Building Health Information Exchanges To Support ACOs and Medical Homes: Delaware's Experience
Building Health Information Exchanges To Support ACOs and Medical Homes: Delaware's Experience
On June 5, 2013, the Innovations Exchange held a Web event titled Building Health Information Exchanges To Support ACOs and Medical Homes: Delaware's Experience.
This was the third Web event in a three-part series designed to share novel experiences and lessons learned in putting accountable care organization (ACO) and patient-centered medical home (PCMH) principles into practice.
Judi Consalvo, Program Analyst at AHRQ Center for Outcomes and Evidence
Jan Lee, MD, Executive Director, Delaware Health Information Network
Dr. Lee is the Executive Director of the Delaware Health Information Network (DHIN). Previously, she was Vice President of Knowledgebase and Content for NextGen Healthcare, a vendor of health information technology (HIT) products and services, where she was responsible for the development of clinical content in 26 medical specialty areas for the NextGen electronic health record (EHR). She transitioned to NextGen from a 23-year career in the United States Air Force, where she had worldwide assignments in clinical settings from outpatient clinics to medical centers, and several academic appointments. Dr. Lee led the EHR implementation in 75 facilities throughout the Air Force for the Department of Defense. Her specific areas of interest are health policy and the use of HIT to improve clinical practice and population health. Dr. Lee was recognized in “Guide to America’s Top Family Doctors” and “Who’s Who in America” and selected by “Cambridge Who’s Who” as Executive of the Year.
Jennifer Fritz, MPH, Deputy Director, Health Information Exchange, Office of Health Information Technology, Minnesota Department of Health
Jennifer Fritz is Deputy Director of the Office of Health Information Technology at the Minnesota Department of Health. Ms. Fritz is responsible for the direction of Minnesota e-Health programs, including the Minnesota e-Health Initiative, Minnesota’s Health Information Exchange Oversight Program, Minnesota’s State Health Information Exchange Cooperative Agreement, and activities related to privacy and security, health informatics and data standards. Prior to serving as Deputy Director, she served as project manager on the state’s health information exchange activities with responsibilities for developing and implementing Minnesota’s strategic plan for health information exchange. Ms. Fritz also worked on a variety of public health informatics projects aiming to improve the development and use of public health information systems.
Gerry Fairbrother, PhD, Senior Scholar, AcademyHealth
Dr. Fairbrother is a Senior Scholar at AcademyHealth, an Adjunct Professor of Health Policy at the George Washington University, and Adjunct Professor of Pediatrics at the University of New Mexico and the University of Cincinnati. Dr. Fairbrother is an experienced health services researcher and evaluator, whose work has emphasized measurement of quality of care, policy research and evaluation, and health information technology and its effects on quality of care. She serves on the Centers for Medicare and Medicaid Services (CMS) Technical Expert Panel on National Impact Assessment of CMS Quality Measures and on the National Policy Advisory Committee of the National Institute of Children’s Healthcare Quality. She received the “Best Ohio Health Policy Award for Independent Scholar or Practitioner” from the Health Policy Institute of Ohio.
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- Next Events
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HITECH* Spurred Dramatic Growth in Technology
- Increase in electronic health records adoption
- Meaningful Use provisions to promulgate standards and promote quality
- Community-wide technology (Beacon Communities Program)
- Health Information Exchanges (HIE) at state and regional level
Growth in Technology
Graph showing the percentage of office-based physicians with EMR/EHR systems in the United States from 2001-2010 and preliminary data for 2011-2012. X axis shows the years 2001 through 2012. Y axis shows the percent of physicians. The data points show a linear increase from 2001 with 18.2% having any EMR/EHR systems up to 71.8% in 2012. A second line shows a similar pattern beginning in 2006 with 10.5% of physicians having a basic system up to 39.6% in 2012.
Image of the United States highlighting the Beacon Communities which include: Inland Northwest Health Services in Spokane, WA; Mayo Clinic Center in Rochester, MN; Western NY Clinical Information Exchange in Buffalo, NY; Eastern Maine Healthcare Systems in Brewer, ME; Rhode Island Quality Institute in Providence, RI; Southeastern Michigan Health Association in Detroit, MI; Geisinger Clinic in Danville, PA; Indiana HIE in Indianapolis, IN; Rocky Mountain HMO in Grand Junction, CO; HealthInsight in Salt Lake City, UT; The Regents of the University of California in San Diego, CA; University of Hawaii at Hilo; Community Services Council of Tulsa in Tulsa, OK; Louisiana Public Health Institute in New Orleans, LA; Delta Health Alliance in Stoneville, MS; Southern Piedmont Community Care Plan in Concord, NC; and HealthBridge in Cincinatti, OH.
HIEs are Key
“…Health information exchange (HIE) is a key driver of efficiency gains…
…Therefore, the success of HITECH hinges, in part, on whether we can jump-start HIEs.”
Adler-Milstein J, DesRoches CM, and Jha AK. Health information exchanges among US hospitals. Am J Manag Care. 2011 Nov;17(11):761-8.
Coverage and Locus
- Coverage and locus of Health Information Exchanges (HIEs) vary
- State (Delaware – linked to other states)
- Local and regional (Cincinnati, Ohio; Buffalo, New York; Indiana)
- Market-based (Minnesota, Arizona)
Growth of Accountable Care Organizations and HIE
- Accountable Care Organizations (ACOs) need population management at system level (data warehouse, registry function)
- Move data from different electronic health record systems to point of care
- Some HIEs have adjusted to become connectors between ACOs
Important Functionality of HIE
- Technology to improve quality (data exchange, alerts, population management)
- Beyond technology: Need to make business case and need for strong governance structure
More than Technology
“HIE is dependent on government to change the way care is paid for…
…Things not related to technology need to happen.”
Blumenthal, David. Interview by Ravi Parikh for Medgadget. September 10, 2012.
