HIEs as Public Service Utilities

Over the course of the past couple of years, health information exchange (HIE) organizations have played an increasingly significant role in public health, enabling unprecedented interoperability. With the advent of cloud-based services and expanded capabilities, HIEs have adapted to new market conditions and expanded support as public service utilities. Building on lessons learned and paving the way for future innovation, they are poised to become more sustainable in their respective states.

In this virtual roundtable, senior leadership from three HIEs share their perspectives on how HIEs have evolved to serve as public service utilities. The panel focuses on the biggest challenges of interoperability, new best practices, and requisite infrastructure to build upon these efforts. The panel was moderated by Robert Horst, senior vice president of partner engagement at Audacious Inquiry, a PointClickCare Company. The IT company provides a connected care platform that facilitates the secure transmission of data across the US healthcare system. 

Panelists

• Erica Galvez is chief executive officer and chief operating officer of Manifest MedEx (MX)
• Martin Lupinetti is president and CEO of HealthShare Exchange
• David Kendrick, MD, MPH, FACP, is the principal investigator and CEO of MyHealth Access Network

Horst: Tell us about some of your biggest challenges in interoperability and breaking down data silos as you work to bring data into your HIE.

Galvez: One of the main challenges Manifest MedEx faces is building a network of participants. Widespread participation among health organizations across the state is necessary so that we have a greater number of participants sharing additional data to provide a more complete picture of the patient. While we have a large reach in the state, there are still organizations not actively participating in health data exchange. California has ambitious goals to address this with legislation passed last year that requires healthcare organizations to share data by 2024; however, state funding to build and support needed health data infrastructure to meet these requirements, as well as incentives to share quality data, remain absent, which will likely limit participation.

Lupinetti: We recognize Epic, the electronic health records (EHR) software, is a major player across the country, and particularly in our geography (Pennsylvania, New Jersey, and Delaware). Many of our largest health system members use Epic to connect to one another, and because of this, they may not be aware or fully appreciate the value the HIE delivers to ensure interoperability and continuity of care for all patients. According to our data, 30-40 percent of patients that are being seen by a large health system using Epic are also being seen by caregivers at non-Epic facilities. Our value in interoperability is integrating all of these disparate provider and care delivery organization’s systems throughout the entire continuum of care.

Kendrick: Individual challenges over time have included vendor data blocking and provider data blocking.

• Vendor data blocking: Despite clear language in the meaningful use programs about the requirements for interoperability, some (not all) EHR vendors created significant barriers to data interoperability, including cost, technical challenges, and adverse business practices. These have largely been addressed with the interoperability rules stemming from the 21st Century Cures Act; however, there are still EHR vendors that require HIEs and other organizations to purchase a separate hub license in order to interoperate with the clinics and organizations using that EHR, and the options to extend interoperability, even to meet federal requirements, are very limited. 
   
• Provider data blocking: This has not been as much of an issue in Oklahoma thanks to early participation of providers in value-based payment models, which clearly demonstrate the importance of interoperable healthcare data. The new rules from the 21st Century Cures act have been helpful in further solidifying broad participation in interoperability. It remains to be seen how impactful Oklahoma’s new government mandate for HIE participation and utilization will be in achieving universal interoperability. Certainly the hope of MyHealth is that wide participation can be achieved through perceived and realized value, rather than the application of force of law.

Horst: During the pandemic, what were your most successful efforts to connect with your healthcare stakeholders (including public health)? Of these efforts, what remains in place? What new best practices or programs will you continue post-pandemic?

Galvez: During the pandemic, MX collaborated with public health departments and officials to identify at-risk populations, monitor trends in health care utilization, and keep a pulse on hospital and health system capacity. Using health data from Manifest MedEx, Health Plan of San Joaquin (HPSJ) was able to identify the highest COVID-19-risk residents in their area and worked to more than triple the vaccination rate. MX aggregated, normalized, matched, and integrated HPSJ claims data, vaccination data from California Department of Public Health (CDPH) and the regional vaccination registry, and clinical data from participating providers to produce a weekly report that identified critical information for HPSJ’s members. This data included their COVID-19 mortality risk, high risk comorbidities, and vaccination status (including vaccine manufacturer, number of doses, and dosing dates).

