A major source of funding for electronic health information exchange has historically been federal grants, such as those provided by the HITECH Act, which included, among other things, grants for the development of statewide HIE infrastructure. With this funding largely gone, the locus of electronic HIE activity has been shifting from the federal government to public — and, increasingly, private — health care stakeholders at the state and local level.
In the absence of federal funding, health care providers, health plans, consumer advocates and state policymakers are all testing new strategies to increase interoperability and to shore up the financial sustainability of their HIE efforts. Not surprisingly, their strategies are diverse and include regional HIE initiatives (e.g., the Santa Cruz HIE and various other regional HIEs operating throughout California) and private proprietary HIE initiatives operated by hospitals that use Epic Care or other health IT tools to connect with health care providers in the community, among others.
Two unique efforts are occurring in California and New York. Both serve as viable options for a large-scale exchange; they also provide a glimpse into how a nationwide health information network might evolve in the post-HITECH world (i.e., in a world without federal grants to fund electronic HIE).
Status of Federal HIE Efforts
The federal government has provided billions of dollars in funding to drive electronic HIE through programs like the State Health Information Exchange Cooperative Agreement Program, the Challenge Grant Program, the Beacon Community Program, the Strategic Health IT Advanced Research Projects Program, the CMS Medicaid Transformation Grants and the Medicare and Medicaid Electronic Health Record Incentive Program. As funds from these programs diminish, there remains no widely accepted single definition of what electronic HIE does or should entail. It also is unclear what role the federal government will play and what levers it will apply to encourage more widespread electronic HIE in the future.
On June 5, ONC issued a “10-Year Vision to Achieve an Interoperable Health IT Infrastructure” that includes a list of guiding principles, goals and “use cases” that illustrate those goals, all of which are to be met within three, six and 10 years. The vision focuses on five building blocks:
- Core technical standards and functions;
- Certification to support adoption and optimization of health IT products and services;
- Privacy and security protections for health information;
- Supportive business, clinical, and regulatory environments; and
- Rules of engagement and governance.
ONC also recently announced that it is working to develop a national interoperability roadmap to achieve its 10-year vision. The roadmap is expected to address three key questions:
- What are the critical technologies and policies (including governance) required to achieve the vision?;
- Who needs to do what and by when (including government, technology developers and technology users)?; and
- How will the roadmap be updated over time and how frequently?
Meanwhile, health care providers, health plans and other health care stakeholders, driven by payment reform initiatives — such as accountable care organizations, medical homes, and bundled and value-based payments — are sharing health information with one another using various strategies.
New York’s SHIN-NY
The Statewide Health Information Network for New York — or SHIN-NY — is a statewide health information network that enables health care providers, health plans and other health care stakeholders throughout New York to share patient health information with one another. The SHIN-NY, which is coordinated by a not-for-profit organization called the New York eHealth Collaborative, unifies existing regional and local HIE initiatives, including those operated by hospital systems and local regional health information organizations, making EHRs secure and accessible to health care providers statewide.
Model
The model employed by the SHIN-NY is that of a statewide, public/private partnership designed to benefit all New Yorkers. It is regulated and supported directly by New York (specifically, the New York State Department of Health). The SHIN-NY is authorized by New York state statute, and the state DOH recently proposed regulations further delineating the operations and governance of the SHIN-NY, including mandating participation in the SHIN-NY by certain types of health care providers. The SHIN-NY is operational and includes participation from more than 80% of all hospitals in the state.
Architecture
The SHIN-NY consists of a network of networks (i.e., the SHIN-NY connects various RHIOs or other HIE initiatives such as those operated by hospital systems), thereby enabling the statewide exchange of health information among stakeholders throughout the state.
Funding
Funding for the SHIN-NY (which has an annual operating budget of roughly $75 million) comes from several sources, including fees that RHIOs may generate by offering value-added services to their participants (e.g., clinical decision support services or access to aggregated patient data for research).
A significant amount of funding also comes from the state itself, as the final New York State Fiscal Year 2014-2015 Budget included $55 million in funding to support the ongoing operation of the SHIN-NY. Due to the state funding, certain basic-level services, including but not limited to patient record look up and Direct exchange services, are provided to all the SHIN-NY participants at no-cost. The SHIN-NY also received early funding under HITECH’s State HIE Cooperative Agreement Program.