Now We Will Hear From
- Representatives of two different HIEs
- How they are organized
- Challenges and lessons learned
Delaware Health Information Network (DHIN)
Timeline for the Delaware Health Information Network (DHIN) beginning in 1997 through 2012. In 1997, Legislation established DHIN under Delaware Healthcare Commission; In 2005, awarded AHRQ Implementation contract ($4.7M); in 2007, operational with results delivery (May 2007), data senders (3 hospitals and Lab Corp), data receivers (5 physician practices); in 2010, enabling legislation amended, DHIN is an “independent, not-for-profit public instrumentality”; in 2011, new board, new management team; in 2012, explosive growth in participation and functionality and financial sustainability achieved.
- Governance, many stakeholders
- Policies and procedures
- Security and Trust Framework
- Consent model: opt-in versus opt-out
- Data model: federated versus consolidated or hybrid
- Environmental scan: electronic health records versus paper, statewide availability of broadband
- Market survey: what exchange services would providers value and actually use?
Community Health Record
- Delaware Health Information Network (DHIN)’s core service
- Federated Data Repository Architecture
- Clinical data sent into DHIN hosting center from many sources: labs, pathology, radiology, hospital admission, discharge and transfer (ADTs), transcribed reports, medication history (subscription service)
- DHIN delivers results to ordering provider…and aggregates into a longitudinal Community Health Record
Community Health Record
Information accessed in several ways:
- Directly populate a practice electronic medical record through interface
- Auto-print for inclusion in a paper record system
- View over a web portal (ProAccess)
- Incorporate into a patient-controlled personal health record
Provider Adoption of DHIN
Graph showing the provider adoption as a percent of Delaware healthcare ordering providers (December 2012). X axis shows the years 2007 through 2012. Y axis shows the percentage. Bar charts for each year show an increase from 2007 with 1% of provider adoption of Delaware Health Information Network (DHIN) up to 98% in 2012.
Current Membership in DHIN
As of May 2013
- Acute care hospitals and Federally Qualified Health Centers (100%)
- Providers (98%)
- Skilled nursing (100%); assisted living (77%)
- Labs (99%) and radiology groups (97%)
- Health home, hospice and pharmacy
- Division of Public Health, health plans, other HIEs
- Hospitals, labs and other data senders: Over $2 million cost saving from results delivery
- Providers/practices with electronic health records
- Payers/health plans: Estimated 30-33% reduction in redundant ordering of high cost labs and radiology studies over 2 years
- Public health: Real world outbreak of swine flu detected in near real time
- Patients: Many “stories” but no metrics
- Results delivery
- Discovery tools: record locator service (RLS), common master person index (CMPI)
- Public health reporting: syndromic surveillance, reportable labs, immunization update
- Electronic health records (EHR) interfaces
- Event notification service
- Immunization query
- Image viewing
- Consumer engagement
- Connect with other HIEs, federal exchange partners via eHealth Exchange
- Integrate newborn screening
- Connect with Delaware prescription monitoring program
- Incorporate continuity of care documents into the community health record
New data types for the Community Health Record
- Medical Device
- Medication History
- Clinical Quality Measures
- Business Intelligence
- Population Health
- Consensus building is slow but essential
- Begin with the willing
- Find out what your market values and will use; do that extremely well
- Use a small number of highly valued services to drive adoption and utilization
- Provide value for everyone; not just the technology elite
- Measure, measure, measure! Know the business case for participation
- Success begets success
- Natural reluctance to change
- Late adopters versus early adopters
- Meet them where they are; not where you wish they were
- Business model for an HIE whose members are business competitors
Minnesota (MN) History
Policy Levers encouraging HIE*
- MN e-Health Initiative (2004)
- MN Health Records Act (privacy law) re-codified to enable HIE, still stricter than most states
HIE Governance Structure
- HIE Oversight Law (2010)
- MN e-Prescribing mandate (2011)
- State-Certified HIE Service Providers (4 as of May 2013)
- Interoperable electronic health record mandate (2015)
State Certification and Oversight
- Establishes oversight by Commissioner of Health to protect the public interest on matters pertaining to health information exchange
- Requires State Certificate of Authority to operate Health Information Organizations (HIO) and Health Data Intermediaries (HDI)
- Allows market-based approach for provision of HIE services; multiple HIE service providers (HIO/HDI) may be certified and operate in the state
Minnesota Approach: One HIE
Diagram showing eHealth Exchange and other eHealth Exchange Nodes connected to Statewide Health Information Exchange and one HIO with an arrow pointing to private practices, hospitals, and other settings.
Minnesota Approach: Two HIEs
Diagram showing eHealth Exchange and other eHealth Exchange Nodes connected to Statewide Health Information Exchange and two HIOs with arrows pointing to private practices, hospitals, and other settings.
Minnesota Approach: Multiple HIEs
Diagram showing eHealth Exchange and other eHealth Exchange Nodes connected to Statewide Health Information Exchange and two HIOs with arrows pointing to private practices, hospitals, and other settings. The HIOs also have arrows pointing to Health Data Intermediaries and then another arrow from that to the private practices, hospitals, and other settings. The Statewide Health Information Exchange is also connected to Direct Exchange through Shared HIE services: directory services and consumer preference management.
