The Gift of Sharing
By Crystal Conde Texas Medicine February 2011

Health Information Exchanges Can Improve Patient Care

Cover Story – February 2011

  Tex Med. 2011;107(2):14-22.

By Crystal Conde
Associate Editor

For the past five years, the Dallas County Medical Society (DCMS) has worked to establish a health information exchange (HIE). It's been difficult, but the arrival of federal funds may help the society and its partners realize its dream of creating a system that allows physicians, hospitals, and other medical professionals to share information about patients.

"The medical community really wasn't poised for HIE before," said David Bragg, MD, a Garland family physician and chair of the DCMS HIE Five Committee, charged with overseeing the medical society's HIE initiative. "Now we have an opportunity to receive grant funding to implement an HIE, and we have representatives from many health care groups involved in our efforts."

In basic terms, says Joseph Schneider, MD, MBA, an HIE is a way to use technology to make patients' health information available anywhere, anytime. A Dallas pediatrician, Dr. Schneider chairs the Texas Medical Association Ad Hoc Committee on Health Information Technology.

Developing HIE infrastructure in Dallas and elsewhere in Texas is rapidly gaining traction due to $28 million in federal Health Information Technology for Economic and Clinical Health (HITECH) funding. The Office of the National Coordinator for Health Information Technology (ONC) allocated $548 million of HITECH funds for all 50 states. Texas is using its share of the federal money for an ambitious venture to establish HIEs in local communities to improve the quality, safety, and efficiency of health care.

Dr. Schneider, chief medical information officer for the Baylor Health Care System, says HIEs have many benefits for physicians and patients. Because physicians ultimately will have instant access to patient data, they'll avoid running duplicative tests, he says. A fully functional HIE also will allow rapid access to hospital discharge summaries and immunization records.

Getting to that point is a lot of work. To establish its HIE, the medical society in Dallas is collaborating with the Dallas-Fort Worth Hospital Council, area health care payment plans, and employers through the Dallas-Fort Worth Business Group on Health. The collaboration, known as the North Texas Accountable Healthcare Partnership, plans to connect major hospitals in the Dallas-Fort Worth area by using the established network of Project Access Dallas.

DCMS worked with community partners to create Project Access Dallas in 2002. Physicians, hospitals, or ancillary partners who volunteer in the program donate their services to see a set number of uninsured patients per year. Project Access Dallas now includes more than 700 physicians, 15 hospitals, nine charity health clinics, 10 ancillary service support organizations, one national laboratory service organization, and more than 40,000 nationwide pharmacies.

"If we could share information even at the very basic levels across these different systems, it could open the door to expand quickly beyond Project Access Dallas physicians to all physicians in the Dallas-Fort Worth area," Dr. Bragg said.

DCMS Executive Vice President/Chief Executive Officer Michael Darrouzet says the medical society is pleased to be participating in the development of a region-wide HIE.

"After many years of work, we feel this collaboration is the single best chance we have to really bring together hospitals, employers, carriers, and physicians," he said.

At press time, North Texas Accountable Healthcare Partnership HIE had applied for Texas Health Services Authority (THSA) grant funding and was securing a vendor contract in hopes of achieving connectivity in the first quarter of 2011.

James Stefan Walker, MD, a Refugio family physician and member of TMA's ad hoc committee, offers an example of how HIEs can improve patient care. He sees in his practice how a lack of coordination can affect patients. For example, he says, once a patient is discharged from the hospital, it can take a long time for the hospital to fax him the records.

The absence of the hospital records at a follow-up visit makes it difficult to determine what procedures and tests that patient received. Dr. Walker says an HIE also would allow quick access to prescription records, thus lowering a physician's risk of prescribing a medication that would cause a patient to have an adverse reaction.

"HIE will provide structured data a physician can incorporate into an EMR [electronic medical record] in a streamlined fashion," he said. "Physicians should join an HIE because getting records connected will be a main building block to an improved medical landscape."

