Opportunity and Driving Forces
- Health care providers and stakeholders have access to shared community information assets to support key clinical decisions across care settings;
- Quality outcomes, patient safety, and population health are improved;
- Costs are contained through improved efficiency and reduction of duplicative services;
- Patients and consumers benefit through an improved experience with the health care system, with special focus on the chronically ill and underserved communities.”
The final rule for stage 2 of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program’s meaningful use criteria contains provisions related to the establishment of HIEs. Specifically, the rule requires that hospitals that transition patients to other care settings or providers must transmit a significant amount of clinical data for at least 50 percent of care transitions. In addition, for at least 10 percent of care transitions, data must be sent electronically. At least one of these electronic transmissions must be successfully sent to a provider on a different EHR platform.
By providing a communication platform that would allow health care providers to send and receive clinical patient information securely, the HealthShare Exchange of Southeastern Pennsylvania HIE would assist hospitals in meeting this stage 2 requirement.
HealthShare Exchange would be especially beneficial to Southeastern Pennsylvania because the region has many diverse, high-quality health care resources, including 12 large health care systems. This diversity leads to a common scenario where patients visit multiple providers. For example:
- Up to 50 percent of patients who are readmitted within 30 days of discharge return to different hospitals than the ones from where they previously received treatment.
- “In network” discharges, those where facilities discharge to ambulatory practices within their integrated delivery systems, account for less than 30 percent of discharges.
- The standards of the region’s 9-1-1 system require that emergencies be brought to the nearest emergency rooms, not to patients’ preferred hospitals. This requirement has the unintended consequence of disrupting the coordination of care that chronically ill patients may be receiving within integrated delivery networks.
These utilization patterns create challenges for care coordination — and opportunities for improved care transitions — through the exchange of health information via HealthShare Exchange.
In fact, The Health Care Improvement Foundation was motivated to take a leadership role in the early stage development of HealthShare Exchange as a result of efforts to improve care transitions and reduce hospital readmissions through the Foundation’s collaborative PAVE Project. By promoting the availability and use of innovative tools, training, and resources for health care professionals, patients, and family caregivers, PAVE achieved significant reductions in readmission rates. At the same time, project outcomes revealed that crucial gaps remained in coordination of care following hospital discharge and during other transitions between care settings. The Health Care Improvement Foundation envisions HealthShare Exchange as a way to reduce these gaps and improve care coordination.
Early Stage Development and Proof of Concept
In summer 2011, representatives from AmeriHealth Mercy, Delaware Valley Healthcare Council of HAP (DVHC), The Health Care Improvement Foundation, and Independence Blue Cross (IBC) formed the Southeastern PA Health Information Organization (SEPA HIO) Steering Committee and began meeting to discuss the early stage formation of an HIE serving the five-county region of Southeastern Pennsylvania. Their work led to the creation of HealthShare Exchange
The Steering Committee determined that a regional HIE would have the greatest positive impact on health outcomes by focusing on clinical use cases related to improvement in care transitions. A multi-stakeholder Quality Committee composed of clinical leaders from health systems, health plans, and large physician group practices and other regional stakeholders selected hospital discharge and medication history/clinical activity summary as the most promising clinical use cases to start with. The value of the use cases was analyzed as part of the multi-stakeholder process to develop a business plan for creation of a regional HIO and HIE.
The purpose of the hospital discharge use case is to create, via the HealthShare Exchange HIE, a standardized process for communicating timely discharge information from hospitals to primary care providers and care coordinators in order to:
- improve the transition of care;
- improve the quality of follow-up care;
- avoid re-hospitalization.
With this use case health care providers can request, via portals or other methods, medication histories from patients’ insurers during office visits, emergency room visits, or in-patient admissions. The medication data will be drawn from health plans’ pharmacy benefits management systems and offer real-time or close-to-real-time lists of dispensed medications including name (brand, generic) strength, supply, and date dispensed. The clinical summary data will include data on visits and admissions, including dates, visit types (office/clinical, ER, inpatient), and providers.