Market-Based Approach Versus Single HIE
- Allows for private sector investments and innovation
- More adaptable to changes in technology trends or requirements (e.g., meaningful use)
- Gives providers multiple options for HIE services
- Can create confusion in the marketplace
- Interoperability requirements
- Many aspects to monitor (technology, policy/legal, changes in national trends)
Accountable Care and HIE
- Adult day services
- Behavioral health
- Birth centers
- Chiropractic offices
- Clinics: primary care and specialty care
- Complementary/ integrative care
- Dental practices
- Surgical centers
- Government agencies (state, county, city)
- Habilitation therapy
- Home care
- Long-term care
Future of HIE in Minnesota
- Interoperability: Need for shared services and agreements between multiple entities, including common standards
- Continued certification of entities providing HIE services and monitoring of HIE marketplace
- Potential updates in laws pertaining to HIE
Future of HIE in Minnesota
- Provider education and technical assistance on HIE options
- Privacy and security to increase provider adoption of HIE
- Interstate/national connectivity
- Movement from basic HIE (e.g., direct secure messaging) towards advanced HIE (e.g., analytics, greater automation, and population management)
Reflections on Delaware’s Lessons Learned
- Consensus: Difficult but essential for sustainability
- Start small with those motivated and those that have a specific use case that can be met by HIE
- Provide a range of HIE options for different HIE needs (basic to advanced)
- Demonstrating Return on Investment (ROI) and Value on Investment (VOI) is critical; harder to do when there are multiple HIE options available
Reflections on Delaware’s Barriers
- Monitoring and adapting technology according to changes in medical practice
- Scalable trust is emerging as a need for HIE sustainability
- Natural reluctance to change: Importance of HIE solutions that are in the provider workflow at the point of care
Reflections on Delaware’s Barriers
- Early adopters can be champions to others
- Meet them where they are, not where you wish they were
- Business model for an HIE whose members are business competitors: Need to overcome for accountable care
- Many type of entities provide HIE services; interoperability is a challenge
- Sustainability requires a sound business model and identification of value added services
- Low provider adoption is linked to low meaningful use requirements
- Don’t underestimate non-traditional settings
- Accountable care requires easily sharing clinical data; HIE need to adapt to shifts in market demands
The Innovations Exchange
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Judi Consalvo: Good afternoon, and perhaps for some of you it's good morning. On behalf of
the Agency for Healthcare Research and Quality, I'd like to welcome you to our web event
entitled, “Building Health Information Exchanges to Support Accountable Care Organizations
and Medical Homes: Delaware's Experience.” I'm Judi Consalvo with AHRQ's Center for
Outcomes and Evidence. We're very excited about today's topic and glad to see that you share
our enthusiasm. We have over 700 registered for this event today.
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The presenter that you will hear from today is an Innovator from AHRQ Health Care Innovations
Exchange. The exchange includes a profile that provides background on the Delaware Health
Information Network that you will be hearing about. For those of you who are new to the
Innovations Exchange, I'll take just a minute to give you an overview.
AHRQ created the Innovations Exchange to speed the implementation of new and better ways of
delivering healthcare. The Exchange offers busy health professionals and researchers a variety
of opportunities to share, learn about, and ultimately adopt evidence-based innovations and tools
suitable for a range of healthcare settings and populations. The site includes a searchable
database of quality tools and service delivery innovations. More recently added are the policy
innovations, such as what you will hear about today. The Exchange also contains both successes
and attempts, Innovators' stories and lessons learned, and expert commentaries.
To assist you in implementing these innovations, AHRQ also supports learning and networking
opportunities, such as web seminars, TweetChats, and podcasts. We post new content to the
website every two weeks on a range of topics and hope that you will sign up to stay connected
with us, if you have not already done so.
We have a number of upcoming web events to share innovative healthcare strategies and
promote the spread of innovations. Our next learning and networking event is our upcoming
TweetChat called “Chats on Change: Home Base Program for Veterans with PTSD.” Join us on
Twitter on Tuesday, June 18th at noon Eastern, for a live Tweet Chat with Dr. Rebecca
Weintraub Brendel, Clinical Director of the Veterans Program at the Red Sox Foundation and
Massachusetts General Hospital Home Base Program; and Dr. Benjamin Miller, Assistant
Professor in the Department of Family Medicine at the University of Colorado Denver School of
We will discuss how the Boston Red Sox Foundation has teamed with Massachusetts General
Hospital to support veterans with PTSD and their families. You can use the #AHRQIX hashtag
to participate in the conversation. Please visit our website for more information at
http://innovations.ahrq.gov. The website also holds an archive of our past web events, podcasts
and TweetChats, and we also invite you to take a look and download some of those materials that
may be useful to you in your practice or setting.
Now, let's turn to our agenda for today. It is my pleasure to introduce our moderator, Dr. Gerry
Fairbrother. Dr. Fairbrother is a Senior Scholar at AcademyHealth and is an Adjunct Professor
at the George Washington University. She has over 20 years of experience leading health
services' research and evaluation projects and leads several quality improvement projects. Gerry
also serves on the CMS Technical Expert Panel on National Impact Assessment of CMS Quality
Measures and on the National Policy Advisory Committee of the National Institute of Children's
Healthcare Quality. Gerry?
Gerry Fairbrother: Thank you, Judi. We'll be hearing today from two HIEs, so I'd like to start
by providing a little background. HIEs and others we've seen an enormous growth in
technology, spurred in part by the HITECH Act. We've seen an increase in electronic health
records adoption, and not only mere adoption but an increase in Meaningful Use; partly because
of those provisions that were promulgated to ensure technical standards and to ensure that quality
standards are in place.
We've also seen an increase in communitywide technology represented by the Beacon
Communities Program, also funded through the HITECH Act. Then, we've seen a growth in
Health Information Exchanges at both state and regional levels.
The next slide shows the enormous increase in adoption of electronic health records in office-
based practices. The blue line at the top shows the adoption of any sort of EHR. As you can see,
about 72% of office-based practices have adopted those. The green line represents adoption of
EHRs that meet particular standards. That's lower, but still an impressive growth; and 40% of
office-based practices have installed EHRs that do meet a set of standards.
The next slide shows the Beacon Communities throughout the country. There are 17 of them,
again funded by the HITECH Act, to put in place electronic health records communitywide to
promote exchange of information in the community and to enable monitoring of conditions
HIEs, though, are key in all of these endeavors. To quote a recent article, “The Health
Information Exchange is a key driver of efficiency gains.” Therefore, these authors say, “The
success of HITECH hinges, in part, on whether we can jumpstart HIEs.”
HIEs are different in different communities. They cover different areas and they have different
locuses of responsibility. There are state level HIEs represented by Delaware, whom we'll hear
from in a moment and represents one of these. The Delaware HIE is linked to other states, but
it's a Delaware HIE.
There can be local and regional HIEs covering an area within a state, or even across states. The
HIE in Cincinnati, Ohio; Cincinnati is located in the corner of Ohio right next to Kentucky and
Indiana, so its HIE covers the tri-state area of Ohio, Indiana, and Kentucky. There are also
regional HIEs in Buffalo and Indiana, are also examples of regional HIEs. Then there are
market-based approaches represented by Minnesota, from whom we'll hear in a moment, and
At the same time that there's been this explosive growth in technology, there's also been a growth
in Accountable Care Organizations. These Accountable Care Organizations need population
management at the ACO system level. They need to have a data warehouse. They need to be
able to have a registry function so that they can see, for example, what proportion of their let's
say diabetic patients have their blood sugar, their HbA1c in control. So the ACOs need the same
kind of functionality that we used to talk about needing at HIEs.
