Five years ago, the state of Tennessee and BlueCross BlueShield formed a partnership whose mission was to rein in rising health care costs, particularly within the state’s Medicaid plan. The resulting program, operated by Shared Health Inc., focused on the inefficient and error-prone methods by which physicians accessed and shared patient medical data. Too often, when a doctor needed information from another provider, he’d make a call and a nurse or administrator would tell him over the phone.
“We wanted to put physicians more in control of all the health care information available within the community, not just within one practice,” said Jana Skewes, Shared Health’s president and CEO. “Physicians told us they could coordinate care more effectively if they could access patient-centered data across all providers” who were involved in a patient’s care.
Shared Health chose Oracle Corp.’s Healthcare Transaction Base (HTB) as the foundation for Shared Health Clinical Xchange, now one of the nation’s largest public/private health information exchanges (HIEs). The system gathers data from health care providers and hospitals’ electronic medical record (EMR) systems, as well as test results from laboratories and medication histories from pharmacies. The data is translated into a standardized format and loaded into HTB’s repository, where physicians can access it via the exchange’s Web portal.
Physicians currently access information about 40,000 to 50,000 patients each month, and the number is increasing by 10% to 15% per month, Skewes said. The system supports about 3,000 users, a third of whom are physicians.
Shared Health reports that its portal has provided substantial health information exchange benefits and efficiencies to the health care community, including the following:
- A 17% increase in overall efficiency.
- 29.8% fewer readmissions.
- A 20% decrease in the length of a patient’s stay.
- 40% fewer emergency room services.
- A 21% drop in cost per emergency room visit.
Shared Health is far from alone. Regional groups of health care providers began setting up HIEs years before the Obama administration officially made a national e-health network a top priority. More recently, the American Recovery and Reinvestment Act began offering financial incentives for health care providers to invest in EMR systems that can share data with other providers’ systems.
The nonprofit eHealth Intitiative’s 2009 annual national health information exchange survey reported at least 193 active health information exchange initiatives, a nearly 40% increase over the previous year. Fifty-seven of the initiatives reported being operational, compared with 42 in 2008. Of these, 28 reported that the exchange improved access to test results, 24 improved quality of practice life, and 23 reported reduced staff time spent on administrative and clerical tasks.
Building an HIE and then extending it across a regional health care community can be a complex and lengthy task, as Shared Health’s case illustrated. Regional health information organizations are thus turning to HIE platform vendors like Axolotl Corp., Wellogic, Eclipsys Corp., Oracle and Vangent Inc.
Products vary a great deal in terms of features and functionality, said Wes Rishel, a vice president at Gartner Inc. in Stamford, Conn. He cites Axolotl and Wellogic as having “complete basic suites.” However, no solution covers all the aspects of an HIE, and most vendors supplement their offerings through third-party partners. Oracle’s HTB, for example, uses Orion Health’s Concerto, a Web portal designed specifically for health care practices.
Beyond the basics, customers need to evaluate how each vendor addresses the following challenges:
Bringing the community into the exchange. One problem health information exchange initiatives face is that a large percentage of health care providers, particularly in rural areas, have no EHR system. Some industry sources estimate that only 15% of small practices, with up to five doctors, have one.
Axolotl offers EHR Software as a Service, for providers that don’t have their own systems. The service enables them to call up patient records, order lab results and do referrals, for about $100 per month, per user.
Balancing security, privacy and access was the part of our implementation that took the most time and thought.
Jana Skewes, president and CEO, Shared Health Inc.
Most systems use the Web portal to provide doctors without EMRs access to data. Louisiana Rural Health Coalition (LRHC), for example, set up a Web-based telemedicine solution. Rural physicians can directly access patient information residing at local hospitals, “instead of faxing everything back and forth,” said Jamie Welch, the coalition’s CIO. “Cutting back on paper saved a lot of time and money.” Most rural hospitals saved a couple of thousand a month, she added.
