One of the most essential elements of any accountable care organization is an electronic health information exchange that allows partners to share information across the organization. Seamlessly sharing information can help ACOs further coordinate care, mitigate risks and, ideally, improve outcomes — all while curbing the cost of care.
The state of Massachusetts has been at the forefront of healthcare reforms and health information exchange implementation. Here, Micky Tripathi, CEO and president of the Massachusetts eHealth Collaborative — a non-profit organization that helped launch one of the first health information exchanges in that state in 2006 — offers advice to accountable care organizations and other healthcare organizations preparing to take the plunge into setting up a health information exchange.
1. Identify what information you want to share and with whom you want to share it. The degree of integration between providers in a health information exchange should depend on the amount of collaboration happening between them, Mr. Tripathi says. For example, a community hospital in an HIE may not need to have the same level of integration with a regional medical center as it needs to have with a large primary care practice referrer in its own community.
There may also be instances in which partners in an ACO or integrated system need to share more information with collaborators that are not officially partners. For instance, a physician-hospital organization that is not contractually part of an ACO might still refer a great deal of patients to providers in the ACO. In this case, the ACO's participants may want to have a richer level of information exchange with that PHO, without allowing the PHO to have complete access to the HIE.
Besides distant relationships with limited HIE demand and closer relationships with PCPs and local providers where a deeper amount of information sharing may make sense, an ACO or integrated care system has what Mr. Tripathi calls its "inner circle" of partners. These are the members of an ACO, the essential partners in the pursuit of managing risks and delivering high quality care. The inner circle of ACO participants should be able to share information to the highest degree within the constraints of the health information exchange's capabilities.
2. Think seriously about HIE governance and organization. Since hospitals are funding and driving many ACOs, they may tend to assume the same infrastructure governance rules for the hospital's individual information exchange will apply to an ACO's. But a hospital's internal record information sharing system and an ACO's HIE are different, involving multiple organizations and information specific to the ACO. It is therefore crucial for members of an ACO to sit at the drawing board and map out a governance strategy, Mr. Tripathi says. Hospitals need to decide if they are willing to take on the legal responsibility that comes with having greater access to records health and patient information.
ACOs that do not sit down to fully consider HIE governance may need to backtrack after the fact. For example, some hospitals in ACOs are not entirely certain they are legally protected with the added information that comes with ACO records sharing. Moreover, technical support issues are surfacing. Mr. Tripathi uses the example of a hospital's information technology help desk being bombarded with customer service and usability concerns from the entire ACO community using the exchange. Hospitals and other members of an ACO should consider long-term sustainability factors and technical support before setting up HIEs.
Mr. Tripathi also suggests setting up an HIE payment agreement plan between partners in an ACO before implementing an exchange. Hospitals driving ACOs may find out the hard way that sustaining an HIE is more expensive than they initially considered. They may need financial help down the road from participating providers to keep HIEs afloat. The cost of adding users, interface and data to the exchange adds up. Who will pay for what is something to seriously consider because setting up — and then pulling off — a successful HIE is neither cheap nor easy.
3. Establish secure back-and-forth email information exchange between partners. The initial level of an HIE allows partners to share confidential information over a secure email. While this is essentially one step above a fax, it's a very important step in creating a robust electronic health information exchange. Establishing a secure email exchange between providers in a uniform way is important from a security perspective because it gets providers to move beyond faxes, which are not the most secure way to exchange information, Mr. Tripathi says.
From a patient permission and audit perspective, the emails are important because they are easily auditable. Organizations can electronically track when emails were sent, and to whom they were sent.
4. Provide the IT capability to identify records across an ACO. After establishing secure email exchange capability between members of the ACO, the next step in integrating an exchange is to enable consistent, accurate and current demographic and medical data on patients — an enterprise-wide master patient index.
"This means having the ability to ask if anyone in the organization has records on a given patient," Mr. Tripathi says. In this step of HIE engagement in an ACO, members of the exchange may not have the ability to necessarily retrieve the records electronically because of legal or business considerations. But knowing where the patient information is and knowing which healthcare provider to contact to get it is crucial to saving time.
5. Create a full-fledged query system that operates outside the episode of care. The final, most advanced level of an HIE is what Mr. Tripathi refers to as the classic model, the idealized health information exchange. Mr. Tripathi uses an analogy to explain it; a patient shows up in an emergency department "naked and unconscious." The patient, of course, isn't able to provide any information about his medical history, but clinicians — assuming they have managed to somehow identify the name of the patient — will have the ability to query the HIE and get a high level of medical information about the patient in a seamless, automated way.
"Right now there are no technical standards for this, and there are all sorts of legal and clinical process and business issues to confront that are aside from the technology," Mr. Tripathi says. "It will still take a lot of time to work out."
For example, it's unclear what information would be included in a query-friendly HIE among ACO participants. Would the exchange include sensitive conditions? Would it function differently when dealing with minors? These, among other legal and clinical issues, will need to be ironed out before any health information exchange is able to live up to its ideal.
"It is mind numbingly complicated," Mr. Tripathi admits.
But the goal is there. With patient consent over time, and over time, this model will offer physicians and support staff what they need to make the most informed clinical decisions. And for an ACO, this could provide the organization with the means to improve quality of care, while reducing costs.