ONC considers the secure sharing of information among health care professionals through HIEs essential to using EMRs in a "meaningful" way, and it is a requirement to qualify for the "meaningful use" financial incentives. An EMR system is a computerized system of accessing in real time a patient's history within a single practice. An EMR's content is analogous to the paper record, but the electronic format creates usable data, improves the efficiency of care, and allows more efficient communication among physicians and easier management of health plans.

As part of a strategy to develop the HIE infrastructure in the state, THSA has established a local grant program with the Texas Health and Human Services Commission (HHSC). In addition, the 2009 Texas Legislature ordered HHSC to create a Medicaid and Children's Health Insurance Program HIE. (See "Texas Medicaid, CHIP HIE Pilot.")

"We're in the early stages of being able to allow a patient's health information to follow him or her anywhere, securely and privately," Dr. Schneider said.

David Fleeger, MD, a member of the THSA Board of Directors, visualizes an HIE as a spider web. Each place where the threads of the web intersect is a point of communication in HIE infrastructure.

"Right now, we're connecting the strands of the web among all the different health care professionals and entities," Dr. Fleeger said. "The end game of making all patient medical information digital is to allow for sharing. Unless physicians can share the data with other doctors and health professionals, we won't accomplish increasing efficiency and keeping better records of patients' interactions with the medical system."

For more information about HIE efforts in Texas, contact TMA's Health Information Technology (HIT) helpline by calling (800) 880-5720 or by e-mailing hit[at]texmed[dot]org.

Texas has several local HIE initiatives in various stages of development that are working on strategies to coordinate care. (See "Texas Health Information Exchanges.")

Local HIEs were applying for THSA grants at press time. HIE applicants that met THSA's criteria were to be awarded grants of $75,000 to develop or upgrade a business and operational plan to support core HIE services and to meet other grant requirements.

THSA planned to announce grant recipients in late January. Visit the THSA website for a list of grant awards.

The grant program requires HIEs to obtain commitments from hospitals and physicians willing to guarantee their support and participation in the local networks. HIEs will receive $300 for each physician and $10,000 for each hospital that joins.

"Under our approach to statewide HIE, a record locator service will be implemented in 2012 that will allow a physician to look up or query other HIEs for patient information," said THSA Chief Executive Officer Tony Gilman.

Physicians can commit to participate in more than one local HIE. When a physician commits to multiple HIEs, however, only one HIE can receive the $300 for that particular physician's commitment. Mr. Gilman says that when more than one HIE claims the same physician, THSA will address the situation on a case-by-case basis.

In late December, HIEs contacted physicians to sign letters of commitment. Beginning in the second quarter of 2011, HIEs will use the funds to implement their local initiatives.

In early 2011, THSA will address what's known as "white space" coverage. The state's white space encompasses the areas that lack local regional HIE activity. THSA will evaluate proposals from entities that can provide HIE services in regions that lack them. Eligible applicants could include vendors, local HIEs, regional extension centers (RECs), or others. By the second quarter of 2011, THSA will award at least one contract to implement HIE coverage in the state's white space.

To access the THSA strategic and operational plans document, which includes information on the local HIE grant program, visit www.thsa.org.

Once HIE systems are up throughout Texas, says Dr. Fleeger, a member of TMA's Council on Practice Management Services, patients won't have to rely on their memories when traveling from one health care facility to another for care. Physicians will have access to patient records from multiple points of care.

Initially, HIEs will include problem lists, medications, allergy information, and laboratory results.

In the future, physicians will have access to x-rays, complete patient histories, physicals, and more data.

He urges physicians to support their local HIEs, but cautions them to do their homework and ask some pivotal questions first. (See "Questions to Ask HIEs.")

Dr. Walker has been on the board of the Health Information Network of South Texas (HINSTX) since September 2009. He encourages physicians to participate in local HIEs, because, he says, the ability to access patient information from other doctors who care for that patient can help improve care.

