Like practically every other health care delivery network, Poudre Valley Health System is slammed with projects to upgrade and broaden the capacity to create, share and exploit electronic health information about its patients. But the Fort Collins, Colo., provider network also is poised to pilot data exchange with rural hospitals in the region and subsequently around the state.

As the business focus shifts from bed-filling and patient-encounter volume to accountability for patient populations—with federal stimulus and health reform laws as catalysts—all providers should be planning how to get information on those populations from beyond the boundaries of their own enterprise, says Russell Branzell, Poudre Valley's vice president of information services and chief information officer.

"Health care reform is going to drive us to remove costs; one of the key ways to do that is to have good, sound information and decision support," says Branzell. "We were rewarded in the past, and even in the present, for being efficient in our islands of information. We will be rewarded in the future for being able to aggregate all that information for communities, or pockets of communities, and being able to care for that population in an effective way."

Such an objective is not possible without health information exchange—the collection of activities and technologies for sharing data generated from separate sources of clinical information—to manage both individual patients and groupings of people with similar clinical

The Health Information Technology for Economic and Clinical Health Act, which began dangling financial incentives Jan. 3 for meaningful use of federally certified electronic health records, has focused provider attention on rounding out the internal capacity to meet those requirements. While HIE requirements are not directly incorporated into the first stage of meaningful- use targets, they are implied today and eventually will be essential, says Claudia Williams, a senior adviser with the Office of the National Coordinator for Health Information Technology.

"Clearly one of the benchmark requirements of meaningful use, for hospitals as well as for providers, is not just recording the information in your electronic health record, but allowing and facilitating that information to follow the patients when they seek care," Williams says. "There are a lot of technical things that need to be worked out, and it's better to figure those out now and be prepared for the future when that's going to be basically what you're paid for."

But planning for that future should not be single-mindedly about adhering to the government's five-year timeline for hitting HITECH marks, says Stephen Moore, M.D., senior vice president and chief medical officer of Catholic Health Initiatives, a Denver health system with 73 hospitals and more than 350 clinics in 19 states. The system's "purposeful moves to become more of an outpatient-oriented organization" may not align directly with HITECH, but Moore says CHI will take whatever incentive payments it can get during the next seven to 10 years while engineering a $1.5 billion initiative to enhance clinical IT and build HIE systemwide. The ultimate aim, he says, is being able to better manage patient populations in real time.

"We're convinced that the ability to respond to health reform—but also to respond to that whole value/cost equation—is completely dependent upon that technology and that health information exchange," Moore says.

The Long Road to HIE

The siren song of regional health data exchange has tempted many during the past two decades, only to dash their hopes after years of fruitless preparations. Health care veterans recall attempts in the 1990s to organize networks going by such acronyms as CHMIS (community health management information system), CHIN (community health information network) and CHIP (community health information partnership). In 2004, the Bush-era ONC tried to drum up interest in what it called RHIOs (regional health information organizations), which struggled to find favor and funding.

So what's different in 2011?

To put it short and sweet, health information exchange makes business sense now, and it didn't before. Pressure to invest in health IT, account for improved outcomes of care, and overcome projected lower reimbursement through greater efficiency "are shaping a market [for HIE] which didn't exist for many years, as we all know," says William Bernstein, a partner with Manatt Health Solutions, a consulting firm based in New York City.

Technical breakthroughs and market forces are powering that market:

•The building blocks of HIE are there. The most obvious problem with '90s-era regional networks is that "back in the old days of CHINs, 99 percent of the community was on paper," says Douglas Dietzman, executive director of an emerging HIE network called Michigan Health Connect, Grand Rapids. Electronic exchanges without electronic data didn't have much value. By contrast, the current push for providers to install EHRs will generate enterprise-level data, and health systems are being required to integrate electronically with outside entities in ways that they had not before, Dietzman says.

•The data and communications technologies are there. Until the Internet came along, data had to be sent through dedicated or rented telephone lines, racking up costs per line or per message. The Internet has stripped out messaging cost and added accessibility and ease of use. Internet technology has enabled sophisticated messaging models and data aggregation by a new crop of HIE vendors. The acquisition of two of them, Medicity and Axolotl, by managed care companies last year is evidence of their potential.