MX also worked with the Riverside County Department of Public Health (RCDPH) and their partners the Inland Empire Foundation for Medical Care (IEFMC) and Riverside County Medical Association (RCMA) early in the pandemic to support public health outreach to vulnerable populations. MX helped RCDPH identify 73,000 high-risk patients in Riverside County based on claims and clinical data in the MX system, which enabled them to quickly launch a two-part outreach program that included a bilingual PSA to high-risk patients and personal case management outreach to 800 of those with the highest risk. HPSJ and RCDPH both continue as active participants in the MX network.

Lupinetti: In response to the pandemic, HSX shifted into action to stand up a variety of reports and smart notifications based on positive COVID-19 diagnosis. The reports included utilization and “hot spots” for COVID-19-positive cases and notified members via a “smart” alert to providers that a patient or health plan member was diagnosed with COVID-19. We quickly shifted gears to support contact tracing efforts once a person received a positive diagnosis. In fact, our master patient index and contact information HSX retains was near real time and very accurate. The city of Philadelphia’s Department of Public Health began using this data to support their contact tracing outreach efforts. We also learned the Pennsylvania Department of Health was struggling to better understand volume case counts in and around the city of Philadelphia as well as the details on each case (e.g., age, race, ethnicity, etc.). We reached out to Dr. Rachel Levine, secretary of the Pennsylvania Department of Health at the time, and HSX immediately began sharing this data at the state level to help with daily tracking and reporting of the pandemic. 

HSX’s response to community and public health needs from this pandemic resulted in HSX being one of ONC’s five STAR grant awardees, with new funds directed to strengthen the collaboration with public health organizations. These funds have advanced a variety of public health data sharing initiatives and has brought many of the surrounding public health, including all area county health departments, to now work directly with HSX on pandemic response efforts. 

Kendrick: MyHealth received Oklahoma’s first positive COVID-19 test in early March of 2020, and that proved to be an organization-altering event, prompting MyHealth to launch a comprehensive response to support our communities as they struggled to address the pandemic. Key initiatives included:

• Authorization by governance: All new use cases requiring access to sensitive, community-sourced data on individuals requires approval by the highly engaged governance of MyHealth. The MyHealth Board of Directors quickly approved a package of activities to enable a comprehensive approach to data acquisition, expanded alerting capabilities, collaboration with official government response efforts, and communications with the public and press around COVID-19.
   
• Data acquisition: MyHealth’s already extensive network covering, at that time, more than 70 percent of Oklahoma’s healthcare activity, needed to be extended to cover as many sources as possible, including new emerging labs, to enable an optimal response to COVID-19. Thanks to a timely and generous grant from Blue Cross & Blue Shield of Oklahoma, MyHealth was able to create the Oklahoma Healthcare Recovery Program, which enabled any organization in Oklahoma not yet connected to the HIE to connect at no cost, removing a critical barrier. MyHealth was able to onboard many new organizations, including labs, first responders, hospitals, clinics, and others, to ensure that the maximal amount of Oklahoma health data was being exchanged to support the remainder of the planned pandemic response.

Horst: Do you see your HIE serving as a public health data utility? If so, what does that information governance look like? What are the benefits of strong HIE information governance? How does interoperability play a role in cross-sector data exchange and governance?

Galvez: Yes. We see Manifest MedEx as a key health data utility for the state of California. As a nonprofit organization, we are first driven by our mission and then guided by our stakeholders and participants through formal governance like our board of directors and advisory committee. A wide range of organizations trust us to maintain and secure their data, ensuring it is shared when and where it needs to be shared, while protecting it from inappropriate use.  Having broad representation across our governance structures from organizations like California hospitals, health plans, medical associations, and health policy leaders helps us ensure we govern our infrastructure and the data we steward in a manner that balances all of those, at times, competing interests. Strong HIE governance and data governance help increase transparency and accountability to network participants, which ultimately builds trust. That trust is what maintains and grows the network and fuels the collaborative innovation required to make bigger, broader goals possible, like California’s Medicaid transformation agenda.

Lupinetti: We do see a significant role for HIEs serving as public health data utilities. That said, this is challenging in states that are represented by multiple HIEs. Unfortunately, this creates much redundancy and service duplication. A multi-state model increases the challenges for public health. During a pandemic, you have multiple access points to completely answer and address a population health concern. We’re hopeful states that have this type of model begin to see value in identifying a smaller subset of HIEs that have scale, capability, and can be relied on to support public health needs, doing away with individual data silos. Our hope is that we build on work done to date with public health and regional stakeholders begin identifying HIEs as a public health utility.

