Printer-friendly format

Before a statewide exchange of health information can become a reality, a statewide exchange of ideas must continue.

While countless doctors’ offices struggle with making the increasingly necessary transition from paper-based records and billing systems to electronic systems, another group of stakeholders has been working quietly to set up the framework and infrastructure for the even more daunting step after that: to establish a statewide Health Information Exchange (HIE).

Whereas health information technology (HIT) refers most commonly to internal applications used in a hospital or office, HIE takes all the various HIT systems and the data they contain and links them together. Ideally, a state HIE would create a sustainable, secure and simple way for any doctor in the state to access (with patient permission) the updated electronic medical records and pertinent information of any Arkansan he or she is treating.

That task is incredibly complex.

Dr. William Golden, director of medical policy for Arkansas Medicaid and a professor of Public Health at the University of Arkansas for Medical Sciences (UAMS), has been working on HIE for Arkansas for the past couple of years.

“It sounds like it should be simple, but boy, it’s full of big issues,” Golden said.

He said numerous case studies from other states with high-profile, expensive failures show how many potential pitfalls exist for such an undertaking. For example, he said a $10 million HIE plan in Oregon blew up before it even began, and one of the most promising early exchanges, started in Santa Barbara, Calif. by David Brailer (who would become the national coordinator for HIT) failed after two years for lack of funds.

Golden said, while many attempts at HIE have been made, very few have become viable, long-term enterprises. For that reason, Arkansas is being extremely cautious in developing its own plan. “What we wanted to do was make sure that if we come up with a plan and start spending money it’s a) realistic and b) sustainable,” he said. “We’ve been working to answer the question: How do we do this in a rational way in our state?”

“So far, we’ve just been taking baby steps, looking at and discussing all the issues involved and formulating our recommendations,” said Melinda Wilkins, who has been part of the HIE planning group. Wilkins is director of the Health
Information Management baccalaureate program at Arkansas Tech University (ATU), has 20 years in the field, and is writing her dissertation on health information management.

She said that unlike many other states that have begun with smaller exchanges of information within a network of private hospitals or a region, Arkansas leaders made the decision early to involve every region and industry stakeholder from the beginning.

“One thing I really feel good about, we’ve gotten everybody together. Government, public, private, insurance companies, pharmaceutical people, medical associations, everybody sitting down together working it out,” she said.

Golden agreed, saying that while it may take longer initially, in the end everybody will be on board and speaking the same HIT language. Difficulty with translation across platforms, systems, procedures and policies may be minimized by giving leaders from every sector a voice and role in the process.

Work on the HIE started when Arkansas was one of four states chosen in 2006 for an HIT grant funded by the Robert Wood Johnson Foundation and the Center for Health Care Strategies and managed by the Arkansas Foundation for Medical Care (AFMC). Part of the Regional Quality Improvement grant’s scope was developing a sustainable business plan for an Arkansas HIE.

Golden said AFMC recruited stakeholders to participate in one of five workgroups, each studying a set of major HIE issues: technology, finances, data priorities, legality and governance. The workgroups studied the issues over a period of months and in 2007 made a detailed report, shared at the October 2007 Arkansas eHealth Conference in Little Rock. The 98-page Arkansas HIE Roadmap Report is now available online through AFMC’s Web site at http://www.afmc.org/Documents/quality_improve/rqi/2008RQIRoadmapReport_sm.pdf.

About 200 people, including the Governor, came to the eHealth Conference. Golden said the next step is distilling the workgroups’ findings in the report to concrete recommendations for the Arkansas HIE.

“It’s taken a little longer than what we thought it would because I think there’s been more information that everyone needs to know,” said Brian Witt of AFMC, who helped organize the group’s efforts over the duration of the grant. “There needs to be a lot of education on the different stakeholders.”

“All over the country, the big issue has been financing the framework to sustain the accuracy and interactivity of all these different data places, to pull all the data together. That’s been the big trick,” he explained. “It’s like everybody’s trying to link up everybody else’s hard drive and laptop and have it all make sense. That’s very hard.”

Wilkins agreed that finding funding to not only start the exchange but to maintain it is, as with the general move towards HIT by the healthcare community, the primary barrier.

“When you look at Arkansas, we have so many rural areas and so many small physician offices. They just don’t have the money to buy a bunch of equipment and train or hire people to manage it,” she said. “Once we can figure out funding, we can really make progress. Nationwide, there are beginning to be more grants and funding routes available. But just to be able to tie that funding all together, link up our doctors with the equipment, personnel, education and resources to make it happen, that’s the key.”

Coincidentally, the first step that the HIE planning group wanted to make, the e-pharmacy services, is also the directive of the Centers for Medicare and Medicaid Services. With 90 percent federal funding, the Arkansas Medicaid program should begin e-prescribing this fall, Golden said.

“Doctors and hospitals will be able to transmit electronically prescriptions to pharmacies but at the same time, all paid claims through insurance mechanisms or Medicaid will be data warehoused so people can get a profile of what has been paid for by a third-party administrator,” he said. “That will cover about 60-70 percent of patients in the state.”

Meanwhile, Arkansas physicians’ offices and hospitals are making progress toward becoming more wired.

Golden said, “We’ve been fortunate in Arkansas to have had a federal pilot grant, probably thanks to Blanche Lincoln’s office, where we had over 200 primary care offices getting free consultations through AFMC about how to do electronic medical record selection and process redesign. We’ve been talking extensively throughout the state to doctors about this, and Medicaid has supported continued activities for pediatricians and obstetricians. There are resources here.”

He recommended that healthcare facilities planning the transition to HIT, work with their medical societies, hospitals, and Medicaid to make sure everything works together. “I would not recommend doing this on your own. He said there are a large number of electronic medical records that are certified by the national system, so they will be ready for the ongoing national standards. “I would avoid do-it-yourself systems. You want to go with big vendors that have the capital to keep up with the national standards.”

Wilkins said there are two basic camps of physicians: those who feel passionately that health information technologies are the future and are being proactive about it and those that feel that HIT is too overwhelming and can’t fathom making such a big change.

“A lot of our work is to make it less overwhelming for doctors,” she said. “I would hate to see the physicians feeling threatened by (the prospect of HIT and HIE). Rather, I think it’s important doctors realize we’ve got a partnership to make this a reality, and in the end we want it to benefit everybody and not be a burden.”

Arkansas has several reasons to feel proud, Golden said. Having everybody at the table, having ongoing intelligent discourse and research about which technology and model would be best and about governance structures, and implementing e-prescribing without a lot of state money are all wise steps that failed HIEs in other states did not take.

“We’ve come a long way over the past two years, and the next big jump is still kind of out there,” Golden said. “The trick is to get more people engaged, particularly at the bedside. The best part is that people have agreed to continue the discussion to make this happen.”

Input from the medical community is welcome, Golden said, recommending that anyone with ideas channel them to the HIE team through their hospital or professional association. “As a community, we want to build a system that works for the health professionals and patients of the state. We are making slow, steady progress and we have the potential to make our first steps without risking a lot of money,” he concluded. “That’s not a bad place to be. We haven’t over-promised.”



July 2008

Tags:

None

Login and voice your opinion!

Do you know someone else who would like to see this?
Your Email:
Their Email:
Comment:	(Will be included with e-mail)
Secret Code	In the box below, enter the Secret Code exactly as it appears above *