They also need to be able to move electronic data around among the entities in the ACOs. Some
HIEs have adjusted to become connectors between the ACOs. Others have made other types of
adjustments, or no adjustments, but in any case it perturbation in the system to have this advent
Important functionality of HIEs, and we'll hear about this later, includes the technology that you
need to improve quality; like data exchange, like alerts to let providers know when a patient has
gone into the hospital or ED, and like population management.
But beyond technology, HIEs need to make a business case in order to stay in existence and
there's a need for a strong governance structure. So as David Blumenthal, the former head of
ONC said, “HIE is dependent on government to change the way care is paid for … things not
related to technology need to happen.” A further indication that more than technology is needed
to make HIEs workable.
Now, we'll hear from representatives from two different HIEs; the Delaware Health Information
Network, and then a reaction from a representative from Minnesota. We'll hear how they're
organized and then challenges and lessons learned. You will hear echoes of the challenges
across the two presentations.
Now, I'd like to introduce our first speaker, Dr. Jan Lee, who will discuss Delaware Health
Information Network. Dr. Lee is the Executive Director of the Delaware Health Information
Network, or DHIN. Previously, she was Vice President of Knowledgebase and Content for
NextGen Healthcare, a vendor of health information technology products and services, where she
was responsible for development of clinical content in 26 medical specialties for the NextGen
electronic health record. She transitioned to NextGen from a 23-year career in the United States
Air Force, where she led EHR implementation in 75 facilities throughout the Air Force for the
Department of Defense. Dr. Lee?
Jan Lee: Thank you very much, Gerry. The legislation establishing the Delaware Health
Information Network, or DHIN, was passed in 1997. If you think back that far, that was when
maybe 10% to 15% of practices nationwide had EHRs, so it was very different environment at
the time. A full decade of planning and work went into preparing to go live in May 2007, and I'll
tell a little bit more about that preparation on the next slide.
We were able to get started with a grant from the Agency for Healthcare Research and Quality
under the State and Regional HIE Demonstration Project. That funding, along with funding from
the State of Delaware and private sources enabled us to contract for a technology solution. In
May 2007, DHIN became operational with data senders and end users in each of Delaware's
Over the next several years we added functionality, added new data senders, grew the user base
and all of that I will go into in more detail on succeeding slides. But I'm happy to say that today
DHIN is an independent not-for-profit public instrumentality, fully self-sustaining from the
services that we provide.
Let's get back to the 10-year period of planning between the enabling legislation and the actual
go live. A great many activities and decisions were undertaken during that time period. First of
all, there's establishing governance, and it definitely needs to represent a broad coalition of
stakeholders. We had many stakeholder groups who provided input on both the business
requirements and the technical requirements.
Business requirements, of course, should be the key drivers and our stakeholders there helped us
to define the “must have” data elements for a complete clinical information sharing utility. Then,
the planning process included a technical requirements' definition that was completed in August
2005 and enabled us to go out with an RSP to actually acquire the solution.
Among the critical questions that need to be answered before you select a technical solution are
questions of your patient consent model and your data model. The consent model refers to the
consent of the patient for their data to be shared across the network. An opt-in model requires
that each patient must individually give consent for their data to be shared before it is exposed on
the network. Whereas, an opt-out model assumes that all patient results are in the network unless
the patient specifically opts out of allowing their data to be shared. In Delaware, we made the
decision to adopt an opt-out patient consent model, but I stress that that was with the input of
patients and consumer advocacy groups in our governance process.
The other major decision is the data model and that refers to how or even whether the data sent
in by multiple organizations is comingled. We adopted a hybrid model and this involves the data
in the source systems of the data-sending organizations that are sent over a secure VPN interface
to a data stage in a hosted datacenter. The fact that it's one hosting datacenter implies a
consolidated model, but the fact that each data sender has their own data stage and that the data
is housed separately and never comingled in storage makes it look more like a federated model.
That's why we say that we've actually got a hybrid.
This arrangement in principle allows any member of DHIN to withdraw membership, if they
choose to do that, and take their data with them. That's important, because by law in Delaware
the data senders retain business ownership of their data. DHIN is just the steward and not the
owner, and written data use agreements govern how the data may be used, by whom, and under
I think the other elements on this screen are self-explanatory so we'll move on.
When we get our market survey in Delaware to determine what Exchange services the healthcare
community would value and use, by an overwhelming majority the most valued service was
electronic results delivery, especially lab results. When we went live in 2007, all we offered was
electronic delivery of lab results, pathology reports, radiology reports and ADTs, or admission,
discharge and transfer reports.
In 2010, we added transcribed reports, so that includes such things as discharge summaries,
history physical, operative reports and so forth. It was not until 2009 that discovery tools were
added, which allowed a user to search for results of tests they had not personally ordered or
By that time there was two years' worth of data aggregated in the hosted datacenter, so when
providers did a search there was actually something to find. This was the real birth of the
Community Health Record. Data from many disparate data senders is stored in a manner that
allows it to be easily searchable and discoverable by properly-privileged users of the network.
The information in the Community Health Record can be accessed by a user in several ways.
The most desirable way is that data coming into the DHIN Community Health Record directly
populates the ordering provider's electronic health record through an interface. In this setting,
the user may not even actually be aware of the fact that they're getting their results through
DHIN, because they stay in the workflow of their EHR until and unless they have to do a search
for something that they didn't personally order.
One of the services that DHIN has provided is to certify interfaces between the DHIN
Community Health Record and various EHRs. We contract with the EHR vendors to create a
single interface to DHIN, across which all result types from all data senders will flow. The
contract specifies that once we've certified that interface, the vendor must offer it at a steeply
discounted rate to all users of that EHR in Delaware. We currently have certified interfaces to 13
different EHRs and we have others that are in varying stages of beta testing and contracting.