•Government money is pouring in. The $548 million in HITECH funds for HIE support being distributed to the states under a cooperative agreement program with ONC is seed money to get at least something going to standardize and connect both existing and newly formed HIE networks, unlike the government's past approach to advise and encourage but not subsidize. The incentives for meaningful use of health IT also require capabilities that either can or must be facilitated by HIE.

•Providers are not just going along, but pushing the pace. Either in concert with state-level HIE programs or independently, health care system competitors are forming cooperatives to jump-start regional data exchange and set themselves up for HITECH incentives and formation of accountable care organizations. "As more and more providers are … moving into the electronic world, and federal requirements are mandating that the connectivity needs to take place in ACOs and things like that, there's no argument anymore that as an enterprise you have to put this stuff together," says Dietzman. Michigan Health Connect started in 2009 with three health systems in western Michigan and now is up to seven participating systems statewide.

Starting Points

Hospitals by and large are enthusiastic, if somewhat perplexed, about getting involved in HIEs. "We really do want information to span the care continuum, and exchange of information to support the best possible care is an important goal," says Chantal Worzala, director of policy for the American Hospital Association. "Markets vary in their existing capacity to do that, and the country is exploring different approaches at local, state and national levels that create tremendous opportunities but also some confusion about how we're going to realize our final goal."

The starting point for HIE participation depends on how much a particular state or region has done to get the infrastructure of exchange in place. Some HIE initiatives are going strong and adjusting for the specifics of HITECH, ACOs and medical-home needs. Others have attempted little, or tried hard but run out of money to continue.

In Maine, the statewide HealthInfoNet has records from participating providers and other information sources on 800,000 of the 1.3 million people in the state, and it's "starting to get to the tipping point of impact," says Executive Director Dev Culver. HIE networks in Indiana and the tri-state region around Cincinnati each have more than a decade of experience operating data exchange for providers, and the New Mexico Health Information Collaborative has all the tools in place to facilitate meaningful-use requirements along with records on 1.3 million patients in a state of slightly more than 2 million residents.

Michigan's initial ramp-up was optimistically planned but abruptly halted. A governor's-office initiative in 2005 split the state into nine medical trading areas, created criteria on which to award grants for HIE planning, and funded them in two rounds of funding in 2007 and 2008. "And then we ran out of money—everything else in Michigan ran out of money," says Beth Nagel, health information technology manager for the state Department of Community Health.

'Blessing in Disguise'

In retrospect, the setback was "a blessing in disguise," Nagel says. With the case for HIE already made, hospital systems and providers came together, realizing that they would have to provide their own money. "And that's when things really started to take off—when it was clear that the state wasn't going to be giving any supplemental funding."

Three systems with facilities in western Michigan—Spectrum Health, Trinity Health and Metro Health—launched independent efforts to tie their hospitals and clinics together through HIE and happened to all deploy the same vendor, Medicity. The systems have overlapping service areas and physicians. "Rather than be competitive in this area and do something dumb like go out and put multiple icons with the same technology on the same doctors' desktops, we agreed that we will not compete in this clinical data exchange and, instead, collaborate with each other," Dietz-man says.

Soon afterward, Lakeland HealthCare and Northern Michigan Regional Health System joined the collaborative discussions, each also independently licensing the Medicity clinical messaging platform. Michigan Health Connect was incorporated as a nonprofit organization in 2009, and shortly afterward McLaren Health Care joined, as did Ascension Health representing five of its ministries in the state.

A budget of  roughly $800,000 for the first 15 months included an equitable distribution of costs to keep things going while long-term sustainability could be figured out and talks continued with other systems that wanted to join, Dietzman says. The model puts each system in control of its own rollout while coordinating efforts to exchange clinical messages, build a community view of the data and avoid costly duplication of infrastructure. "What we're doing is bringing all those independent activities together, pointing them in a common direction, and making sure that we're marching toward the same place."

Coordinating Statewide Efforts

Health care communities without an established HIE network may have to start their own march. The federal government's approach is to work with existing HIE efforts rather than fund them from scratch, providing the connective technology and shared services that make wide-ranging HIE possible, says the ONC's Williams.

