Category Archives: HIE

The Search for Business Models for Public Health Participation in an HIE

Marcus Cheatham
Health Officer
Mid-Michigan District Health Department

Have you read the recently released report by the Trust for America’s Health “Healthier America 2013”? It is an excellent attempt to summarize the opportunities for public health to transform itself during the roll-out of the Affordable Care Act. Over and over again the urgent need for public health to work hand-in-hand with health care systems is highlighted in the report.

Public health departments must adapt to work with new entities and financing mechanisms in the reformed health system, such as by working with Accountable Care Organizations (ACOs) or within newly capitalized care structures and global health budgets, to help improve health beyond the doctor’s office.

A key component of this, obviously, will be the ability to exchange health information with other parts of the health care systems electronically. Let’s consider my health department’s Children’s Special Health Care Services (CSHCS) program as an example. This program coordinates care for children with qualifying medical conditions. Our health department has an electronic health record (EHR) system. We manage our CSHCS cases using the EHR which works quite well. We are completely paperless—well, almost. In managing these cases we collaborate with Medicaid Health Plans. Information going back and forth between us and the health plans still goes by old-fashioned, messy faxes.  Just this morning, I found two “lost” CSHCS faxes floating around in our copy room.  We would love to join a Health Information Exchange (HIE) so we would be able to exchange this information directly out of our EHR and ditch the faxes.

In fact, last week we met with one of the two big HIEs in our state to talk about doing just that. This HIE offers a sweet product for managing referrals which is exactly what the CSHCS program is looking for. Physicians’ offices in our area are starting to jump aboard the HIE, and even some of the Medicaid health plans are on their system.  We would love to go forward, but there is a snag: the cost.

Participating in the HIE would only cost a few thousand dollars. The problem is that our health department is looking at budget cuts next year of many tens of thousands of dollars. Our state pays for part of public health out of a health fund that is going to take a big hit this year; there is sequestration; and some of the counties in our district are warning that their general funds are still underwater. If joining the HIE allowed us to expand CSHCS, maybe we could use that additional revenue to join the HIE. But the CSHCS caseload is fixed. The way CSHCS is managed in our state, the Medicaid health plans gets first crack at the most lucrative billable services in CSHCS and we get what is left. We actually expect CSHCS revenue to fall, with or without the HIE.

Another complicating factor is that our health department is between two large medical trading areas, each with its own HIE. In order to provide CSHCS services electronically across our district, we would need to join two HIEs, at twice the cost. Most frustrating of all, the two HIEs only exchange information between themselves using a protocol called Direct, which is very limited.  It’s kind of like secure email. It would not permit the kind of exchange we really need to make CSHCS referrals efficiently.

Yet not joining the HIE at this point poses a risk, too. As more and more physicians join the HIE more of them will be making referrals electronically using the HIE’s product. If the health department does not appear in their system because we haven’t joined, referrals for things like women’s health, family planning and the various testing and screening services we offer will start going elsewhere. Now, I don’t think government should be competing with the private sector to deliver these services. My concern is that medically complicated or vulnerable people who should be seen at a health department may miss that opportunity. Our services need to be sustainable so that we can be here for those who need us.

That’s the challenge we are wrestling with now. We need to come up with a business model through which we partner with the health care system and generate the revenue we need to be part of our local HIEs. Fortunately we are in a community where our hospitals are interested in helping us make that happen. We have a meeting scheduled this month to begin exploring potential solutions

*Note blog submission reflects dates in April 2013*

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Public Health Informatics Virtual Event on July 16-18, 2013 – Call for Abstracts!

Connect with colleagues at your own convenience!

ph informatics virtual event

This virtual event provides the opportunity to learn and discuss the latest initiatives in public health informatics with attendees from all over the country and internationally. Call for abstracts is now open and will continue until May 31, 2013. This year’s theme is “Strengthening Public Health – Health Care Collaboration.” Abstract submissions are encouraged in the following areas:

1)  Informatics policy and practice: virtual sessions will focus on national and international policy issues and their implications for public health informatics programs; applied informatics projects for programmatic support; and new initiatives

Examples might include:

  • ICD-10 CM/PCS –deadline for implementations 10/1/2014
  • Meaningful Use & Electronic Health Records
  • Interstate data exchange
  • Data exchange to support ACOs

2)  Research & Innovation: virtual sessions will focus on informatics research and technological innovation to public health and clinical settings.

Examples might include:

  • Applying analytics to new and existing data sources
  • Leveraging Big Data for population and public health
  • Learning health systems to support integration of primary care and public health
  • Novel technologies for population and public health education and communication (mobile, web, social media)

3)  Supporting Public Health Evidence Based through Informatics Practice: virtual sessions will focus on strengthening public health through knowledge sharing, evaluation, visualization and reporting.