Through a Request for Proposal process, The North Highland Company, a respected national management consulting firm, was engaged to facilitate a multi-stakeholder process in the development of a business plan regarding the formation and implementation of a regional HIO and HIE for Southeastern Pennsylvania.
Three working committees - Governance and Financial Sustainability, Technology, and Quality -were established to assist with the plan’s development. A wide range of health care stakeholders, including the City of Philadelphia, health plans, safety net providers such as federally qualified health care centers, and physician groups and organizations were involved. DVHC staff participated on each of the committees, as did chief executive officers, chief information officers, and quality leaders from 12 hospitals and health systems.
HealthShare Exchange stakeholders, its member hospitals, and representatives from the insurer community have been active participants in the original Pennsylvania eHealth Collaborative, now authorized as the Pennsylvania eHealth Partnership Authority, the multi-stakeholder committee structure and planning process put in place by the Commonwealth’s Healthcare Information Technology Coordinator to support the deployment of HIE in Pennsylvania.
Through this involvement, HealthShare Exchange stakeholders:
- Provided input and feedback with the aim of ensuring that the state’s HIE strategies recognize the needs and concerns of Southeastern Pennsylvania;
- Developed an understanding of the state’s HIE-related goals and technology approaches, to ensure that HealthShare Exchange efforts would align with the state framework.
HealthShare Exchange stakeholders continue to participate in all four of the eHealth Collaborative’s “tiger” teams — Technical; Financial; Policy and Operations; and HIE Certification — to define the HIE capabilities and services needed at the state level, as part of the Community Shared Services layer.
HealthShare Exchange plans to utilize the CSS layer and functions that support inter-HIE and national exchange over time as it evolves from DIRECT to robust query exchange. The Commonwealth of Pennsylvania, as part of its CSS services, continues to explore if it will become an “Opt-in” or “Opt-out” state. This “Opt-in / Opt-out” functionality is a privacy mechanism whereby patients can consent to include their patient medical information in a health information exchange; it is generally managed at the state level. HealthShare Exchange will be prepared to support either option.
In alignment with state efforts to incentivize the use of federal Nationwide Health Information Network (NwHIN) DIRECT specifications for the secure transfer of electronic patient information, HealthShare Exchange’s technology approach is based on the use of the DIRECT federal specifications to stand up the regional HIE, with a planned migration to a more robust query model of health information exchange.
Organization, Structure, And Governance
HealthShare Exchange is in the process of seating a full board of directors in Q1 of 2013, with significant representation from the hospital and payer communities as well as physician and consumer advocacy representatives.
HealthShare Exchange will recruit and build the staff necessary to manage the day-to-day operations of the HealthShare Exchange HIO and HIE, including an Executive Director, administrative, outreach, and project management functions.
Business And Financial Sustainability Models
Value: Health care stakeholders, including hospital and insurance leaders involved in the development of the Southeastern Pennsylvania Health Information Organization (SEPA HIO) Business Plan assessed and quantified the value of the discharge and medication summary use cases in terms of their potential to:
- reduce redundant care;
- enhance the clinical information available at point of care;
- prevent adverse health care events;
- decrease administrative burdens.
Costs: HealthShare Exchange costs were estimated based on the technology and staff required to start up and operate a regional HIO and HIE for Southeastern Pennsylvania and were validated via cost proposals received during our vendor selection initiative.
Return on Investment: HealthShare Exchange has performed extensive financial modeling of the cost savings associated with its initial clinical uses cases and anticipates the cumulative value of health information exchange to significantly exceed the cost of start-up and operations over a four-year time horizon via better quality outcomes, reduced patient readmissions, reduction of adverse drug events, etc.
HealthShare Exchange will enlist an independent entity, Health Care Improvement Foundation (HCIF), to provide independent grant evaluation and monitoring services that will include monitoring HealthShare Exchange performance against project benchmarks, and developing and implementing metrics to measure the efficacy of the implemented HealthShare Exchange clinical use cases.