The second way that information in the Community Health Record can reach a provider is
through the Auto-print function. The practice must have the DHIN utility installed on a
computer or server, which is always on and connected to the Internet. Based on configuration
settings which the practice chooses, results are queued up to print on a designated network
printer at designated times and in the order that the practice designates. This allows them to
capture some administrative efficiencies and allows DHIN to provide value even for practices
that are still using a paper record system.
The third way to receive results from the Community Health Record is in a clinical inbox
accessed through a web portal called ProAccess. Much like an email inbox, the results of tests
the provider has ordered are sent to their electronic clinical inbox and when they login into
ProAccess that is their initial point of entry. Of note, ProAccess is also the tool used to search
for unknown data on a known patient, or to search for data on a previously unknown patient.
It should also be mentioned that clinical data in the Community Health Record can be delivered
into a personal health record which the patient controls. With the Meaningful Use Stage 2
requirement that at least 10% of a provider's patients must actually view their data online and
download or transmit it, we do expect that adoption of this functionality is going to increase over
This slide illustrates the growth in adoption of DHIN. Our denominator for this slide is our best
estimate of the number of providers in Delaware who place orders and would, therefore, expect
to receive their results electronically. By the end of calendar year 2012, we were up to 98%
adoption and that's probably a steady state considering that there are always providers entering
practice and leaving practice.
I would also point out that our largest year-to-year jump in adoption was between 2008 and
2009, and interestingly that represents the time when we introduced the query tools that allow a
provider to query the Community Health Record for previously unknown results. This illustrates
the very obvious truth, that when they perceive value in the tool it definitely drives adoption.
This slide illustrates current membership in DHIN as of May 2013. I'm very proud to say that
participation in DHIN is and always has been completely voluntary. This growth has occurred
because of a clear and compelling value proposition. We've had very strong community support
and lots of principal persuasion to draw in later adopters, but no one has ever been forced against
their will to join DHIN.
As a matter of fact, we've had several out-of-state labs and a Maryland hospital near the Southern
Delaware border who have come to us requesting to join DHIN because of the value they see in
participating. We've also entered an agreement with the Maryland State HIE to exchange ADTs
on residents of our own state who've been seen in a hospital in the other state.
We're very focused on the continuum of care and closing gaps in the continuum of care. In
2012, we were successful in enrolling all of Delaware's skilled nursing facilities in DHIN, and
we're now actually up to 80% of the assisted living facilities, along with a small number of home
health and hospice organizations participating.
The benefits listed on this slide are as of November 2011. It looked at the period from 2009
when we introduced query tools to 2011, and we are currently in the process of updating this for
the period of 2011 to 2013. So I hope that within a few months we will actually be able to
provide updates to this with even more exciting benefits to document.
The data senders in DHIN saved over $2 million in the cost of results delivery over that two-year
period by having DHIN deliver the results electronically. Now the data senders only get that
savings if they are using DHIN to deliver results instead of, not in addition to the ways that they
previously did so.
One of our key business metrics is our signoff rate. When a practice signs off, they are agreeing
to accept DHIN as the report of record and shut off all other methods of results delivery. Our
signoff rate is now at 78%. That's considerably higher than it was in November 2011 when this
result was obtained, and so I think that as we update this toward the end of 2013, we're going to
see that the savings to the data senders is dramatically larger.
The providers and practices within EHR also get a significant savings from the steeply
discounted cost of the interface to DHIN, because a single interface can get them all result types
from all senders. That one interface is offered at markedly lower than usual market rate. Each
practice with an interface to DHIN can save anywhere from $18,500 to $28,500 in the cost of
their EHR interfaces.
Now, one of the presumptive benefits of a longitudinal Community Health Record is that it
allows you to avoid unnecessary repetition of tests. DHIN has actually seen a 30% to 33%
reduction in the ratio of high-cost labs and radiology studies to unique patients in the database
over the two-year period from 2009 to 2011. That rate appears to be continuing to drop. Besides
the cost savings to the health plans, there is also a very real reduction of risk exposure for the
patients in avoiding unnecessary radiation, as well as avoiding lost work time and out-of-pocket
co-pays that go with redundant testing. Both payers and patients get a benefit from that
reduction in redundant testing.
Public Health has seen improved efficiency in timeliness of receiving required reporting to them.
We do have many patient stories of benefits that they've received, but of course it's harder to get
a population-level metric in that setting. So we have a lot of stories, but no metrics.
Summing up the current services that DHIN offers, we still offer our results delivery and
discovery tools that comprise the Community Health Record. The Community Health Record is
our core service and it will always be the heart and soul of what DHIN offers.
We also support the Public Health reporting requirements of Meaningful Use, and I'm happy to
say that we had started work on that even before the HITECH and Meaningful Use came along.
We've already discussed our Public Health reporting and the steeply-discounted EHR interfaces,
so I won't belabor that further.
This has been a very busy year for us in terms of development of new services. Meaningful Use
is creating a demand for exchange services well beyond simple electronic results delivery.
Because DHIN is already the trusted provider of information exchange in Delaware, we find that
the providers and hospitals are naturally looking to DHIN to provide solutions for the
Meaningful Use interoperability requirements.
We're currently developing an event notification system, which will allow us to notify providers
and health plans when one of their patients has been discharged from the hospital or emergency
department. This will promote continuity of care, early follow up and case management, and it
will allow providers to bill under the new E&M codes for care transition management.
We're working with several EHR vendors to be able to query as well as update the state
immunization registry from within the user's EHR. We're conducting a pilot with two of our
hospitals to enable the end user to click on a link in the radiology report that they already receive
through DHIN and be taken to the actual image, and this supports one of the Meaningful Use
Stage 2 menu objectives.
We're working on tools to enable the patient to receive updates of their chart in the Community
Health Record on their mobile device, as well as to engage in secure messaging with their
provider. We expect to become an exchange partner on eHealth Exchange just as soon as our
vendor successfully completes confirmation testing of the technology. This will allow us to
exchange data with federal partners such as the VA, Department of Defense and Social Security
Administration, as well as with other HIEs.
We're working with Public Health to integrate the newborn screening registry into the
Community Health Record. We're working on a link inside ProAccess to the Delaware
Prescription Monitoring Program. That is actually in testing right now and should go live within
a matter of a couple of weeks.
