Tag 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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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)