"Physicians have an opportunity to redesign the whole health system and to improve quality and efficiency. This is an exciting time to be in medicine," Dr. Walker said. "We can build exchanges to enable better quality metrics, improve communication, and allow us to practice medicine more safely."

Matt M. Murray, MD, a pediatric emergency medicine physician and member of TMA's Ad Hoc Committee on Health Information Technology, was part of a THSA work group to develop the Strategic and Operational Plans for Statewide Health Information Exchange.

He says widespread adoption of electronic health records (EHRs) by physicians and hospitals, along with the development of an infrastructure that allows secure sharing of EMR information, are necessary for physicians to get the most value out of the meaningful use of EMRs. The Centers for Medicare & Medicaid Services (CMS) released final meaningful use standards in July. Physicians must meet those standards to qualify for up to $44,000 in Medicare incentive payments from 2011 to 2016, and up to $63,750 in Medicaid incentive payments from 2011 to 2021.

To qualify for the meaningful use incentives, physicians must meet 15 core criteria and select an additional five from a menu of 10. To access the list of criteria, view the meaningful use rules, and learn how to register for the incentive programs, visit the TMA website. 

Dr. Murray makes presentations on HIT and educates physicians about the importance of developing HIE infrastructure while promoting EHR adoption by hospitals and health care professionals. An EHR is a computerized history of a patient's health care record that includes data from multiple sources of care. Because they are interoperable, meaning they can be accessed across networks by computers using a variety of operating systems and software, EHRs can be accessed at any authorized point of care.

"HIE maximizes the potential of an EHR to serve as a tool that enables us to provide the high quality of care we all strive for. An EHR can give us real-time access to our patients' medical records when and where we need it. But if I can see only what I've entered in my own EHR, I'm missing out on information from other local health care entities, such as the diagnostic findings during a patient's recent ER visit, or prescriptions written by a consultant," he said.

To help physicians adopt EHRs and achieve meaningful use, Texas has four federally funded RECs. 

Dr. Murray is chair of the North Texas REC. He says the RECs can:  

• Help physicians choose and implement the right EHR;
• Analyze their workflow before EHR implementation;
• Evaluate the implementation plan;
• Answer questions and concerns during implementation;
• Provide technical assistance; and
• Assess the EHR's functionality and how a practice uses the technology to achieve meaningful use after implementation. (See "A Great Deal: Meaningful Use Help from RECs.")  

Many Texas physicians could benefit from REC services. TMA conducted a survey on EMRs in 2009. The percentage of physicians who reported using an EMR continued to rise, with 43 percent reporting current use, up from 33 percent in 2007 and 27 percent in 2005. Forty percent reported a desire to implement an EMR. The percentage of respondents with no plans to implement an EMR decreased to 16 percent in 2009 from 25 percent in 2007.

In addition, 59 percent of the physicians indicated they will try to qualify for incentive payments by meeting meaningful use criteria. Twenty-three percent responded that they won't attempt to qualify for stimulus funds, while 18 percent indicated they need more information or assistance meeting the meaningful use criteria.

Physicians who need help selecting and implementing an EHR and achieving meaningful use may contact TMA to take advantage of the association's resources. For more information, call (800) 880-5720 or e-mail hit[at]texmed[dot]org.     

In addition, TMA offers a meaningful use webinar that covers EHR benefits in quality of care, patient safety, and efficiency. The webinar summarizes eligibility for the Medicare and Medicaid incentives and what physicians need to do to meet meaningful use measures. This on-demand resource is $25 and includes answers to some of the most common questions and access to additional tools.

Physicians can earn 1 AMA PRA Category 1 Credit^TM for completing the webinar and paying the $25 continuing medical education processing fee. For more information, contact the TMA Knowledge Center at (800) 880-7955 or visit the Distance Learning Center on the TMA website. 

To participate in a local HIE, physicians should sign a letter of commitment. Dr. Fleeger promotes physician participation in local HIEs because doctors will need to actually share information to qualify for meaningful use incentives in Stage 2, which begins in 2013.