We're in pilot testing with several practices to incorporate continuity of care documents into the
Community Health Record. We're very excited about that, because it will be our first
opportunity of incorporating ambulatory practice-level data into the Community Health Record.
Our long-term vision for DHIN is a very expansive one. The value in the Community Health
Record is greatest when all the patients are in it, all of their data is in it, and all of the healthcare
community is using it. For all practical purposes, we have all Delaware citizens and all
Delaware providers in.
We are still looking for ways to add other data types that would add even more to the value of
the Community Health Record. We're beginning to explore the potential to layer on analytic
tools that will allow the data to be used for more than just point of care clinical decisions. There
are technology, privacy and security, consent, data use agreements and legal issues that all have
to be dealt with, but these tools will be critical assets in the formation of Accountable Care
Organizations and patient-centered medical homes in Delaware.
By any measure DHIN is a mature, highly-successful state HIE. This slide encapsulates some of
the lessons learned; things that I believe we did right. Consensus building is slow, but it is
essential if you're going to make progress with business competitors. Start with those who are
willing to work with you. Don't wait until everybody is ready to jump in. Find what your
market values and will use and do that extremely well.
One of the things that we did in DHIN, and I do believe this was a good decision, was we started
with a small set of functionality that we knew our community would value. We've used that to
drive adoption and utilization, and now as we add new functionality we've already got a built-in
echo chamber of people who are accustomed to using DHIN.
I would also say it's important to provide value for everyone, not just the technology elite. You
need to measure the value of what you're doing, because that's what's going to persuade the late
adopters to come in, and success begets success.
Finally, there are barriers that have to be addressed and overcome. Technology issues are not
trivial. You should get a good consultant and get strong technical input from all of the
organizations that are committed to the effort. Trust is an issue. Data senders must decide not to
compete on the basis of the data. Providers must decide whether they are going to trust all of the
data in the Community Health Record, or trust it all equally, and whether they trust the patient
Patients have to decide whether they trust that the privacy and security of the system gives them
adequate protection. There's a natural reluctance to change. Some people just prefer the devil
they know. There will always be early adopters and late adopters. Early adopters tend to be
more fault tolerant than later adopters. At this stage of DHIN's adoption curve, our users expect
us to be just as reliable and available as electricity.
Meet your users where they are, not where you wish they were. There's always going to be a
mix of the tech-savvy and the tech-averse; sometimes within the same organization.
Finally, a major issue that must be addressed by a state HIE or other public HIE whose members
are business competitors is the business model for the HIE. What is the fair way to distribute the
cost of providing the HIE services across all of those who receive value for the services? The
HIE does have to be viewed as a business with a revenue stream to support every service offered.
I'll just conclude by saying, if it were easy anybody could do it. So I'll turn it back over now to
Gerry to introduce our next speaker.
Gerry Fairbrother: Thank you, Dr. Lee, for an excellent presentation. Before I introduce our
next speaker, let me remind the listeners to send in questions that you may have. There's a
question-and-answer period at the end.
Next, we'll hear from Jennifer Fritz, who will discuss Minnesota's approach to their HIE.
Jennifer is the Deputy Director from the Office of Health Information Technology at the
Minnesota Department of Health. Ms. Fritz is responsible for the direction of Minnesota e-
Health programs, including Minnesota e-Health Initiative, Minnesota's Health Information
Exchange Oversight Program, Minnesota's State Health Information Exchange Cooperative
Agreement, and activities related to privacy and security, health informatics and data standards.
Prior to serving as Deputy Director, she served as Program Manager on the State Health
Information Exchange activities with responsibilities for developing and implementing
Minnesota's strategic plan for Health Information Exchange. Jennifer?
Jennifer Fritz: Thank you, Gerry. I'm going to share a slightly different perspective than Jan,
really one that is coming from a state that sees multiple Health Information Exchange entities
and acts in more of a role of government oversight. First, I'm going to start with a little bit of
Thinking about e-Health and Health Information Exchange in Minnesota, Minnesota first
established its e-Health Initiative in 2004, which legislatively chartered an advisory committee to
make recommendations on e-Health to the Commissioner of Health.
As a result, Minnesota has really taken a little more of a policy-oriented approach to e-Health
Health Information Exchange over the years. For example, recently Minnesota's privacy laws
were updated to enable electronic exchange of information and this was pre-HITECH. Still,
Minnesota actually has a much stricter privacy requirement than most states.
Thinking about post-HITECH, as most of you know HITECH passed in 2009, and in response to
ONC's requirements for Health Information Exchange governance, Minnesota adopted a market-
based approach to Health Information Exchange and passed a law requiring all entities providing
HIE services in the state to get certified. That's our HIE Oversight Law, which was passed in
As of May 2013, Minnesota has four state-certified HIE service providers that are currently
operating in the state and we have other entities that are exploring whether or not they should be
certified as well.
Although it was passed prior to the HITECH Act, Minnesota adopted an e-prescribing mandate
requiring e-prescribing by 2011. Then also a mandate for interoperable electronic health records
by 2015. The 2015 mandate is significant because it includes all types of healthcare providers,
including providers not eligible for Meaningful Use, and the mandate also has the Health
Information Exchange component requiring providers to connect to a state-certified HIE service
provider in Minnesota.
Now, I'm going to talk just a little bit about the state certification role in oversight. Essentially,
that state certification establishes oversight by the Commissioner of Health to protect the public
interest on matters pertaining to Health Information Exchange. Our office at the Department of
Health oversees that process. It requires state certification of authority to operate two types of
entities in the state. One is the Health Information Organization, and the other type is a Health
What it does is it allows market-based innovation and approach for the provision of HIE services
in Minnesota. What we see is that we have multiple HIE service providers operating in the state
and then that they must be certified in order to operate in the state.
Here's a pictorial view of what HIE looks like in Minnesota. On this slide you can see what it
looks like with one HIO, which is kind of the more robust type of HIE entity operating in the
state. There's statewide HIE by connecting to Minnesota healthcare providers, and then there's
also connectivity to the Nationwide eHealth Exchange.
