respectively. Another 15% are on the chopping block this year, if the proposed state budget holds true, leaving Baden with all-time low staffing levels. On July 1, the state's fiscal woes worsened to the point that the Minnesota government shut down for the second time in six years.

However, Baden and his team don't necessarily view the health IT challenges for Minnesota negatively. They have a sense of mission that they are helping patients and the people eligible for state social services.

Baden hopes to collaborate more with other state HIT coordinators to create something of an informal national health IT collaborative, like Dolly's formal West Virginia group, so he can apply their best ideas -- and, he hopes, code -- to Minnesota's infrastructure. He also sees, eventually, cloud vendors being a potential savior for state health IT systems, taking over the "boxes, wires, operating systems and software" tasks for which state employees are currently responsible.

"Doing this with less staff than we've ever had -- in a budget-challenged environment -- it is unbelievable, yet [we know] it's the right thing to do and we need to do it," Baden said.

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