September 17, 2007

Hoosier Daddy
By Kathryn Foxhall
For The Record
Vol. 19 No. 19 P. 26

Buoyed by an uncompromising spirit of cooperation, Indiana has become a national leader in medical information exchange.

Because states are payers, regulators, and representatives of their populations, the concept that they are natural coordinators of health information exchange is garnering a good deal of attention.

Although perhaps only a dozen or so have active health information exchanges (HIEs), the Office of the National Coordinator for Health Information Technology (ONCHIT) is promoting states as a focal point of the push for interoperability. As a result, state governments themselves have more actively explored the potential in the last year.

Amid all the discussion, Indiana may be mentioned more often than any other state as a model for how to develop a successful HIE.

Like many places, the Hoosier state probably has less than 20% of its physicians using an electronic medical record. But the Indiana Health Information Exchange (IHIE) has implemented, among other services, a clinical messaging system that serves roughly one third of the state’s population by delivering 35,000 electronic documents per day to physicians’ computers from 25 hospitals and other facilities. The system, known as DOCS4DOCS, delivers lab and radiology reports, electrocardiogram results, transcriptions, and images, among other information, to roughly one half of the state’s doctors—a total of approximately 5,000. For most physicians, the system has become integral to their practice, according to J. Marc Overhage, MD, PhD, IHIE’s president and CEO.

Most messaging is being conducted within the Indianapolis area. However, other areas are in the process of setting up the IHIE system to get doctors connected. “We really started in central Indiana and have been building outward from there,” Overhage says. And even more information is on the way. “We're starting to build as many sources of information flowing into the system as possible,” says Thomas Penno, IHIE’s chief operating officer.

Clinical Messaging
Beyond the factors of a solid medical informatics infrastructure and community support, clinical messaging became a reality in Indiana basically because five hospital CEOs said to doctors, "If you want to get results from our hospital, you have to get hooked up to the IHIE system," says Penno, who spoke to a recent subgroup meeting of the State Alliance for e-Health. Without that hospital directive, he believes, IHIE probably would have encountered more resistance from physicians.

But the doctors aren’t rebelling now that they know they can look for most of their results in one place, and their office personnel are free to provide billable services rather than answering phone calls and helping find misplaced or undelivered documents.

Kenny Stall, MD, an obstetrician and state medical association representative to IHIE, says he cannot think of one physician who does not like the messaging. Indeed, he says, doctors are asking when IHIE can take the system to the next level, with more and more sophisticated communication.

It’s the Revenue, Stupid
One big reason the Indiana operation is celebrated nationally is its emphasis on sustainability. In fact, DOCS4DOCS is now paying for itself. Typically, hospitals and labs pay IHIE less than 23 cents to deliver a document immediately as compared with the estimated 80 cents to $1.50 it previously cost to send it via fax, mail, or courier. According to Penno, hospitals have stopped printing thousands of pages of paper. He says one hospital dropped the courier service that had cost $200,000 annually.

IHIE has been the beneficiary of a lot of “sunk costs” in prior work during the previous 30 years, including medical informatics research and a processor physicians network, says Penno. Nevertheless, he asserts, “I become even more convinced every day that clinical messaging is that component that a community can get started doing and then start to build from there.”

Valuable Incremental Steps
Overhage also emphasizes how important it was for IHIE to begin modestly, a strategy that centered around its decision to implement clinical messaging. He believes, like many other people, that HIT done right can transform healthcare. But, he cautions, “You have to take small, incremental steps that are clearly defined with clear value propositions. Things that are achievable, that build creditability, that build trust, and, importantly, that allow you to finance the whole thing without breaking the bank.”

Some communities, Overhage says, have tried to go too fast, getting money from various sources, and then had those funds cut off when they couldn’t perform everything they had hoped.

On to Electronic Health Records (EHRs)
Currently, most physicians using IHIE receive results via computer but still convert them to paper to place in patient records. However, a milestone was reached this summer when the exchange began to push electronic messages directly into EHRs. This achievement was not as easy as flipping a switch, says Penno, but after IHIE created what he calls a simple standard, he was surprised and delighted to discover that close to one dozen EHR vendors stepped up and made the connection work.