Examples might include:

  • Evaluation methodologies and findings
  • Decision support for population health Health status and performance management dashboards
  • Community Health Assessments as part of the community health improvement process
  • Return on Investment (ROI) and Value of Information (VOI) analyses for informatics programs and systems

If any of the items above relate to your area of work, do not miss the opportunity to submit an abstract!

Help us get the word out and share this blog post with your colleagues and friends! And if you’re ready to submit an abstract go straight ahead here.

Meeting sponsors include CDC, NACCHO, and ASTHO.

Celebrating National Public Health Week: Local Health Departments utilizing EHRs for ROI

This week is National Public Health Week (NPHW), celebrating the contributions of public health workers in communities all across the nation as they strive to improve the health of all of their residents. In commemorating National Public Health Week, the ePublic Health blog is highlighting some of the great successes achieved by three local health departments that are moving into 21st century healthcare through the use of EHRs.

This year’s theme, “Public Health is Return on Investment (ROI): Save Lives, Save Money” highlights the value of prevention and the importance of well-supported local public health systems that work to  prevent disease and save lives. But achieving those goals are getting harder in the context of a fundamental fact that American healthcare costs continue to grow.

Local health departments play a vital role in the health and care of patients where they live. They provide unique services and have data reporting requirements to state and federal agencies. Clinical care and population-specific interventions are funded in a variety of ways and settings and many continue to face systematic funding challenges that complicate the delivery of their services.

Whether it’s at the municipal, county, state or federal level, these organizations provide coordinated care to some of the country’s most vulnerable citizens. And one tool used by these departments to improve population health is Electronic Health Records (EHRs). EHRs already play a vital role in helping prevent disease and save lives while working to coordinate care and help control healthcare costs for underserved populations across the country.

Otter Tail County, Minnesota

In Fergus Falls, MN, the Otter Tail County Public Health Department predominately serves adults who are enrolled in the county’s medical assistance program.

“Most of our clients have chronic health and comorbid conditions,” explains Diane Thorson, the Director/CHS Administrator at the department.

“The best value or ROI due to the recent implementation of the EHRs is the ability to query information regarding whether clients have had the appropriate immunizations such as flu, pneumonia, TDAP, and Zostavx,” Thorson says.

Thorson said she believes the ability to quickly obtain aggregate data through the EHR is important. The EHR, she says, describes outcomes of care rather than the numbers of units of service and helps the department avoid duplicate immunizations. It gives the health workers the ability to “guide evidence-based practice.” Otter Tail’s team uses tools available from the Public Health Informatics Institute (PHII) and talks with colleagues at other departments to guide decision making and exchange lessons learned.

Through the use of the EHR, the Otter Tail health department has been able to better manage and coordinate care for patients who rely on the care provided by doctors and nurses in the county health department.

District Health Department 10, Michigan

The District Health Department #10 (DHD10), which is responsible for 10 counties in Michigan, serves a similar underserved population as the Fergus Falls health department. More than half of the people DHD10 serves (54 percent) live in rural areas and are at, or slightly above, the national poverty level. With an unemployment rate of about 15 percent, about 55 percent of births in the counties DHD10 serves are reimbursed by Medicaid.

According to Sheryl Slocum, the EHR Liaison/Family Planning Supervisor for District 10, many of their patients have co-morbidities and unhealthy lifestyle habits. The population struggles with obesity, smoking and abusive behaviors.

Because of the diversity and difficulties in treating its residents, District 10’s Family Planning and Breast and Cervical program has 10 local sites which patients can use, each with connection to the LHD-wide EHR system.

The benefits of this portability are telling, according to Ms. Slocum. Quality assurance activities are now more efficient. While quality improvement activities are underway, it is expected that the EHRs will make processes more efficient and streamlined.

Cabarrus County, North Carolina

Since the fall of 2011, the Cabarrus Health Alliance (CHA) of North Carolina has been systematically implementing an electronic health record, Insight, throughout the clinical and support areas, according to William Pilkington, CEO and public health director.

The patients Cabarrus serves often can’t afford health insurance or treatment and many of these low-income patients live with multiple social stressors that often compound their existing medical conditions.

A particular area of specialty for CHA is high-risk maternity patients. Although maternity patients are seen in the clinic daily, given the clinic’s staffing issues (only one obstetrician), deliveries are often handed off to experienced OB/GYNs who work at the local hospital.

Before the alliance adopted the use of EHRs, it was common for patients to receive additional tests and more extensive pre-natal exams when they arrived at the hospital, because their medical records didn’t travel with them. While it is critical to have this information if a mother delivers early, this is precisely when the paper system was most likely to break down, Pilkington explains.

Now, a mother’s medical record is available to labor and delivery staff at any hour on any day of the week, even when the delivery is unexpectedly early, thanks to the EHR.

