April 28, 2008

Virtual Neighbors
By Elizabeth S. Roop
For The Record
Vol. 20 No. 9 P. 22

After more than three years of planning, preparation, and training, the Wisconsin Health Information Exchange (WHIE) went live in March with a pilot project that linked three emergency departments (EDs), enabling them to share registration data and two years of state Medicaid records.

Initially, data will be shared between EDs in Milwaukee’s Aurora Health Care Sinai Medical Center, Wheaton Franciscan Healthcare-St. Francis, and Columbia St. Mary’s, Inc. The pilot project was designed to start small with information that was readily available from all three participating facilities, says WHIE cofounder Edward N. Barthell, MD, an emergency physician.

In addition to the comprehensive Medicaid data, including medication histories and past diagnoses and procedures, clinicians at the participating facilities will be able to access initial registration information created when a patient presents at any of the EDs, including the date of encounter and chief complaint. Those initial records will be supplemented with data collected through any additional care encounters, such as follow-up care sought at clinics affiliated with the three hospitals.

“We wanted the hospitals to start with a very simple approach, so we are just interfacing with one system—the registration system—to show that we can do it, that we can manage the security, the matching of records across multiple institutions, and that we can get it in front of clinicians at the point of care,” Barthell says. “Once we’ve proven that, we anticipate that we’ll turn on other data sources that are available electronically.”

Drawing on Past Experience
The WHIE was founded in 2004 by Barthell; Seth Foldy, MD, Milwaukee’s former health commissioner; and Lawrence Hanrahan, PhD, chief epidemiologist at Wisconsin’s Division of Public Health, with $5 million in grants from the eHealth Initiative’s Connecting Communities for Better Health, the Wisconsin Department of Health and Family Services, and the Centers for Medicare & Medicaid Services.

Microsoft is also donating Azyxxi, which marks the software platform’s first application in this type of health information exchange, as well as technical services. The participating hospitals are providing additional financial support in the form of membership fees.

The idea of linking EDs was something the founders focused on from the beginning, having seen firsthand the impact it can have on the speed and quality of diagnoses and treatment plans. “It was apparent in my own day-to-day practice how the lack of data sharing was impairing my ability to optimize care for my patients,” says Barthell, who has collaborated on other information sharing and messaging projects between public health departments and clinicians. “We had some successes there, and it opened our eyes to the potential of sharing patient data.”

But the founders and WHIE leadership did not draw only from past successes when determining the direction the regional health information organization (RHIO) would take. They also evaluated the challenges faced by past initiatives, including a community health information network that failed, in part, because community providers were hesitant to participate in an initiative owned by a competing practice.

“The business model we had did not effectively address the social capital elements. … It was hard for [providers] to be customers with a model owned by one of their competitors,” says WHIE executive director Kim R. Pemble.

This time, the WHIE used its seed money to establish a consensus group, governance model, and bylaws that could help alleviate competitive issues and other potential obstacles. It also created a clear mission and vision for how the RHIO would benefit the whole community through improved care.

A not-for-profit organization, the WHIE is governed by a broad-based board of advisors representing all the major health systems, as well as payers, employers, and patient advocates.

“Getting to where we are today was driven by a business plan created by our initial start-up efforts. Its focus was, in the governance model and initial grant, to create something that can add value back to the community,” says Pemble.

“On a broader scale, it is also about building relationships in the business community,” adds Barthell. “This idea is relatively easy to explain to people and has a certain inherent logic. The devil is in the details, so it is a matter of building relationships with people and getting them engaged enough in the idea so they will contribute to how the details work out.”

Meeting Immediate Needs
The WHIE’s focus on addressing immediate challenges faced by local EDs and physicians was an important factor in the decision by Wheaton Franciscan to participate in the initiative, according to Cory Wilson, MD, FACEP, medical director of the facility’s ED and president of Emergency Medicine Specialists, S.C., which contracts with Wheaton to provide coverage in the ED.

“We felt it was important for us in providing emergency care in this area to have as much information about patients when they walk through our doors as possible. One of the things that has been quite elusive is getting medical information from other health systems at the point of care in the emergency department,” he says. “If they’ve been to one of the other systems, we have to go the fax route, and we have to have consent for that. We have to find someone in medical records at 3 am, and that’s been spotty over the years. It’s been a lot of work for not a lot of gain, and it’s not timely. So this is a way to share important information immediately when patients are hitting our door that will affect which way we go in creating treatment plans and treating them.”