Penno believes the IHIE has now achieved such a critical mass in Indiana that vendors feel they should be working with the organization.

Public Health Functions
Beyond clinical messaging, IHIE has promised to become more involved with public health systems, according to Roland Gamache, PhD, MBA, director of the state health department’s health data center. Lab data on conditions that are legally supposed to be reported to the public health department are sent from hospitals in central Indiana and all the national laboratories in the state, he explains. In addition—in a feat that impressed public health professionals elsewhere—72 hospitals relay information on emergency department (ED) patients’ chief complaints directly to the health department.

Something of a public health landmark happened recently, says Gamache, when incoming ED data alerted state officials to two different disease outbreaks even before any doctor had contacted the agency.

“We have to be able to not only receive information from [hospitals] but to also process that information and provide feedback,” says Gamache. Currently, he says, the system is working with the visualization department at Purdue University to allow officials to make speedier decisions concerning public health issues.

Surging Into Quality
In a promising development, IHIE is beginning to use information from physicians’ offices and payers’ claims in an effort to improve quality of care.

Overhage says area physicians have agreed on measures that should improve community health. Captured information on those measures will be used to generate quality reports to all physicians, starting with primary care doctors, as well as payers. For example, the IHIE could analyze data from diagnosis or A1C tests to determine that a physician’s practice has approximately 100 diabetics. The report, sent via DOCS4DOCS, could further break down the data to inform the physician that only 50 of those patients have had a recent A1C test.

“It’s just a really neat thing to see this whole package come together,” says Overhage, particularly in light of estimates that a minority of physicians can generate their own list of diabetic patients. According to Penno, payers are prepared to reward primary care doctors who improve the quality of care to diabetes patients by roughly $15,000 to $20,000 per year.

Grants support this “Quality Health First” operation, but IHIE hopes it will be self-sustaining within 18 to 24 months of its start-up, a goal it sets for all its services.

Why Indiana?
There are a number of reasons the Hoosier state has become a national model, say leaders there.

One huge advantage is the presence of the Regenstrief Institute, a prominent, 38-year-old informatics and healthcare research body affiliated with the Indiana University School of Medicine.

Not only did Regenstrief offer longtime experience in medical records applications, including the development of Health Level Seven, but its presence gives five local hospitals something to agree on. In the end, it only made sense for the community to use the DOCS4DOCS clinical messaging system that Regenstrief had developed and continues to develop, says Penno.

Overhage, who serves as Regenstrief’s director of medical informatics, says that, ironically enough, Indiana’s medium size helps. There is one medical school in the state and not many nearby large medical communities: “There was less bickering and competition than in some markets.”

That one medical community also made for some helpful connections, he says. For example, one physician would call another who he had trained under or been in a fraternity with 20 years before.

But there was also enlightenment about health connectivity in the other segments of the community, Overhage says. For example, he says the leaders of the Indianapolis company Eli Lilly understand HIT’s value, talk about it, and use it. The company’s employee health clinic has had an EHR for years.

Overhage cites the contributions of Indianapolis Mayor Bart Peterson, who is on the IHIE board and regularly attends meetings, as another factor. “There are not many mayors who can talk about potential savings from physician order entry for both ambulatory and hospital patients,” Overhage says.

He also says there is a “coherence” on HIT from local foundations, the state heath department, an economic development initiative called BioCrossroads, and universities. “We are not all one big happy family by any means,” he says, but there is a level of understanding that helps them move forward.

Can Other Communities Do It?
Stall agrees community spirit helped move Indiana ahead and mentions his amazement at CEOs of competing hospitals sitting on the same board, attending meetings, and agreeing to share data.

But does that mean communities without that atmosphere and lacking the other factors working in Indiana’s favor can’t build a similar model? Says Stall: “Not now that Indiana has shown the way. As with many other impossible innovations, somebody [Indiana] didn’t listen and did it anyway. Now, people elsewhere will say, ‘Well, I guess that it can be done.’”

Indeed, Penno says IHIE is now talking to different parts of Indiana and to communities elsewhere in the nation to see if they share this vision of clinical messaging, emergency room data sharing, and quality programs.

— Kathryn Foxhall is a freelance writer in the Washington, D.C., area. She covers health informatics, public health, health policy, reimbursement, mental health, and other issues.