The EHR has also made it possible for clinicians to automate best practices throughout the Alliance’s facilities, such as in CHA’s Pediatric Clinic in Kannapolis, NC.  The American Academy of Pediatrics instituted its Bright Futures curriculum in 2011.  Bright Futures is a national health promotion and disease prevention initiative which includes extensive, evidence-based preventive services recommendations for pediatric practices.  Recommended screenings and services are now automated by the EHR which presents age-appropriate material based on the curriculum.

Mothers and their newborns who are treated by the Cabarrus Health Alliance can be assured that their records will provide their doctors with the right information they need where they need it, thanks to the adoption of EHRs across the county facilities, helping to make the care they receive that much more efficient.

The Return on Investment for Public Health

While ROI is typically thought of in a purely business sense and revolves around financial gain, many local health departments are actively demonstrating that EHRs can provide a return on investment in different ways. These tools have been proven to help connect patients with needed health and social services in Cabarrus County and ten counties in Michigan. They are streamlining processes and saving valuable time in Otter County.

But one thing is clear, those departments that are using EHRs won’t be going back to paper records because they are seeing the benefits of health IT.  They are demonstrating that Public Health ROI does save lives and money – goals that are worth celebrating during National Public Health Week.

A special thanks to Kathy Cook, Diane Thorson, Sheryl Slocum, and William Pilkington for their
contributions to this post.

Insights from Kansas Information Management and Exchange Workshop

Recently Vanessa Holley and I were asked to facilitate a workshop with local health departments (LHDs) in Kansas.  We were slated to discuss how to help LHDs make two decisions:

  • Do they need an electronic health record (EHR) system?
  • If/how should they connect to the health information exchange (HIE)?

Through the course of the discussions, it quickly became apparent that the decisions to have an EHR or connect to the HIE were only part of the story and in some ways were over emphasized because they are easier to conceptualize.  But the discussions began to broaden and clarify some of the issues.  As it turns out, I think we actually stumbled upon a pretty good road map for ePublic Health.

Let’s look closer at what I mean.

Before you can effectively take advantage of any technology or HIE option:

  • Step 1: develop the future vision for your LHD and clarify both what value and what services you plan to offer your community.  You first need to determine what services your LHD will be focused on in the new world of healthcare.  This is critical because if, for example, your health department is not going to continue to heavily invest in clinical services, then considering a practice management or EHR system may not be a good investment – despite current needs.  On the other hand if you plan to increase your case management and care coordination role in the community, you’ll want to be sure whatever system you purchase or build takes into account those requirements in order to best support your work.
  • Step 2: is to create or update your statewide collaborative Health Information Management Plan and planning body with a wide representation from LHD, state, and program personnel.  Even if this already exists, ensure that representatives are both well informed and doing a complete job of communicating out decisions that are made.  To begin this step you have to begin to coordinate at a heightened level with your state and neighboring LHDs.  In Kansas, they have had a great relationship with their state and a very active LHD association.  However, they still realized that they could benefit by making a more formal body that is charged with coordinating and collaboratively developing the Health Information Management Plan for public health.  This is different from the statewide HIT plan because it is much more than information technology and is solely focused on creating one public health voice for health departments throughout the state.  This is so critical because your partners need to hear a coordinated and unified voice for public health.  Also, most of the Meaningful Use solutions are designed and managed at the state level.  Therefore it is imperative that LHDs are collaborating with the state to understand how their information needs will be met and how these solutions will interact with their local systems.  There has been so much to keep up with in the fast pace of Meaningful Use that many states have not yet formalized this body and its charge.  However states that have recently created such a coordinating body, like Ohio, report huge successes in making decisions and dealing with unforeseen issues related to the changing world of ePublic Health (See CDC Charter Lite Template).
  • Step 3:  gain a clearer appreciation for your LHDs capabilities, needs, and desires. This can often involve an assessment of the systems you have, the needs that are met and the gaps that exist.  It might even be good for the aforementioned Health Information Planning group to survey LHDs and display results.  This will help LHDs identify peers they can work with and peers who can offer peer assistance or advice about vendors.  It is important that this not be done from a standpoint of competition or condemnation, but rather of bettering each health department.
  • Step 4: delineate the benefits of practice management and EHR systems. Though clinical operations and responsibilities for LHDs can vary wildly, most LHDs have some sort of specialty clinics that they run (examples include STD/HIV, TB, Maternal and Child Health, etc).  And though the state is often preparing systems to meet Meaningful Use requirements, LHDs must come up with their own solutions for meeting the demands of these clinics.  Complicating matters, LHDs often have cross over between local clinic information needs and programmatic reporting to state or federal partners.  In our discussions in KS, we discovered that even with smaller programmatic clinics there are good reasons to deploy one or both of these types of systems.  Especially since costs have decreased dramatically in the past 5 years.  Benefits include more efficient programmatic reporting, increasing overall clinic efficiency resulting in a higher volume of visits, increased recovery of costs and billing, decreased need for record space, etc.  Once you have determined that the benefits offered by these systems fit within your LHD vision, conduct a review of specific systems based on your unique requirements, and understand the costs and benefits you can expect, then you can make an informed decision as to which system you should deploy (see NACCHO’s All-Systems-Go tool).
  • Step 5:  know your requirements for exchange and assess/pursue your local HIE options to support those requirements. For this final step, our discussions in KS turned to the HIE options that exist in their state.  Since they have been a leader in Health Information Exchange and LHDs have been heavily involved, they have a couple of really nice options.  In their state, LHDs can get basic HIE services for free, which include direct secure messaging and access to a provider web portal.  And KS LHDs are finding really interesting ways to use these services – like using the web portal for case investigations and sending follow-up testing requests and outbreak summary reports to physicians using direct secure messaging.  The state health department is working to connect their reporting systems to LHDs through the HIE, but work remains to make local and state systems interoperate in this fashion.  It also came to light that there were other exchange requirements that the LHD had that aren’t a part of their “free” set of services, but have enough value that they will want to understand the costs/benefits and pursue those options.  For example, local clinic managers would like to perform clinical assessments on their clients and provide test results and other clinical notes to the referred provider or receive visit summary documents when the referred visit is complete.  Though there is still much work to do, what was clear was that in the not so distant future one could imagine LHDs in KS having an efficient and interoperable connection to the state and other community based systems through their HIE.  In order to have this sort of success, it is critical that your LHD get involved, stay involved, or increase involvement locally with your HIE options.  Be aware of what services your HIEs provide, how these services can benefit your LHDs vision for the future, and see if you can negotiate special rates for LHDs.

