September 26, 2011

State HIEs Face Assessment Deadline to Maintain Federal Monies
By Laura Kolkman, RN, MS, FHIMSS
For The Record
Vol. 23 No. 17 P. 36

A critical deadline is looming for states and state-designated entities awarded monies under the State Health Information Exchange (HIE) Cooperative Agreement Program: Progress Assessments and updated Strategic and Operational Plans.

For many, the assessment process will pose challenges. For some, unclear objectives established at the outset will complicate the evaluation. For others, the problems lie in a lack of expertise or resources. However, the rewards for overcoming these obstacles and completing a successful evaluation go far beyond compliance with federal requirements.

State HIE Program in a Nutshell
In 2009 and 2010, the Office of the National Coordinator for Health Information Technology (ONC) made 56 State HIE Cooperative Agreement Program awards totaling $548 million. Authorized under the HITECH Act, the program is designed to help states develop and advance the exchange of health information to improve the quality and efficiency of healthcare.

The goal of the four-year program is to advance regional and state-level HIE, in part by ensuring that eligible providers have at least one option for information exchange that meets the requirements of the Medicare and Medicaid EHR meaningful use incentive programs.

The ONC identified five HIE domains within which states are to develop capabilities: governance, finance, technical infrastructure, business and technical operations, and legal/policy. They must also establish multistakeholder support for statewide HIE, as well as determine and oversee the role of the private sector in providing efficient, scalable HIE services in compliance with standards for interoperability, privacy, and security.

To ensure its objectives are being met, the ONC built into the program requirements for two levels of evaluation. One is a national-level evaluation conducted by the ONC. The other is a state-level performance management evaluation to assess each state’s progress within the five domains. Because each state’s approach to HIE varies, the ONC did not mandate a set methodology for the evaluation. Instead, it allows each to establish its performance metrics and design its own performance evaluation.

While the lack of a standard methodology for assessing HIE progress allows a state to tailor its evaluation based on its unique approach to HIE, the lack of specific guidance can lead to assessments that fail to provide a clear picture of strengths and weaknesses—and therefore do not identify gaps in capabilities which must be addressed.

Identifying the Challenges
Creating and following the appropriate evaluation methodology from the beginning is critical to ensuring a sustainable HIE. The HIE must be evaluated in terms of the value it provides in enabling improvements in the quality and efficiency of care, population health, and delivering cost reductions.

The first step toward developing an effective assessment is to identify the desired state. To effectively assess progress, goals must be known. Therefore, goals should have been included in each state’s HIE Strategic and Operational Plans.

States need to understand specifically what progress has been made against these goals. If the initial goals were “fuzzy” or not easily measurable, it will make this assessment more difficult than if clear and measurable goals were established. For those whose goals were not crisp, improving the specificity should be one of the first results of an assessment.

The ONC emphasizes the involvement of stakeholders in state HIE plans. It is important for states to assess the level of stakeholder engagement and participation in their efforts, as these are key to sustainability.

Finally, it is important to address any knowledge gaps or resource limitations that exist. Assessments must be based upon a deep understanding of the HIE environment from various perspectives, including the federal, state, and local regulations and initiatives, as well as an understanding of the current state of the industry.

Designing an Assessment
Each assessment outcome will be unique—based on a state’s HIE approach. As mentioned earlier, the objectives created in the initial operations plan will provide the basis for the evaluation.

However, there are several elements that all assessments should include. These arerepresented in the HIE Maturity Framework and defined in The Health Information Exchange Formation Guide: The Authoritative Guide for Planning and Forming an HIE in Your State, Region, or Community, published by HIMSS.

At this time, most participants in the state HIE program are in the formation or operational stage. Understanding where a state is in its HIE journey provides an indication of which milestones—identified in the framework and explained in the book—should be achieved, what metrics indicate they are complete, and how to best prepare for the next steps.

For example, in the case of HIEs in the formation stage, metrics can be used that focus on their progress in developing a formal entity, securing funding, developing policies, and determining their technical approach. For those in the operational stage, metrics should focus on specific capabilities such as offering services for e-prescribing or sharing clinical results. Governance should be formalized and there should be ongoing activity to ensure stakeholder participation.

These capabilities can be easily measured. An assessment of these measures will evaluate an HIE’s progress toward the services required by the ONC (eg, e-prescribing, laboratory ordering and results delivery, clinical summary exchange, eligibility and claims transactions, public health reporting, quality reporting). This is a start.

However, these required services are not sufficient for sustainability. An assessment should also include communications with stakeholders to understand the value they place on current services and to understand services that should be added. The services may range from expanded clinical or administrative data services, workflow enhancements, and/or additional quality reporting capabilities. Stakeholder communication must be an ongoing dialogue.

Finally, the best assessments will evaluate an HIE’s flexibility and scalability. This includes its readiness to meet new requirements—such as the upcoming meaningful use stages 2 and 3. The most successful HIEs will be those that are forward looking, consistently engaging in a dialogue with their stakeholders, and agile enough to rapidly respond to regulatory and market changes.

No Room for Error
This first state-level HIE assessment will do more than comply with the federal mandate. If done well, it will set the stage for state HIE that is aligned with its stakeholders, developing capabilities that will make it sustainable and, most importantly, provide the capabilities to help improve the quality of care for those who are depending on it.

For these reasons, states may find that the best approach to completing their assessment is to bring in outside experts. Consultants are a good choice for performing assessments because they bring expertise and experience, objectivity, and proven tools and methods.

The best-fit consultants possess specific expertise in the planning, formation, and operation of HIEs. They should have a solid understanding of and experience in the HIE environment at the national, state, and local levels. Good HIE consultants are well versed in best practices and emerging trends.

Whether a state brings in outside expertise or opts to manage the process internally, the key to a successful, productive assessment is to identify those metrics that will best indicate progress and/or identify areas for improvement. A solid assessment with well-executed follow-up will ensure that a state is on the right path toward a sustainable HIE that delivers value to its stakeholders, the state, and the patients depending on it for better healthcare.

— Laura Kolkman, RN, MS, FHIMSS, is founder and president of Mosaica Partners, an HIE consulting firm, and coauthor of The Health Information Exchange Formation Guide: The Authoritative Guide for Planning and Forming an HIE in Your State, Region, or Community.