After multiple attempts to launch a health information exchange in California, the Institute for Population Health Improvement, part of the UC-Davis Health System, is the latest organization to assume the task. It recently signed a 16-month, $17.5 million cooperative grant agreement with the California Health and Human Services Agency to facilitate the flow of information between physicians, hospitals and other providers.
Called the California Health eQuality program, or CHeQ, the latest HIE project follows close on the heels of Cal eConnect, a not-for-profit, public benefit corporation that served as the state-designated governance entity until it was effectively abandoned in August.
Cal eConnect’s predecessors were the California Regional Health Information Organization and the California eHealth Collaborative. All three organizations have left footprints in an effort to implement an HIE over the past eight years. Â
CHHS remains the grantee for the statewide HIE effort spurred by the federal Office of the National Coordinator for Health Information Technology. Â
“As a government agency, we do not have the bandwidth to oversee the programmatic aspects of HIE,” said Pamela Lane, California’s deputy secretary for health information exchange
California received a four-year grant for $38.8 million in 2010 from ONC to develop and recommend privacy and security policies for the California HIE. The $17.5 million, granted to UC-Davis, is what remains of the initial funding.
Bringing Value to HIE
UC-Davis’ Institute for Population Health Improvement is expected to select a statewide advisory committee, composed of approximately nine people experienced in health IT; consumer engagement; health care policy, quality, and improvement; and/or health IT standards. Nominations are being accepted through Oct. 26.
According to UC-Davis officials, CHeQ intends to promote health care quality and coordination by either expanding underserved communities’ capacities to exchange health information or provide access to standards enabling the easy transmission of secure, encrypted health information between authorized care providers over the Internet.
CHeQ also aims to promote sharing of immunization, laboratory and care information, as well as provide tools to assist providers in identifying private, secure, standardized and trusted systems.
Although there is no official mandate for establishing a state HIE, the American Recovery and Reinvestment Act of 2009 established meaningful use requirements governing the use of electronic health records — a stepping stone to HIE — that enable eligible providers and hospitals to earn incentive payments by meeting specific criteria.
HIE can help break down silos of health care information, said Jonah Frohlich, managing director of Manatt Health Solutions who previously served as California’s first deputy secretary for health IT.
Nearly half of U.S. physicians plan to join a health information exchange, according to the fourth annual U.S. Ambulatory Electronic Health Record & Practice Management Study by CapSite. The survey also indicates that 43% of respondents (950 physician groups nationally) have successfully attested to Stage 1 meaningful use criteria.
Lessons Learned From Previous HIE Attempts
Although Cal eConnect and CHeQ share the same goals, Lane said the focus will change under the new management.
“When Cal eConnect started three years ago, it concentrated on technology solutions. But now we have solved many of those problems, especially as providers become more engaged in electronic health records,” she said. She sees a shift to an emphasis onÂ data-driven outcomes.
In evaluating CHeQ’s predecessor, Lane said there were many lessons learned. “The biggest is just how hard the project is. A large board of directors, dictated by legislation, weighed down Cal eConnect. It was a startup trying to understand new technology and conform to federal grant requirements, while developing as an organization. Too much ‘newness’ and not enough time to stabilize,” she said.
Frohlich at Manatt said Cal eConnect moved too slowly in developing an HIE infrastructure and also was late in seeking qualified vendors with HIE capabilities and hiring a chief technology officer.
Timathie Leslie, vice president for Booz Allen Hamilton in San Francisco, agrees with Frohlich that Cal eConnect faced a time crunch in getting HIE up and running.
Frohlich notes, however, that Cal eConnect was responsible for creating a board, updating bylaws, conducting an e-prescribing analysis, and developing standards and an infrastructure for provider directory services.
“The task won’t necessarily be easier for UC because developing an HIE program is challenging for any institution,” he said. His advice is to move more quickly and be thoughtful about what is needed to reach HIE goals.
Lane also has not lost sight of Cal eConnect’s accomplishments, including funding five community health information organization initiatives, reducing the cost of connecting, and developing a prototype for exchanging data across communities and state borders using national standards.
She applauds the efforts of regional programs, such as the Santa Cruz HIE, one of the country’s oldest exchanges (it implemented the first exchange of clinical information in 1996) because she said it is difficult to be all things to all people — especially in a large state such as California with its diverse population.
The California Office of Information Integrity recently chose the Santa Cruz HIE as one of two demonstration sites for testing privacy and security policies across a spectrum of health care stakeholders.
Lane recommended the state focus on what it can do for the patient, enabling more preventive self-care and empowerment through access to health records.
Leslie concurred with Lane that the size of California is an important factor. “California is a very large state, ambitious, innovative and at the forefront of HIE,” Leslie said. “We want to maintain our diversity and size, along with a desire to develop a total solution for everyone, but that doesn’t always allow for incremental innovation and change.”
“We want to be everything to everyone, but we need to look at individual communities and their needs,” Leslie added.
Carladenise Edwards knows all too well how difficult it is to create a statewide HIE program. She served as founding CEO and president of Cal eConnect and now is founder and principal consultant for The BAE Company, a strategic planning firm specializing in health IT with offices in Oakland and Miami.
She acknowledges that Cal eConnect set the foundation for HIE, creating an infrastructure and appetite for information exchange across competing entities.
“Now we need to create an imperative and desire for fluid information,” she said.
Edwards said she anticipates UC-Davis will be more successful at generating state funds to match federal funding than Cal eConnect had been. “UC-Davis because it is a state-funded entity can use existing resources to serve as an in-kind match, which places less pressure on the university to generate cash revenues,” she said.
Edwards also believes that Cal eConnect could have provided a service or public benefit by creating a public utility that would have enabled HIE to be sustained with a diversified revenue profile, including tax revenue and user fees. Â
Ultimately, she is optimistic that California will develop a technology platform that creates standards and protocols to exchange data privately and securely.
“If consumers/patients, providers and caregivers demand improved care coordination, their requests for electronic data will force vendors to respond,” Edwards said.
Although Lane said CHHS deliverables are many, she will not commit to any hard and fast deadlines for the new organization — at least not before a California HIE Stakeholder Summit takes place on Nov. 1 toÂ Nov. 2.
Heading the list of goals are:Creating an environment enabling providers to share information and develop effective health care information systems; Putting strategies in place to support meaningful use; Using grants to stimulate the development of a robust HIE infrastructure in California; Tracking HIE progress to benchmark, monitor and report changes in the California HIE landscape; and Driving HIE adoption through communications and education to engage stakeholders.
With such a laundry list of HIE components to tackle, Leslie advocates for a bottom-up solution, starting with a robust communications plan, immunization information systems, vendor acceptance, and an endorsement of standards but above all, interoperability.
“Everyone is watching California. We want to be successful in our efforts and benefit the rest of the country by sharing our expertise,” Lane said.