If LHDs earnestly and systematically pursue these five steps, I believe they will have a thriving and successful transition into becoming an efficient LHD of the ePublic Health future.  At NACCHO, we’re working with our ePublic Health workgroup to develop more detailed tools that will support LHDs who go through each of these steps – so stay tuned.  I want to give a special thanks to the Kansas Health Foundation, Kansas Association of Local Health Departments, and Kansas Department of Health and Environment for allowing me into their rapidly developing world of ePublic Health.

HIE and LHDs – Getting Started

A couple of years ago, I was presented with the opportunity to serve on the local Wichita Health Information Exchange Board and the Kansas Electronic Health Advisory Council at the state level.   Those opportunities coupled with a grant from the Kansas Health Foundation to review how the state immunization registry would work with the health information exchange (HIE), thrust me into the unknown world of health information technology (HIT) and HIE.

My observation during this period of learning is that connecting to the HIE is not on the radar of many local health departments. Leadership is needed at state, local and regional levels and if you’re not sure how to get started, I’d suggest beginning with the questions below.

1) Is connecting to the HIE part of my Health Department’s strategic plan?

All local health departments are responsible for monitoring communicable diseases and protecting the community from health threats.  At the very least, exchanging data with community health partners about clients with reportable diseases is a reason to participate in the system.

2) Is my Health Department at the HIE table?

You can start by checking with your state health department for information about the state HIE board.  Find out which Regional Extension Center serves your jurisdiction.  Check with your State Association of County and City Health Officials for an HIE committee or workgroup. Check with your local and state medical societies to identify where leadership is coming from.  Ask if you can participate on some level, perhaps through a committee or representing local health departments on a board.

3) Has my Health Department figured out what is needed from the HIE and how to get it?

In Kansas, an HIE Committee has been formed through the Kansas Association of Local Health Departments.  The local health department representative on the State HIE Board and I chair this committee.  We have focused on education and awareness of new developments in the state until recently.  At our last meeting we decided to engage a consultant who could assist us with the process of answering the following questions:

What do you need information for?

  • Assessment
  • Surveillance
  • Analysis and investigation
  • Case management
  • Care coordination

 What are short, intermediate and long-term needs?

 How often and when is the information desired?

 Individual client vs. aggregate level de-identified?  Geo-coded?

 What kind of information might be available from the HIE?

  • Patient
  • Laboratory
  • Pharmacy

 What is the best way to have access to this information? Choices include through:

  • Electronic Medical Record (EMR)
  • Clinic management system
  • Linked clinic management system and EMR
  • Partially linked clinic management system and EMR with toggle
  • Direct through HIE
  • Intermediary like the state health department

What plans does the state health department have for maintaining or beginning a registry linkage to the HIE? 

I urge you to get involved and utilize NACCHO’s resources to guide you through the  health IT maze.  Once the HIE is fully functional, LHDs will have a new opportunity to demonstrate value to the public health system. Now is the time to take a seat at the table.

Be well,

Claudia Blackburn MPH, RNC, CPM
Health Director, Sedgwick County (KS)

(view Claudia’s bio here)