In New Jersey, where no state HIE plan was in place, chief executive officers of more than 10 hospitals and two large physician groups formed Jersey Health Connect a year ago. To accelerate the pace and avoid start-up capital expenses, it contracted with vendor RelayHealth to "rent" its exchange platform instead of building an infrastructure. "We can't wait any longer, so that's why we started going down this road," says Linda Reed, chief information officer of Atlantic Health, one of the network members.

Even rural outposts are taking matters into their own hands. In a topographically constrained region of Oregon carved out along the Columbia River, most of the major hospitals, physician clinics and health and community agencies dropped the gloves in the fall of 2009 and agreed to form Gorge Health Connect to share information on the region's 48,000 residents, says Brian Ahier, the network's president and health IT evangelist at participant Mid-Columbia Medical Center.

The provider-sponsored HIE initiatives in turn are working with their states to plan for and receive the federal money to start their work in earnest. Williams says HIE investment is concentrated in three areas:

  • Where provider density is low and information-exchange capability scarcely exists—typically in frontier states or rural pockets nationwide—the focus is on "lightweight, rapidly mobilized ways to get information moving over the next couple of years."
  • As HIE capacity develops in a state, the focus is on bringing existing capabilities up to speed quickly, and determining the best investments to make with available resources.
  • To connect the multiple HIE initiatives, such infrastructures as provider directories, identity authentication tools and messaging interfaces can be implemented in common.

In New Jersey, four independently operating HIE networks were granted a total of $11.4 million under the federal cooperative agreement program, including $3.3 million to Jersey Health Connect. Four of its 11 participating health systems are already on the software-as-a-service HIE platform, and HIE expenses are low because no technical staff is necessary—the expertise is purchased as part of the service, says Reed.

Likewise, four networks, including Michigan Health Connect, are cooperating under the umbrella of the state-sponsored Michigan Health Information Network to employ technology standards, a provider index, a record-locator service for aggregating information on individual patients from multiple origins, and other infrastructure essential to sharing electronic health records, Nagel says. The substate HIE networks hold seven of 13 seats on a governing board, which includes the state's three biggest health insurers.

Meanwhile in Colorado, Poudre Valley Health System is poised to begin a pilot data-exchange effort with smaller facilities in the northern part of the state, the first collaboration with the Colorado Regional Health Information Organization, the agent receiving and managing the federal HIE grant. "With so many patients coming in here from rural areas, from our outreach areas, we need to be early in this process to then support those [rural hospitals] in the exchange process," says CIO Branzell.

The first phase of exchange, which includes lab tests, clinical reports and patient demographics, is expected to be operational by the end of March, he says. But that's just the beginning.

Taking HIE National

The federal HIE program gives providers latitude in each state to execute according to local needs, but not necessarily the focus to look at how natural service areas and referring patterns cross state lines, Branzell says. "The current model for HIE in nearly all cases is health information exchange within a state-defined area, as if something magic happens at the borders and patients don't move back and forth." In northern Colorado, for instance, patients from Wyoming, Nebraska, Kansas and even as far away as Utah flow into the state for care, he says.

If a state were to go to a completely different technology and model that does not mirror its neighbors, that's a new problem. "It's kind of like everyone going out and buying their own software package and then saying, 'All of us should work together,' " Branzell says. "Well, unless somebody defined what working together meant on the front end, you couldn't get there."

To pre-empt those problems, the College of Healthcare Information Management Executives has formed a collaborative called StateNet to forge best practices and guiding principles nationwide on everything from a business model to a technical conceptual framework to exchange core information, Branzell says. He's chairman of StateNet, which covers every state and the District of Columbia.

Another wrinkle on the cross-state challenge: multihospital systems that are national in scope. Catholic Health Initiatives is in the process of selecting an HIE vendor flexible enough to share information within its hospitals and clinics in each state, mesh with whatever a given state decides to deploy, and tie all the sites across its 19-state reach together in a common information infrastructure, says Cristina Thomas, vice president for clinical information technology strategy.

The internal HIE step is the most important for the time being, Moore says. For any setting in which a patient interacts with CHI services, "we will have a fully mobile and effectively acting HIE. And then we also hope that we'll be tying that into state exchanges and other regional exchanges to further augment that [CHI-specific information exchange]."

John Morrissey is a freelance writer in Chicago.