Health Train Express: Sustaining the Unsustainable by Creating New Institutions Costing more to spend less.

In the world of health information exchange development process and implementation are very slow.

I previous posted here about the Inland Empire Health Information Exchange becoming operational on April 1, 2012.

In an article by Lauren McSherry, California Healthline Regional Correspondent she ably outlines the processes, delays and pitfalls of developing an entirely new entity.

“After two years of planning and negotiation, an information-sharing network linking health care providers throughout Riverside and San Bernardino counties is almost ready to go live.

Health officials say the Inland Empire Health Information Exchange will be one of the largest in the nation, covering a geographic region nearly the size of Maine with a population of 4.2 million. About 15 hospitals and 2,000 doctors are expected to participate in the health information exchange. California has a strategic plan for the mobilization of health care information electronically across organizations within regions, communities and ultimately the state.

"Our challenge in the Inland Empire is that our counties have some of the lowest health outcomes when it comes to some of the more chronic diseases," said Christina Bivona-Tellez, regional vice president of Riverside and San Bernardino counties for the Hospital Association of Southern California. "This is a tool we can use to more expeditiously intervene and make a difference," she said.

In June, supervisors in Riverside and San Bernardino counties passed resolutions recognizing the exchange as the designated HIE network for the region. Each county's department of health will participate in the exchange.

In the future, regional HIEs will share information through state HIEs, with the ultimate goal being national connectivity. So far, $22 billion has been allocated through the 2009 Health Information Technology for Economic and Clinical Health Act, or HITECH Act, as part of a national push to link health care providers.

California has 17 HIEs and is working to build its own state HIE, called Cal eConnect.

Costs and Other Challenges

With an estimated cost of $2.2 million to $2.5 million annually, building and maintaining the exchange is an expensive proposition.

"One of the most critical things is being able to make it work financially," Bradley Gilbert -- CEO of the not-for-profit Inland Empire Health Plan, a participant in the new HIE -- said, adding, "The difference [from other exchanges] is you've got health care entities that will be providing the dollars for the program to work. You've got different fee structures for the different kinds of entities."

The high cost of maintaining and operating HIEs is not unusual, and sustainability is one of the biggest challenges facing HIEs across the nation, said Jennifer Covich Bordenick, CEO of the eHealth Initiative, an independent not-for-profit organization in Washington, D.C.

An eHealth Initiative survey released July 14 found that at least 10 HIE initiatives have closed or consolidated since 2010. HIEs totaled 255 in 2011, but only 24 initiatives reported having sustainable business models.

"You're talking about infrastructure that can be created so that doctors can talk to pharmacies, and pharmacies can talk to labs, and patients can look up their information in their homes," Covich Bordenick said. "There are issues of who pays for this because there are so many different users of the system."

The HITECH Act spurred growth in HIEs across the nation. But as the number of HIEs grows, so does the competition to attract health care providers to participate.

"Some groups are collaborating or absorbing other HIEs," Covich Bordenick said.

Meanwhile, experts are paying particular attention to ensure that the Inland Empire HIE will be sustainable and not be reliant on grant funding, so it can survive and grow.

"HIEs that have been started predominantly with grant funding have had difficulty sustaining themselves," Gilbert said. "You cannot be dependent on grants because grants eventually dry up and stop."

Covich Bordenick said an example of a successful HIE that has not relied on public funding is HealthBridge, an HIE serving the greater Cincinnati area, which covers parts of Indiana, Kentucky and Ohio.

The Inland Empire HIE will be a subscription-based model with annual fees to support the initiative, Gilbert said. One model used in developing the Inland Empire network has been the Santa Cruz HIE, which dates back to 1995 and has brought together more than 400 health care providers.

Other HIEs are encountering challenges related to technical aspects and systems integration as they attempt to share information.

Looming Health Care Reform

The importance of ‘anchor participants’ for a health information cannot be overemphasized because it provides a bedrock of financial sustainability. Financial stability has been a major and impenetrable wall for most plans, save a few. Even those that became operational (Santa Cruz RHIO) failed when the initial grants expired.

Being a part of the Inland Empire HIE is particularly important for Inland Empire Health Plan because its membership is growing dramatically, Gilbert said. Compared with other health insurers in the region, the health plan has the largest proportion of low-income residents.

The importance of ‘anchor participants’ for a health information exchange cannot be overemphasized because it provides a bedrock of financial sustainability

The unemployment rate in the region has been hovering around 14%, and many residents currently are unable to afford health insurance. The Inland Empire area has more than one million uninsured residents, according to a February study by the UCLA Center for Health Policy Research.

By June 2012, the Inland Empire Health Plan expects to have more than 600,000 members, fueled by the economic downturn and the state's mandate to transition Medi-Cal beneficiaries into managed care plans, Gilbert said. Medi-Cal is California's Medicaid program.

By 2014, when many insurance provisions under the federal health reform law take effect, IEHP's membership is expected to reach 900,000, Gilbert said. The HIE will help keep patient records easily accessible and organized during a time when the sources of health care for a large number of people will be in constant flux.

"As members come in and out of our program, the HIE is very critical," Gilbert said. "People have been losing their jobs, losing their commercial insurance and transitioning to IEHP. The more data we have about them for our doctors and hospitals, the better."

If a patient has been seen in the past by another physician or was admitted to an emergency department elsewhere in the region, those records can be retrieved by the new health care provider. The key point is that the information will be easily transmittable and can be accessed wherever the patient seeks care, Gilbert said.

Starting Small

The diversity in participants -- from large hospitals to physician groups and county clinics -- makes the Inland Empire HIE unique, Gilbert said. In addition to the two counties, stakeholders include the Riverside County Medical Association and the San Bernardino County Medical Society.

A pilot project to test the exchange will be launched in the next four months. Loma Linda University Medical Center, Beaver Medical Group, Riverside Community Hospital, Parkview Hospital, Riverside Physicians Network, Riverside Medical Group and Inland Empire Health Plan have agreed to participate in the initial pilot project, Bivona-Tellez said.

The idea is to start small and then expand the exchange.

"The pilot project will last until we demonstrate it is functioning properly," Bivona-Tellez said. "You make sure you've got everything covered. Then you go bigger."

Bivona-Tellez said that a crucial aspect of the new HIE will be the design of its interface, which could make or break the success of the new system.

"You don't want to slow down the work of a frontline provider in caring for a patient in a critical situation," she said, adding, "You want the ability to look up something to enhance the care needed at that time."

In recent years, HIEs that were not able to present complicated information clearly and in a timely manner have failed, she said.

"Ease of use is probably the biggest concern and the ability to look at disparate information displayed in one place," she added. "If you have a system that isn't user friendly, your physicians and others won't use it. Some large institutions have dropped multimillion-dollar projects because the end users didn't like it."

Ultimately, all of the participants who join the Inland Empire HIE will be doing so with the goal of improving patient care, one of the motivations behind the passage of the HITECH Act.

Hard evidence as to whether HIEs are effective in improving patient care is difficult to come by, but anecdotal evidence suggests they are making a difference.

"The issue with collecting evidence about improved patient care is that it's hard to draw a direct correlation because there are so many groups on the exchange," Covich Bordenick said. "What we hear from doctors and patients is that it is more convenient, that the information is there when they need it. That's really important."