The next slide here shows what it looks like when you have multiple entities operating in the
state. So really the challenge that we see in Minnesota is the interoperability requirements
between them. You have HIO #1 and HIO #2 just as an example.
What we've done to address the interoperability requirements in Minnesota is what we call a
Statewide Shared Services. That's services that are utilized by HIE service providers that are
competitors to one another to be able to share information about the providers across the state.
In this picture, you see the Statewide Shared Services as sort of the interoperability component
between them, and then you see multiple HIE service providers in the picture; so HIO #1, HIO
#2, and then you also see the health data intermediaries also with connectivity to the Nationwide
There are some pros and cons to a market-based approach to Health Information Exchange. On
the one hand, it does allow for more private sector investments and innovations. For example, in
Minnesota we really haven't had to invest significantly in the HIE infrastructure from a
government standpoint. It allows for more maybe adaptability to changes in technology trends
or requirements. For example with Meaningful Use changes, it allows for that adaptability. It
also gives providers multiple options, because maybe they have different needs depending on
what their HIE needs are.
On the other hand, it can also create a little bit more confusion in the marketplace. As I
mentioned, it does create challenges around interoperability, because when you have multiple
entities you want to make sure that the information can flow across the network of HIE service
From our perspective in the government role, there are also many aspects to monitor. For
example, we're constantly having to monitor the technology trends, various policy and legal
changes, both nationally and within the state, to make sure that we're implementing our oversight
This next slide represents several different types of settings that we think are important for
Health Information Exchange. In this case just as an example, these are actually the settings that
are required to have an interoperable electronic health record by 2015 in Minnesota. When we
think about Accountable Care and HIE, I think these are settings that are important to consider
when considering marketing or building any type of HIE infrastructure.
Next, I want to talk a little bit about the future of HIE in Minnesota. We know that there are
multiple entities providing HIE services in the state. As I mentioned, interoperability continues
to be a big need for us and we'll be continuing to implement the Statewide Shared Services to
support our ongoing interoperability needs.
Secondly, we know there are more entities out there providing HIE services and we'll be working
to continue to certify those entities to make sure that they go through the right process. We've
seen that the HIE market can change quickly and it requires constant monitoring of national
activities in order to stay current. We also know that Minnesota's HIE oversight law at some
point will probably need to be updated to more accurately reflect the current HIE marketplace, as
it has changed in the last few years.
The next slide continuing on the future of HIE in Minnesota, we know that because of having
multiple entities providing HIE services and potentially the type of confusion that it can create
by providers in the marketplace, we will want to continue focusing on providing provider
education on the HIE options. For example, helping them explore what HIE solution might best
suit their needs. We know that we will be focusing on privacy and security to really help
increase the adoption of HIE, which currently privacy and security is sort of a barrier to HIE
adoption in Minnesota.
Then, we'll also work on interstate and national connectivity to other HIEs. We're seeing HIE
service providers starting to move from more basic HIE to what I consider more advanced,
which is really moving more towards analytics, more towards the type of HIE that's needed for
Now, I want to just reflect a little bit on the lessons learned from Delaware. First, I really want
to commend Delaware's achievements that they've made in HIE. It sounds like they've made
remarkable progress, both in terms of HIE adoption by providers, as well as actually
First, I want to comment on the comment about consensus. We have seen that achieving
consensus can be a lot of work, but it's really the key for sustainability. In Minnesota, we've
found this to be true in regard to shared services where natural HIE competitors have come
together to reach consensus regarding technical aspects of shared services. We've also worked
together on a policy and governance framework, as well as sustainability plans for how they're
going to sustain those services together.
We've also found it's helpful to start with those motivated to do HIE. In Minnesota, the providers
that we've seen more enthusiastic regarding HIE have actually been providers not eligible for
Meaningful Use. In our case, we've actually seen quite a bit more interest from providers such as
local public health and long-term care. We've created programs for the broad continuum of
providers to encourage those ready and interested in HIE to participate. Because there will be a
range of providers interested in HIE, those with and without certified EHR technology, it's
important that HIE service providers anticipate the range of HIE needs from more basic needs to
Those options need to create value based on business needs. We're seeing especially with the
evolving models of healthcare, for example in Accountable Care, that this is really important.
Coincidentally, we have also found that this is a little bit harder to do in Minnesota when there is
market-based approach, because there is more competition in the marketplace.
The next slide is really just a reflection on some of Delaware's barriers. In Minnesota, we have
also found that it's critical to monitor emerging trends in technology and adapt the HIE solutions
based on changes in medical practice. The types of HIE services that were being offered in
Minnesota only three years ago are much different today. For example, it's really because of
Accountable Care and the need for more advanced data analytics and HIE solutions resulting
We've also found that scalable trust and, for example the work like national groups like Direct
Trust are working on, is foundational for expanding HIE beyond just a community.
Finally, Jan's comment about the natural reluctance to change I think is true in Minnesota as
well. We hear from providers that they want HIE solutions that are directly in their workflow
and at the point of care in order to create value and willingness to change the way they're doing
care just through HIE.
The next slide continues talking about Delaware's barriers and reflecting in Minnesota. We
believe that early adopters can be great champions for HIE to others. Although in Minnesota's
experience it's difficult to get those early adopters to make those investments, especially if there
isn't a critical mass exchanging. Actually, that's been one of our challenges in Minnesota.
We have found that thinking of the range of providers that want to participate in HIE, but
meeting them where they are in terms of HIE readiness and capabilities is a first start to getting
provider adoption of HIE. Again, in Minnesota the providers that have had a higher demand for
HIE have actually been the providers not even eligible Meaningful Use. But, on the other hand,
some of those providers might be the types of providers that are needed for Accountable Care.
Finally, a comment about the business model for HIEs where members or providers are business
competitors; we think about the goals of Accountable Care and the responsibilities that go with it
much more as a collaborative model that will be needed in order to achieve those outcomes of
increased quality of care and lower healthcare costs.
A couple of final observations about the HIE marketplace and Accountable Care. We know that
there are going to continue to be many types of entities providing HIE services. For example,
Stage 2 Meaningful Use really kind of fosters more of a market-based approach to HIE. The
challenge we see will be finding ways to create interoperability between these entities across
communities statewide and even across state borders.