For now, Stage 1 meaningful use criteria require physicians only to prove they can share information. In Stage 1, one of the core objectives says physicians should perform at least one test of their capacity to electronically exchange key clinical information. To access the list of criteria, visit the TMA website.

According to the meaningful use final rule, the test must involve actually submitting information to another health care professional with EHR technology or another system capable of receiving information. Real or "dummy" patient data can be used.

In an office with multiple physicians using the same system, only one test is needed to satisfy the requirement for all the physicians seeking the incentive.

Dr. Murray says a robust HIE system will benefit patients and physicians by improving quality of care.

"The bottom line is that HIE infrastructure and use need to be about improving quality of care for patients. In the future, the ability to access information available through an HIE … may prevent me from ordering redundant labs, repeating radiology tests, or prescribing the wrong medication," he said.

Dr. Murray says that Texas is focusing on building local HIE infrastructure and getting local physicians to buy in first because that's where physicians will get the most value from sharing information. Eventually, local exchanges will connect across the state and expand connectivity to other states and the nation.

Local HIEs will communicate with THSA using master indices of patient and physician information. THSA will then feed the information into the Nationwide Health Information Network (NHIN), a public-private venture that will connect HIEs, physicians, pharmacies, government agencies, laboratories, health care payment plans, and other stakeholders into a national network.

John C. Joe, MD, MPH, who serves on the Federal Health Architecture Leadership Council, says that in September 2008, several operational HIEs nationwide successfully conducted NHIN demonstration projects by electronically and securely transferring medical information for hypothetical patients moving to multiple physicians across the country.

Dr. Joe is the chief medical information officer of St. Luke's Episcopal Health System and executive director of the Greater Houston HIE.

The Federal Health Architecture Leadership Council supports federal HIT needs by creating a coordinated federal framework for HIT that promotes interoperability within and between the federal government and public- and private-sector organizations.

Before all HIEs can link up to the outside world, they have to function locally. Dr. Walker says that once South Texas has a fully operational HIE, it will accommodate organizations within 31 area counties.

In March 2010, HINSTX joined the area Diabetes Care Coalition to form a unified HIE for the Coastal Bend region. The HIE includes representation from stakeholders such as Christus Spohn, Corpus Christi Medical Center, Driscoll Children's Hospital, the Nueces County Medical Society, the Coastal Bend Rural Health Partnership, Texas A&M Health Education Center, Texas A&M University-Kingsville, and others.

"What makes our network unique … is we really have all the major players at the table. Our HIE includes all the area's major hospital systems, colleges and universities, nursing schools, public health agencies, and federally qualified health centers. Many of these entities normally compete, but they're all working together toward a common goal of health information exchange," Dr. Walker said.

HINSTX has a unique vision for HIE in the Coastal Bend area. In addition to providing a conduit for the exchange of data among physicians and health care facilities, the HIE will use de-identified data to track disease in the community.

"We want to use our data to determine health trends and to intervene at the local level when necessary," he said.

At press time, HINSTX reported its HIE was in the third stage of development, meaning it was requesting money from the state to develop a business plan.

HINSTX Executive Director Donna Deeb says the network also plans to seek support from local health care professionals.

Challenges to HIE Development

The concept of physicians and local hospital systems electronically sharing information seems simple enough, but there are challenges to making that happen

Dr. Joe says the real challenge is for EMR and HIE vendors to update and certify their products quickly. To be eligible for the Medicare or Medicaid incentive program, physicians must use EMRs certified by an ONC Authorized Testing and Certification Body. ONC lists all certified products on its website, http://onc-chpl.force.com/ehrcert.

HIEs also face the problem of long-term sustainability. THSA grant funding ends in 2013, and local exchanges will need to develop a financial model for the future.

In thinking about the long-term financial sustainability of HIEs, Dr. Bragg says cost is a major factor. Right now, he says, the HIE developed by DCMS doesn't plan to charge physicians for use.