The calculation of the value of the use cases was based on a phased-in physician adoption rate: 20 percent of the region’s physicians in year one; an additional 40 percent in year two; 20 percent more in year three; and 20 percent more in year four.
The ‘critical mass’ of hospital and health system participation is defined as follows: In order for HealthShare Exchange to be effective and viable, the participating hospitals and health systems must account for at least 80 percent of the region’s patient encounters. This metric was established by the DVHC Board of Directors as part of the determination to support HealthShare Exchange’s application for a state Community Shared Services grant. At this early stage, this requirement has been met; letters of commitment have been received from hospitals and health systems, accounting for close to 90 percent of patient encounters in the region.
HealthShare Exchange’s financial sustainability model is an annual subscription model based on a fair share approach, with contributions from both the insurer and hospital communities. In December 2012, HealthShare Exchange received a $1.5M grant from the Commonwealth of Pennsylvania to support plans and some costs for start-up and implementation. See Community Share Service grants for more information.
Initial contributions for HealthShare Exchange are being secured from acute care hospitals in Southeastern Pennsylvania and insurance companies that have enrollment in the region. Physicians and primary care providers will be encouraged to participate in HealthShare Exchange but will not be expected to provide a financial contribution during the initial phase. As HealthShare Exchange expands participation to include non-acute care facilities, those entities would be included in the financial sustainability model and would be expected to contribute to HealthShare Exchange. Likewise, as payer participation expands, those companies would be required to contribute to HealthShare Exchange.
Public Funding Opportunities
Because of HealthShare Exchange’s expected impact on the quality and cost of care delivered in Pennsylvania’s largest metropolitan area, the organization has received strong support from government funders. Two grant sources are anticipated:
- Through funds originally allocated from the federal HITECH Act, the Commonwealth’s Community Shared Services grant program was established to support the implementation of regional health information exchange and provide financial sustainability for the new Pennsylvania eHealth Partnership Authority.
- In recognition of the positive impact of health information exchange, the Centers for Medicare & Medicaid Services (CMS) has made available Medicaid 90/10 enhanced funding to states, to support the development of HIE. Enhanced funding is available for HIE start-up costs and is allocated based on the extent to which the Medicaid program will benefit from the HIE services. Medicaid funding is contingent on demonstrated commitments from other benefiting stakeholders.
Funding from the CMS Medicaid grant is included in HealthShare Exchange of Southeastern Pennsylvania’s year-one funding model.
HealthShare Exchange of Southeastern Pennsylvania applied for a Community Shared Services (CSS) state grant in the amount of $1.5 million. It was received in December 2012 and includes provisions for payment of a 75 percent stakeholder match to be paid back to the state over a period of one year to help fund the Community Shared Services capabilities needed for health information exchange on a statewide level. The statewide exchange will eventually build capacity for exchange among the regional HIEs in Pennsylvania and care providers in New Jersey, Delaware, and other states.
The schedule for payment of the 75 percent stakeholder match to the Commonwealth is as follows:
- $225,000 at the grant signing;
- $375,000 on January 1, 2013;
- $375,000 on March 1, 2013;
- $225,000 on June 1, 2013.
The first two payments have been made to the Commonwealth.
On behalf of HealthShare Exchange of Southeastern Pennsylvania, the Pennsylvania Department of Public Welfare has prepared a draft funding request and plans to send submission to the Centers for Medicare & Medicaid Services. It is anticipated that a decision on HealthShare Exchange’s grant submission would occur in Q2 of 2013.
Technology And Infrastructure
HealthShare Exchange’s technology approach is to:
- Use existing and ‘commodity’ off-the-shelf industry solutions based on existing and emerging standards;
- Leverage existing provider and insurer stakeholder investments in technology;
- Select technology that supports current and future business capabilities and allows for incremental implementation that builds on existing investments and is not “throw away”;
- Align with and support the Pennsylvania eHealth Partnership Authority and the statewide HIE under development.