We've seen that the evolution from more basic HIE to more advanced HIE that sustainable HIE
service providers really need to be able to offer value-based services. Many times that means
going above and beyond the basic HIE services and also the basic requirements for Meaningful
We've experienced in Minnesota a lag in provider adoption of HIE. We think actually it might
be due to the somewhat lower HIE requirements for Meaningful Use, at least for Stage 1. But
we think that that will be increasing with Stage 2, and then also as the demand for Accountable
Finally, we think it's also important to consider the range of settings interested in HIE, especially
in the Accountable Care model. HIE service providers will need to adapt their offerings and how
they market their services with this in mind.
So thank you and now I'll turn it back over to Gerry.
Gerry Fairbrother: Thank you, Jennifer, that was excellent. We've had a number of questions
come in. The first one is on this exact point. It's about Accountable Care Organizations and the
relationship. So recognizing that the state HIE governance structure in Delaware and Minnesota
are very different and that Delaware does not yet have Accountable Care Organizations, what do
each of you see as the role of the HIEs in each of your states, if any, in supporting ACOs in the
future? Are the HIE entities in your states working with ACO administrators or those interested
in forming ACOs to discuss exchange and connectivity? Why don't we start with Jan and then
go to Jennifer.
Jan Lee: I would be glad to. In Delaware, we do not yet have any ACOs. We do have a couple
of different hospitals that are contemplating moving in that direction and are sort of lining up
their resources and their plans to do so. I will tell you that each of them sees DHIN as being
absolutely critical to their ability to do that.
We're also working, as many other states are, with the State Innovation Model's Planning Grant.
With Delaware being a small state, DHIN is a major existing IT resource that everybody believes
should be leveraged for any additional HIE needs to support new models of care delivery and
So, we are very busy right now doing the planning around what would it take to add in the kind
of actuarial and analytic tools that would be needed to support these new models of care delivery
and payment. There's every expectation that we will leverage the tools that DHIN already has,
which includes identity matching tools. It's not just the data in the system that is a valuable
resource. It's the identity matching tools, it's provider registries, it's patient registries that already
exist. So yes, I think that we are very much going to be involved in the move ahead to forming
Gerry Fairbrother: Thank you, Jan. Jennifer, can you speak to this a little bit more? I know you
covered some of this in your slides. Can you speak a little bit more to the HIE and Accountable
Jennifer Fritz: Yes, absolutely. So in Minnesota we definitely see alignment between HIE and
ACOs. In Minnesota, we currently have three of the pioneer ACOs in the state. We also have
our state Medicaid agency that has been funding or developing sort of an ACO type of model
across the state with Medicaid activities. We're also one of the state innovation model testing
states, so we're going to be working on developing what we're calling the Minnesota
Accountable Health Model.
There will be a fair amount of ACO activity happening in the state, and through our state
certification process we do see that that plays a role. So for example, we anticipate that the HIE
entities that are providing those services to the ACO organizations or ACO communities, we
anticipate that they will at some point need to be certified. We are hearing interest right now
from the community about that, and so we expect that those players will be expanding our HIE
marketplace in Minnesota.
Gerry Fairbrother: Thank you both. The second question and this is also to both of you, is
around using your HIE as a registry. The specific question is whether it's being used to collect
HEDIS data. But, you could speak to it more broadly as a registry to create a denominator and
the denominator could be the HEDIS population, and then the numerator of how many people
That's broad enough, but there is a second part of it which has to do with consumer reminders for
preventive care. So first, the registry function particularly used to collect data for HEDIS
purposes, and then reminders and alerts. Jennifer, let's start with you.
Jennifer Fritz: Both of those services I would say are services that we would consider valuable
in Minnesota. I don't know that any of the service providers that are currently certified offer
either of those services. I know that there has been some interest around the quality measures
and I think there's some exploration there. In terms of the consumer-based reminders, I'm
actually not aware of anyone working on that currently, although I wouldn't be at all surprised if
that doesn't emerge in the near future.
Gerry Fairbrother: Thank you, that's good. Jan, do you want to tackle this question now?
Jan Lee: We are not currently a registry for HEDIS, because we're not getting health plan-level
data yet. But again, I would say that the basic underlying infrastructure of DHIN puts us in a
position to, if anyone is going to do that statewide, it's going to be DHIN. Because again, we
already have the matching tools, the algorithms in place and so forth and it would be a relatively
low lift to leverage the functionality and the technology that we already have to layer on those
services. That's some of the discussions that are taking place right now with our State Innovation
What was the second piece of that?
Gerry Fairbrother: It had to do with alerts or reminders.
Jan Lee: We are working on an alert function for health plans and providers. The patient
engagement tools that we're in the process of implementing right now are really intended not so
much to push out reminders of when things are due, because that's not really information that
DHIN necessarily has available. I mentioned we're not currently getting a lot of input from the
ambulatory practices. Now if that changes and we have the data sources, then there's certainly
a lot more we can do with it.
What we do expect to provide to consumers is the ability to anytime new data comes in to the
Community Health Record, no matter who the data sender is, as new data comes into DHIN, we
are going to be able to push that right out to the patient so that they are immediately aware of the
fact that new data has come in and they may wish to engage with their providers around a
discussion of those results.
Gerry Fairbrother: Thank you. So, we have a number of other questions, but I believe we're out
of time. So I thank you both for a really interesting presentation. I've enjoyed moderating it and
I'll turn it back to Judi Consalvo.
Judi Consalvo: Thank you, Gerry. Thank you very much and I want to thank our presenters as
well as our audience. Please remember to complete the web event evaluation. It helps us to
improve our offerings in future events.
For more information on the Delaware Health Information Network, we included a hyperlink on
this slide to the profile on the AHRQ Healthcare Innovations Exchange. If you have some
questions, there is a comment section which you can direct your questions to on that particular
profile. We invite you to visit our website. Follow us on Twitter for all the latest developments.
You can also contact us anytime at firstname.lastname@example.org. Watch out in the near future the
slides and the transcript from today's presentation will be posted. Again, we welcome your
questions and to contact us at any time. Thank you again for joining us.