He says health insurers receive the primary benefit from HIEs through reduced costs due to fewer duplicated tests and procedures, as well as other money-saving outcomes. In the future, Dr. Bragg says, health care payment plans and hospitals may be partners in helping to maintain the financial stability of HIEs.

TMA policy is that "any costs of supporting systems providing health information technology incentives to physicians should be borne by all stakeholders, clearly defined, fair, simple to understand, accountable, and should support the financial viability of the considered practice."

In line with TMA policy, Dr. Schneider recommends physicians resist efforts by HIEs to charge physicians for use once the exchanges are fully operational. He agrees with Dr. Bragg that health plans may eventually pay for the benefits they realize from a robust HIE infrastructure.

Another challenge is overcoming patients' and physicians' privacy and security concerns. Dr. Walker says the legislature will tackle patient consent this session.

In the meantime, physicians may consult the Texas Medical Practice Act provisions on releasing medical records to patients or to persons designated by patients. Physicians have the right of ownership of the physical pieces of paper or the physical hard drive that contains the records they develop when treating their patients in their practices. Patients generally have a right to access that information or receive copies.

TMA's Office of the General Counsel developed a Release of Medical Records white paper that covers requirements for written consent to release records; Health Insurance Portability and Accountability Act (HIPAA) authorizations and Texas consent to release; medical records and minors; fees for copies of records; time limits to respond to requests for medical records; conditions under which a physician may refuse a request for release; and other regulations.

To request the white paper, call the TMA Knowledge Center at (800) 880-7955 or e-mail knowledge[at]texmed[dot]org.  

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail.   

SIDEBAR

A Great Deal: Meaningful Use Help From RECs

Regional extension centers (RECs) can provide education and technical assistance for physicians – particularly those in primary care – to achieve "meaningful use" of certified electronic health record (EHR) technology.

Physicians participating in Medicare who achieve meaningful use are eligible for up to $44,000 over five years, and those participating in Medicaid who achieve meaningful use can receive up to $63,750 during 2011–21.

Texas is home to four RECs:

• North Texas Regional Extension Center, anchored by the Dallas-Fort Worth Hospital Council;
• Gulf Coast Regional Extension Center, led by The University of Texas Health Science Center at Houston;
• CentrEast Regional Extension Center, directed by Texas A&M Health Science Center-Rural and Community Health Institute; and
• West Texas Regional Extension Center, headed by Texas Tech University Health Sciences Center.   

To contact the RECs and enroll in their services, visit the TMA website.

The federal government subsidizes RECs' consulting services. All four Texas RECs charge primary care physicians an annual subscription fee of $300 for their services. In return, they receive services worth at least $5,000. Physicians who are specialists but can attest to providing primary care services are also eligible to receive REC consulting services at the subsidized rate. Other specialists can receive a quote for customized services.

RECs can help physicians with workflow analysis and practice redesign; EHR vendor selection; education; and meaningful use achievement.

TMA worked hard to make sure physicians hold half of the seats on the REC governing boards.

"Working with the RECs allows me to help doctors get the aid they need to implement health information technology. RECs are going to be crucial in helping physicians select, implement, and achieve meaningful use," said Matt M. Murray, MD, chair of the North Texas REC.

Dr. Murray says the North Texas REC had enrolled more than 200 physicians for services at press time, with more than 500 others in various stages of commitment. The North Texas REC has a goal of helping 1,498 physicians implement EHRs in the next two years.

TMA will educate physicians about REC services. For more information, visit the TMA website. Also, see "RECs to the Rescue: Regional Centers Help Physicians Use HIT," April 2010 Texas Medicine, pages 61-66.

TMA staff can answer your questions about REC services. Call HIT Director Shannon Moore at (800) 880-1300, ext. 1411, or (512) 370-1411, or e-mail her. You also can call HIT Marketing and Resource Coordinator Tyler Patterson at (800) 880-1300, ext. 1372, (512) 370-1372, or e-mail him.