Kendrick: Yes. MyHealth is very much a health data utility for public health, but also for general health and wellness—impacting healthcare delivery, social services, value-based payment models, public policy, and much more. MyHealth’s core role is to serve as the secure source of high-quality clinical, claims, and social determinants of health (SDoH) data. In this sense, the HIE’s role is similar to the utilities that provide clean water or electricity, where and when it is needed, and in a form that complies with standards and regulations, enabling the safe use of the services. Governance and trust are the critical tools that must be used successfully to build and maintain the health data utility. This is an area of particular strength for HIEs that have emerged from the communities they serve and have succeeded in building the governance and trust needed to get sensitive data exchanged. This accomplishment of community-wide trust and buy-in needs to be acknowledged, and the maintenance of it, certainly more significant than the cost of the software and systems to support HIE, needs to be supported with appropriate local, state, and federal resources.

Horst: As you look ahead to new HIE efforts and programs, what infrastructure will you need to build upon these efforts?

Galvez: As California implements ambitious changes in the health information landscape, including Medicaid transformation initiatives and frameworks like the CalHHS Data Exchange Framework (DxF), there is a clear need to build reliable, scalable health data infrastructure that will enable and drive success for the entire state. MX is already putting in the work to ensure that California’s health organizations have data that is accurate, timely, and actionable. The most critical work ahead is ensuring that all providers and plans are connected to data infrastructure that allows them to put data to work for transformation. California is a big state, and getting everyone connected requires substantial investments in incentives and technical assistance to mobilize and support universal participation. Once we achieve this, the state can more effectively address health inequities, potentially save billions of dollars in health care costs through better care coordination, and improve the health outcomes of our residents.

Lupinetti: To enable scale, build upon our performance and be able to access data and report on it in a variety of ways, HSX is migrating to a complete cloud-based technology and model. That’s a big part of the next frontier in health data sharing. We’re also implementing a separate data warehouse that mirrors our production system to conduct analytics reporting, and quality improvement programs focused on chronic disease management. The HIE gives any quality improvement programs a significant jump-start since we already have the health data and data-sharing agreements already in place, and many of the needed health stakeholders as HXS members with focus on improving health outcomes. We plan to focus on diabetes, behavioral health, opioid crisis, etc. We’ve received NCQA’s Data Aggregation Validation credential that certifies HSX to use the data to represent quality measures and improve the support of value-based care arrangements and improve HEDIS scores resulting in increased reimbursement levels from Medicare and Medicaid. 

Kendrick: Assuming that the spectrum of HIE use cases recognized by providers, payers, employers, and local, state, and federal agencies continues to grow at a rapid clip, the HIE’s need to be prepared with the essential local infrastructure and a clear pathway toward a national infrastructure. The Patient Centered Data Home™ program represents a very impactful initial effort in which more than 40 HIEs covering more than 200 million lives collectively have partnered to enable nationwide ADT alerting, and important advancements to that capability are underway now through CIVITAS, the association of HIE’s and regional healthcare improvement organizations. Consolidation of HIEs is also underway as local efforts recognize opportunities for scale and cost reduction through collective purchasing and, eventually, through unified governance. This is a trend that must be watched closely to ensure that the essence of HIE success, that is local governance and engagement, continues to be a foundational element in decision-making. The trust of patients, communities, and agencies must be maintained if the potential of this critical national infrastructure is to be realized.

Horst: What has been your HIE’s role in care coordination across hospitals, providers, and community programs to improve public health? How do you see the HIE’s role in care coordination evolving in the future?

Galvez: MX enables proactive data sharing through a robust notification service coupled with longitudinal health records for more than 32 million Californians, the combination of which is critical to timely care coordination. MX does the hard work of maintaining and tracking patient panels for providers and eligibility files for health plans so that as soon as someone enters the emergency department (ED) or gets admitted to the hospital, MX knows who needs to be notified to support that patient and immediately triggers that notification. Once a provider or plan is notified that their patient is in the ED or hospital, their care coordination teams move into action, frequently using MX’s longitudinal records to understand the broader health context for that patient. The ability to translate data into practical, actionable insights for care coordination teams helps reduce readmissions and cost over the long term through more timely and complete care coordination. As care coordination becomes increasingly important to all healthcare organizations in the future, HIEs will continue to evolve as a key partner in ensuring that the data required for collaboration is reliably delivered and accurate to assist patients.