Governance
At the local level, governance of the SHIN-NY is provided by the RHIOs, which enforce their participants’ compliance with their participation agreements and policies and procedures. Specific policies and procedures for the SHIN-NY, including those relating to technical standards and privacy and security, are set at the state level through a collaborative process featuring multiple health care stakeholders that is overseen by the New York eHealth Collaborative. As of press time, the New York State Department of Health had proposed to codify those policies in regulation.
Consent Model
Individuals must “opt in” to having their health information shared through the SHIN-NY by signing a consent form, which authorizes a health care provider to access any records about an individual that are stored by other health care providers participating in the SHIN-NY.
California’s Cal INDEX and Other Interoperability Efforts
The California Integrated Data Exchange — or Cal INDEX — is a mutual benefit corporation formed in August by Anthem Blue Cross and Blue Shield of California to develop a statewide health information exchange in California. The new exchange is scheduled to be operational — at least in its initial phase — by December.
Model
Cal INDEX is a voluntary, statewide private effort designed to benefit all Californians. Cal INDEX expects to provide participating health care providers and payers with secure access to the health records of about 9 million Californians — nearly 25% of the state’s population — by the end of 2014.
Architecture
Cal INDEX will aggregate clinical data from health care providers and claims data from payers to create comprehensive, retrievable, patient-centered records known as longitudinal patient records (LPRs). Participating providers can access their patients’ LPRs through a portal, to be developed by Cal INDEX that displays data, alerts and analytics. Participating providers also will have access to basic care management tools, including admission, discharge and transfer alerts, and reminders. Health plans will be able to access the data to create a more comprehensive picture of their members’ health and to increase the safety and quality of patient care across the health care ecosystem. In addition to connecting directly with health care providers and health plans, Cal INDEX intends to establish connections to existing regional and local HIEs operating throughout California, as well as to ACOs and other initiatives that rely on HIE.
Funding
Cal INDEX is funded by $80 million in seed money from its founders, Blue Shield of California and Anthem. This funding will cover Cal INDEX’s operating costs over the next three years and will support the initial integration of approximately 30 large provider organizations across California. After three years, participating providers and insurers will fund Cal INDEX through subscription fees.
Governance
Cal INDEX will be governed by a five-member board of directors consisting of representatives from its founding members, medical providers, the public sector, consumers and health plans. Cal INDEX is currently working with its initial participating members to develop its standard agreements and policies and procedures. Cal INDEX is building its policies based on recommendations and lessons learned from experts in HIE and in patient privacy.
Consent Model
Any patient of a participating doctor or member of a participating health insurance plan who does not want their health information accessible through the exchange can choose to opt out and not have their data shared through Cal INDEX.
Cal INDEX’s unique model — a privately-funded and operated HIE network that is designed to serve as a public utility for all health care stakeholders throughout the state — may have been influenced by past efforts to achieve statewide HIE in California. These included Cal RHIO, an early effort to create a statewide utility-model HIE network throughout the state that folded when the state chose Cal eConnect to serve as the “State Designated Entity” to develop a statewide HIE network using HITECH’s State HIE Grant Cooperative Agreement Program funding. Cal eConnect shuttered after two years without connecting the state’s various local and regional HIEs into an interoperable statewide network.
While these efforts failed, another effort to knit together the many existing regional and enterprise HIE efforts in California is proceeding on a track parallel to Cal INDEX. That effort is being led by the California Association of Health Information Exchanges (CAHIE), a statewide group of community and enterprise health information organizations working together to advance HIE throughout California.
CAHIE has developed a working California version of the federal Data Use and Reciprocal Support Agreement (called the CalDURSA) and has created the California Trusted Exchange Network (CTEN), a set of common policies, processes and lightweight technologies designed to enable disparate HIEs throughout California to share information according to agreed-upon standards and policies. Cal INDEX is basing its standard documents in part on the Cal DURSA model.
Meaningful Use & HIE
HITECH requires that ONC and CMS, in implementing the Medicare and Medicaid EHR Incentive Program, focus on HIE to improve individual and population health. However, the HIE requirements in Stage 1 of the meaningful use program were minimal. While the HIE requirements in Stage 2 were more robust, health care providers are having difficulty meeting Stage 2’s two HIE-related goals (i.e., (i) supporting transitions in care; and (ii) implementing data sharing with patients through secure portals and email).
Therefore, while funding for meaningful use still is available, the program is unlikely to serve as a significant driver of interoperability. Five years after the enactment of HITECH, electronic HIE remains at the beginning of what promises to be a long evolutionary process. Large-scale HIE experiments like the SHIN-NY and Cal INDEX will play an important role in defining the future landscape of electronic HIE and health care at large.