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Texas Medicaid, CHIP HIE Pilot

In 2009, the legislature directed the Texas Health and Human Services Commission (HHSC) to establish a Medicaid and Children's Health Insurance Program (CHIP) health information exchange (HIE). House Bill 1218 requires the commission to establish an HIE pilot project in at least one urban area to determine the feasibility, cost, and benefit of exchanging secure electronic health information between the commission and local or regional HIEs.

The pilot project must include the participation of at least two regional HIEs.

In developing the pilot project, HHSC must:  

• Ensure the use of information exchanged through the pilot project benefits patients;
• Specify which health care professionals will use which data elements obtained from HHSC and for what purposes; and
• Ensure compliance with all state and federal laws and rules related to the transmission of health information.  

Joseph H. Schneider, MD, MBA, chair of the Electronic Health Information Exchange System Advisory Committee, says the pilot initially will focus on exchanging patients' medication histories. The committee counsels HHSC on implementing the HIE pilot.

HHSC plans to award grants to local HIEs later this year to assist them with planning and development. HHSC doesn't expect the HIEs to be fully operational until 2012. In addition, Dr. Schneider says HHSC will seek out an entity to provide HIE services for those areas of Texas not served by a local HIE.

For Medicaid-participating physicians to take part in the pilot, Dr. Schneider says they must use an e-prescribing program or have an electronic medical record system.

"Overall, the Medicaid organization is working hard to securely and privately open up the Medicaid databases to help physicians provide better care to Medicaid and CHIP patients," Dr. Schneider said.

By this fall, Dr. Schneider says, the Medicaid Eligibility and Health Information Services (MEHIS) project will be in full swing. Physicians will be able to access eligibility, drug, and Texas Health Steps information, as well as claims, encounters, and eventually immunization data. The MEHIS client portal will provide on-demand access to patient health information included in the electronic health record.

For more information about the pilot project and MEHIS, visit the HHSC website.

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Questions to Ask HIEs

Before committing to a local health information exchange (HIE), physicians need to ask questions. Physician health information technology experts recommend physicians consider the following:

• What information will be shared via the HIE? Some HIEs will share only laboratory data, while others will allow access to discharge summaries, notes, test results, and more.
• How will physicians be able to determine the source, date, and time of the data? Answers to these questions will help physicians reconcile contradictory information they may encounter, such as a "penicillin allergy" for a patient pulled from one electronic medical record but "no known allergies" pulled from another.
• What privacy and security mechanisms does the HIE feature? Physicians should learn the HIE's policies and procedures on how they'll obtain patient consent for using the data. If a patient chooses to exclude some data from being shared, the physician should make sure the HIE discloses that fact.
• Does the HIE include the patient populations, referral networks, and the hospitals and other physicians the doctor works with? Make certain the HIEs connect to the local hospitals, labs, radiology services, and other facilities. Taking part in an HIE with limited connections could leave doctors having to make decisions based on partial information.
• Will the HIE be financially viable in the future? It's not simple to move from one HIE to another. Physicians should ensure the HIE has a thorough business plan with strategies for long-term success and staying power. If the HIE has been in existence for a while, physicians should ask their colleagues about the exchange's track record and functionality.
• Is there a fee to participate? Many HIEs will be free initially, but physicians should ask whether potential future fees have been addressed.
• Who is on the HIE board of directors? HIE governance should represent health care stakeholders in the community.
• What are the computer system requirements to connect to the HIE?
• Does the HIE use a centralized or decentralized model? Physicians participating in exchanges that use a centralized model obtain a patient's permission to have their records and information stored in a database. Physicians and other health care professionals can query the database for patient information and share it with others. In a decentralized model, the physician stores patient information and permits access by authorized personnel and entities.
• Are there opportunities to provide feedback on HIE operations? Physicians should inquire about their ability to attend HIE meetings and to weigh in on the system's functionality.  

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