UPMC-Backed Health Information Exchange Connects Pennsylvania Hospitals
Kaiser Permanente, Social Security Administration Launch HIE Pilot
The state of Massachusetts has been at the forefront of healthcare reforms and health information exchange implementation. Here, Micky Tripathi, CEO and president of the Massachusetts eHealth Collaborative — a non-profit organization that helped launch one of the first health information exchanges in that state in 2006 — offers advice to accountable care organizations and other healthcare organizations preparing to take the plunge into setting up a health information exchange.
1. Identify what information you want to share and with whom you want to share it. The degree of integration between providers in a health information exchange should depend on the amount of collaboration happening between them, Mr. Tripathi says. For example, a community hospital in an HIE may not need to have the same level of integration with a regional medical center as it needs to have with a large primary care practice referrer in its own community.
There may also be instances in which partners in an ACO or integrated system need to share more information with collaborators that are not officially partners. For instance, a physician-hospital organization that is not contractually part of an ACO might still refer a great deal of patients to providers in the ACO. In this case, the ACO's participants may want to have a richer level of information exchange with that PHO, without allowing the PHO to have complete access to the HIE.
Besides distant relationships with limited HIE demand and closer relationships with PCPs and local providers where a deeper amount of information sharing may make sense, an ACO or integrated care system has what Mr. Tripathi calls its "inner circle" of partners. These are the members of an ACO, the essential partners in the pursuit of managing risks and delivering high quality care. The inner circle of ACO participants should be able to share information to the highest degree within the constraints of the health information exchange's capabilities.
2. Think seriously about HIE governance and organization. Since hospitals are funding and driving many ACOs, they may tend to assume the same infrastructure governance rules for the hospital's individual information exchange will apply to an ACO's. But a hospital's internal record information sharing system and an ACO's HIE are different, involving multiple organizations and information specific to the ACO. It is therefore crucial for members of an ACO to sit at the drawing board and map out a governance strategy, Mr. Tripathi says. Hospitals need to decide if they are willing to take on the legal responsibility that comes with having greater access to records health and patient information.
ACOs that do not sit down to fully consider HIE governance may need to backtrack after the fact. For example, some hospitals in ACOs are not entirely certain they are legally protected with the added information that comes with ACO records sharing. Moreover, technical support issues are surfacing. Mr. Tripathi uses the example of a hospital's information technology help desk being bombarded with customer service and usability concerns from the entire ACO community using the exchange. Hospitals and other members of an ACO should consider long-term sustainability factors and technical support before setting up HIEs.
Mr. Tripathi also suggests setting up an HIE payment agreement plan between partners in an ACO before implementing an exchange. Hospitals driving ACOs may find out the hard way that sustaining an HIE is more expensive than they initially considered. They may need financial help down the road from participating providers to keep HIEs afloat. The cost of adding users, interface and data to the exchange adds up. Who will pay for what is something to seriously consider because setting up — and then pulling off — a successful HIE is neither cheap nor easy.
3. Establish secure back-and-forth email information exchange between partners. The initial level of an HIE allows partners to share confidential information over a secure email. While this is essentially one step above a fax, it's a very important step in creating a robust electronic health information exchange. Establishing a secure email exchange between providers in a uniform way is important from a security perspective because it gets providers to move beyond faxes, which are not the most secure way to exchange information, Mr. Tripathi says.
From a patient permission and audit perspective, the emails are important because they are easily auditable. Organizations can electronically track when emails were sent, and to whom they were sent.
4. Provide the IT capability to identify records across an ACO. After establishing secure email exchange capability between members of the ACO, the next step in integrating an exchange is to enable consistent, accurate and current demographic and medical data on patients — an enterprise-wide master patient index.
"This means having the ability to ask if anyone in the organization has records on a given patient," Mr. Tripathi says. In this step of HIE engagement in an ACO, members of the exchange may not have the ability to necessarily retrieve the records electronically because of legal or business considerations. But knowing where the patient information is and knowing which healthcare provider to contact to get it is crucial to saving time.
5. Create a full-fledged query system that operates outside the episode of care. The final, most advanced level of an HIE is what Mr. Tripathi refers to as the classic model, the idealized health information exchange. Mr. Tripathi uses an analogy to explain it; a patient shows up in an emergency department "naked and unconscious." The patient, of course, isn't able to provide any information about his medical history, but clinicians — assuming they have managed to somehow identify the name of the patient — will have the ability to query the HIE and get a high level of medical information about the patient in a seamless, automated way.
"Right now there are no technical standards for this, and there are all sorts of legal and clinical process and business issues to confront that are aside from the technology," Mr. Tripathi says. "It will still take a lot of time to work out."
For example, it's unclear what information would be included in a query-friendly HIE among ACO participants. Would the exchange include sensitive conditions? Would it function differently when dealing with minors? These, among other legal and clinical issues, will need to be ironed out before any health information exchange is able to live up to its ideal.
"It is mind numbingly complicated," Mr. Tripathi admits.
But the goal is there. With patient consent over time, and over time, this model will offer physicians and support staff what they need to make the most informed clinical decisions. And for an ACO, this could provide the organization with the means to improve quality of care, while reducing costs.
More Articles Related to Health Information Exchanges:
Hospital Association Comments on Health Information ExchangesUPMC-Backed Health Information Exchange Connects Pennsylvania Hospitals
Kaiser Permanente, Social Security Administration Launch HIE Pilot