Doctors without an EMR can use Shared Health Clinical Xchange’s portal to access patient records securely, and download them into whatever system they use to store data, said Skewes. However, “building a portal was only step one,” she said. This lets doctors “look up everything about the patient both within their practice and within the community, and integrate that data with their existing EMR system.”
Most proprietary EMR systems can’t share data, however, unless it’s first converted to a standardized format. Some hospitals are pushing their provider communities to adopt the same EMR system, but that’s often just not practical. Evolving government and industry standards, such as the Health Level 7 electronic interchange protocol, are starting to make this easier. Meanwhile, established HIE vendors like Axolotl have developed translation software for a range of popular EMR systems.
Inconsistent patient IDs is another problem. Too often, a patient will be Ellen Kravitz on one EHR system, and Ellen A. Kravitz on another. Shared Health and LRHC both used Initiate’s Initiate Patient to standardize patient identities and set up an enterprise master patient index.
Security and compliance is a challenge. “Balancing security, privacy and access was the part of our implementation that took the most time and thought,” said Shared Health’s Skewes. “We need to make information easily accessible to doctors, but we also need patients’ trust.” Her group used Oracle’s Identity and Access Management offering to set up granular access to HTB data, based on roles: nurse, doctor, staff member. Fortunately, BlueCross BlueShield of Tennessee already had a directory of physicians throughout the region, including attributes such as “who is licensed, authorized and credentialed,” Skewes said.
LHRC’s Welch noted, “We had to be incredibly flexible yet stringent about who has access to what,” in order to comply both with HIPAA and patients’ stated preferences. Her group chose CA Inc.’s Identity Manager and Access Control products, which enabled coordination and management of access rights across 24 hospital global directories and security systems, Welch said. CA’s Web Access Manager provides authentication control for the Web portal.
Easy information access: Push as well as pull. Health information exchanges need to provide information in a proactive, prioritized and organized fashion, so physicians don’t have to hunt for it, sources agree. This not only improves practitioner efficiency and effectiveness, but it also ensures that the system gets used more often.
If it takes too long to call up data about a patient, doctors often won’t do it because of time pressure and/or lack of motivation -- even though they know it’s useful, Gartner’s Rishel said. For example, a doctor ordering a test has no strong motivation to take the time to find out whether a patient has already had a test. More critically, an emergency room physician with an apparent stroke victim may feel too rushed to find out if a previous stroke was ischemic, “which determines whether blood thinners will help or kill,” Rishel said.
A study performed in 2007 by Quality Health Network (QHN) in Grand Junction, Colo., showed that when both push and query technologies were made available to physicians for accessing patient data from hospitals, 99.3% of all electronically viewed results were those that were pushed to the physicians, while only 7% were viewed via a query.
“When we were just displaying data electronically and the doctor had to scroll to get the right information, our adoption was modest,” Skewes said. The big breakthrough happened when her group added a decision support engine that applied national wellness and care guidelines to patient records, in order to identify “what we call care opportunities: gaps in care,” Skewes said.
For example, the system might send physicians an alert if a diabetic patient hadn’t had her hemoglobin injection, or if a child hadn’t been immunized or given a well-child check up in a timely fashion. This saves nurses from “culling through data and diagnostic codes to find out this person is asthmatic and needs a medication refill,” said Skewes.
Shared Health reports that its providers have realized the following health information exchange benefits from the DSS system:
- 25% increase in colon cancer screening rates.
- 10.3% increase in child wellness screening rates.
- 25% increase in influenza vaccination rates.
“Physicians told us they didn’t just want data dumped on them in digital form,” said Skewes. The decision support component helps providers run their businesses more effectively, as well as improve performance. Furthermore, Blue Cross offers financial rewards to doctors based on predefined metrics, such as how regularly they do immunizations of children or eye examinations of diabetics, she noted. “We give them the technology to improve the outcome.”
Elisabeth Horwitt is a contributing writer based in Waban, Mass. Let us know what you think about the story; email firstname.lastname@example.org.