In fact, linking EDs had been a topic of informal discussions among Milwaukee’s emergency physician community for awhile. The fact that the WHIE was focusing on a problem that would directly address their needs helped generate interest and buy-in from the physician community—something many deem as critical to the long-term success of any RHIO.

Hospital CEOs made up another key stakeholder group that identified EDs as an area where efficiencies and practices could be improved with better access to patient information, says Wilson. “They feel that helping us get the information we need at the time of the patient visit will help our processes. That is an area where we totally agree with our administrators. That’s a win-win,” he says. “That makes us a unique project because we’re talking about sharing information between systems—online, up-to-the-minute, updated systems. And not just us but also the state Medicaid population.”

Another factor behind the widespread support for the RHIO was the WHIE’s decision to bring the community health clinics—which provide the majority of care for the region’s Medicaid, uninsured, and underinsured population—to the table at the start. The idea was to find ways that the initiative may help reduce the number of patients seeking nonemergent care through EDs. Too often, these patients were bypassing the community clinics and turning up at the ED because they did not know where or how to access care through the health clinics or because an appointment was not available.

“They are interested in fixing that break in the system and [since] their patients are already in the database because they are on Medicaid, it was a very logical source of information to try and tap into,” says Wilson. “We can now track a patient’s behavior through the Medicaid system. It will even help us know where they should be going for follow-up, even if they don’t.”

Wilson and other emergency physicians went through several months of training and user acceptance sessions on the WHIE ED linking system in preparation for go-live.

While it’s too soon to tell just how much of an impact the data exchange will have on patient care or how well it will be accepted by all ED physicians, Wilson is optimistic that he, for one, will be using it regularly. “It won’t be something that I’ll just tap into once a week or every other week. It will be impacting patient care on a daily basis. I wouldn’t say hourly, but if I work an eight-hour shift, I would expect this to affect my decision making on a dozen patients,” he says. “As we get further in and can extract from a larger database, I would expect that, eventually, nearly all my patient encounters will be affected by utilizing this in the majority of my encounters.”

Proof First, Then Expansion
Initially, the WHIE has the potential to link information collected from more than 1 million ED visits per year based on the population of Milwaukee County. That figure will rise considerably as the initiative expands to encompass the 2 million residents of the RHIO’s full nine-county service region.

On average, one of every three people will visit an ED each year, and each individual will have an average of three encounters with the healthcare system. “If we ultimately capture all the visits in the area, it will be between 6 to 7 million per year, but that’s down the road,” says Barthell.

Also down the road are plans to expand the type of data that are exchanged, so laboratory and prescription histories, as well as data for public health agencies to use in identifying trends, outbreaks, diseases, etc, are included.

However, the WHIE must first establish that the concept has merit, which is key to securing financial support from certain groups, such as payers. To accomplish that, the WHIE is working with the University of Wisconsin on a formal evaluation process that rolled out with the three-hospital pilot system to quantify the data sharing’s economic benefits.

“We want to have those results to drive the business plan,” says Barthell. “That is essentially how we will sell it to the payers who we want to pay for this eventually. We’ve engaged the payers to monitor the progress and to look at how we’re evaluating [the results] so that they’ve bought into the process from the beginning. We’re not asking them to cut a check until we’ve proven it.”

Pemble adds that monitoring and quantifying results will play a key role in maintaining the engagement of the community and the WHIE’s business partners, which in turn will help ensure the initiative’s long-term success. “Failure to do that is a guarantee for failure in the initiative. You need to be able to show value in each of the steps you take,” he says.

The WHIE must also prove that it can ensure patient privacy and security, a task Pemble expects will be aided by recent legislative changes that bring Wisconsin’s privacy statutes more closely in line with HIPAA regulations.

Beyond that, “Winning the lottery wouldn’t hurt. But seriously, strong business partners both within the community and on the technology side are critical,” says Pemble. “This is really about quality of care, patient safety, and improving the efficiency of care delivery. … [We] have been pounding the drum on patient safety for quite some time, and this is one way to start moving forward on that.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.