In accordance with this framework, HealthShare Exchange will use the NwHIN DIRECT specifications as its start-up suite of protocols for exchanging health data among local providers and plans. This technology provides a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet. The standards adhered to in this specification resulted from the NwHIN DIRECT Project, an open government initiative started by the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology.
The use of DIRECT will allow hospitals participating in HealthShare Exchange to capitalize on their investments in electronic health records (EHRs) and other health care information technology. Many hospitals have EHRs that are DIRECT-capable or DIRECT-ready. According to 35 hospitals that responded to a DVHC survey fielded early this year:
- over 90 percent had implemented an EHR;
- nearly half are almost or fully DIRECT-ready;
- about one-third are somewhat DIRECT-ready.
HealthShare Exchange is in the process of selecting a technology partner to assist with the
creation of an HIE in Southeastern Pennsylvania. To that end, HealthShare Exchange:
- Created a Vendor Selection Committee consisting of hospitals, insurers, and other stakeholders;
- Invited potential partners to respond to a Request for Information (RFI) about how they would support the implementation of the HealthShare Exchange HIE;
- Invited potential partners to respond to a Request for Proposal (RFP) about how they would support the implementation of the HealthShare Exchange HIE;
- Conducted HIE service demonstrations with HealthShare Exchange’s stakeholder community in advance of selecting two vendors to participate in final offer negotiations.
Nine vendors responded to the RFI, and six vendors were identified as able to meet HealthShare Exchange’s technology needs. In light of the evolving healthcare technology environment, the Request for Proposal (RFP) phase was opened to include additional technology providers.
The HealthShare Exchange Board will be responsible for the final selection of a vendor and negotiation of a final contract. The vendor selection process is expected to be completed by the end of Q1 2013.
Security of confidential patient information is a key concern of HealthShare Exchange, and the chosen technology approach is in full compliance with HIPAA and other applicable privacy regulations. HealthShare Exchange’s technology approach follows the Nationwide Health Information Network's (NwHIN) DIRECT technology framework as described above and is built on common Internet standards for secure email communication.
It is expected that HealthShare Exchange stakeholders will seek to evolve their technical capabilities to include integration with their EHR systems. HealthShare Exchange anticipates supporting end-to-end system connectivity to facilitate email-to-EHR communications. This model can co-exist with the DIRECT model of exchange to ensure that privacy-protected medical data is delivered only to those healthcare stakeholders who are authorized to evaluate this information, for care management purposes only.
Once HealthShare Exchange selects a technology partner, an implementation schedule will be developed for the exchange. This schedule will include those hospitals and payers that have executed Letters of Commitment to the exchange and that wish to be part of the initial deployment phase of implementation. This plan and timeline will be developed in collaboration with the selected technology vendor.
When ready, HealthShare Exchange anticipates a rapid deployment of health information to be exchanged given the deployment of a DIRECT model for initial health information exchange.
How stakeholders connect to the HealthShare Exchange HIE depends largely on the nature of the health care IT tools and systems, such as secure email and electronic health records, that are already in place within their organizations. The most common scenarios for connecting to the HIE are:
- sending and receiving clinical information via secure email according to DIRECT Project standards;
- sending and receiving clinical information via a web portal;
- sending and receiving clinical information from the organization’s electronic health record system. Incoming clinical information would be integrated into the appropriate patient electronic health records. Outgoing information would be sent from those records.
The resources needed by individual hospitals, providers, and other stakeholders to participate in the exchange vary greatly depending on the type of technology already in place and the desired method of connection. The EHRs and other technology in place at most of the region’s hospitals are DIRECT-ready to some degree, so hospitals are well-positioned to participate in the HealthShare Exchange HIE.
Consumer Access To Personal Health Information
Per the Meaningful Use Stage 2 objective of providing patients with the ability to access their health information, the access point for this information will be focused on the Provider and the capability of their EHR Technology. HealthShare Exchange will support providing patients with access to their health information within the context of its objectives of improving quality outcomes, patient safety, and population health.