Lupinetti: In the spirit of improving public health, currently HSX is responding to a state procurement for a closed loop referral system for community-based organizations. As a result, the HIE will inform providers and caregivers that a patient has been referred to a community-based organization and can provide follow-up care based on results of the program. This is the next generation of HIE value and the future of care coordination. HSX provides its encounter notification service to over 7 million patients, where a provider health plan care coordinator can receive data in real time to more effectively manage and coordinate their care.

We are now seeing an influx of new facilities in the home health space joining HSX. This is also a future trend in care coordination: monitoring a patient’s care in their home. These types of organizations see much value in the encounter service and understanding what’s going on with patient when they receive care at home or, for example, when they have fallen and have been rushed to a nearby hospital. This encounter data can deliver real-time awareness to the care coordination team so they know what happened, where they were taken, and what else may be needed to further coordinate their care. 

Kendrick: MyHealth has long served as the most comprehensive source of real-time information for patient care across Oklahoma. MyHealth handles more than 110,000 clinical encounters per day,  has more than 6,000 users of its systems, and provides alerts on tens of thousands of those encounters to the patients’ care teams daily. These efforts have received a boost recently, as MyHealth was named the State Designated Entity for Health Information Exchange. Regarding how the HIE’s role in care coordination will evolve:

Improving the function of public health systems: HIEs are in an ideal position to provide the critical data and capabilities needed for the following public health use cases, and MyHealth is currently or soon will be actively supporting all of them:

• Disease detection and outbreak surveillance and monitoring: use of the real time clinical data, especially ADTs;
• Pandemic response: case identification and tracking, healthcare resource utilization and availability tracking, impact of public health policies such as masking;
• Various disease and condition registries: HIEs lower provider burden by organizing and reporting the data via secure automated pathways and eliminating manual reporting;
• Immunization administration tracking: HIEs can lower provider burden by automating reporting, and improve vaccination rates by alerting the potential of vaccine gaps that providers can address; and
• Violence against healthcare workers: MyHealth has established protocols for reporting violence against healthcare workers to enable early warning of security systems when a patient with a history of violence presents or is planned to present for care. This is an ideal use case for HIEs because patients with a propensity for violence often utilize many different delivery systems as their behavioral issues escalate. In Oklahoma, the events of June 1, 2022, at Saint Francis Health System have made this initiative an imperative.

Improving the actual health of the public: Virtually everything the HIE does is focused on improving the health of the public, and the performance of HIEs is best judged by their impact on the health of the population they serve. The following are tangible ways that community-based HIE’s can best improve the health of the public:

• Better, safer, timelier care: Ensure that clinical, claims, social determinants, and any other data relevant for each individual’s diagnosis and care are available whenever and wherever they are needed. No other type of entity can assemble this much data across multiple domains effectively and securely to support these services. This reduces duplication of services and speeds time to diagnosis and treatment and, perhaps most importantly, helps to improve safety by avoiding mistakes in care.

• Better policy and public resource use: Provide truly comprehensive individual level data to support evidence-based policymaking. This applies to planning for new policies and strategies but also for assessing the impact of previous policies and strategies. An example is MyHealth’s real-time impact of mask mandates put forth by cities during the COVID-19 pandemic, which showed a dramatic impact on positivity and cases per 100,000 individuals.

• Better public health systems: There is little question that the infrastructure of the health data utility is much better utilized to support public health than building a parallel infrastructure that will double costs and the labor or providers required to use it.

• Better research, innovation, and systems improvement: Nearly all clinical and health delivery systems research is hampered by limitations on the timely availability of comprehensive data on the study and intervention populations.

• The utilization of HIE data (including clinical, claims, social determinants and other person-centric data sources) for these purposes (with appropriate governance oversight) addresses many of these limitations and also ensures that principles of equity, equipoise, and to which, “do no harm” are adhered. Research should be able to proceed much more rapidly as the data is already gathered and organized, and also more safely, as the downstream effects of new interventions can be monitored over a longer term than before. The existence of an HIE with readily available real-world data is also a potential economic development opportunity because enabling innovators to more rapidly prototype and iteratively improve their ideas in the real world increases likelihood of successful innovation.

Robert Horst is the senior vice president of partner engagement at Audacious Inquiry, a PointClickCare Company.