HIEs are major hurdle for Medicaid and HIT

A "master planning" approach is needed to effectively leverage all of the incentives and resources for building statewide Health Information Exchange (HIE) capacity, says Lynn Dierker, RN, project director for the Chicago-based AHIMA Foundation's state-level HIE Consensus Project.

"One of the most significant challenges is developing a real and effective working public-private collaboration involving state government," says Ms. Dierker. "There are cultural and operational challenges on both sides of this." This is true both for the state Medicaid agency as well as whatever multi-stakeholder organizational entity is leading governance and statewide HIE planning, says Ms. Dierker.

Working relationships need to be structured, expectations established, and day-to-day project management approaches agreed upon. "There is a new role in the mix, that of the state HIT coordinator, whose job is to foster collaboration across state agencies," says Ms. Dierker. "Historically, this has been a daunting challenge in many states."

To get in a better position to move forward with HIEs, Ms. Dierker says that state Medicaid agencies should be doing these things:

— Identify key personnel internally to be part of the collaborative efforts. These individuals should have, or be able to develop, a working knowledge to contribute to the agency's internal planning. "Strategically, it is important that agencies pursue internal working knowledge about statewide HIE development," says Ms. Dierker. "Given economic constraints, this may take some resourcefulness and creativity."

— Provide strategic leadership. This can be done by helping to identify use cases for HIE development that are part of deploying "meaningful use" payments, says Ms. Dierker.

— Work closely with the statewide HIE entity. This includes developing priorities for implementing HIE services to support "meaningful use" statewide.

"Many Medicaid agencies feel uncertain about federal-level expectations and are concerned about complying with federal guidelines," says Ms. Dierker. "Leadership is important now. Monitor developments, ask questions, clarify information, and compare notes."

This involves active communication and outreach, both to state HIE leaders across the country, to the Office of the National Coordinator, and to the federal Medicaid agency. The State HIE Leadership Forum is a valuable resource for state HIE leaders, adds Ms. Dierker, including Medicaid agencies.

HIEs in early stages

"Health information exchanges are still emerging," says Harry B. Rhodes, MBA, RHIA, CHPS, CPHIMS, FAHIMA, director of practice leadership for the Chicago-based American Health Information Management Association. "Of the 150 HIE organizations identified in the 2009 e-Health Initiative survey, only 57 claim to be operational."

In addition, information exchanged may be limited to only certain types, such as laboratory, radiology reports, medication list, or claims. "This information is often only available in view-only mode," adds Mr. Rhodes. "Lack of discrete data elements and interoperability prevents information from being transferred directly from one EHR to another."

To get into a better position to move forward with HIEs, Rhodes says that state Medicaid directors should determine these factors:

— the critical elements of a workable HIE business plan;

— the key components of a business sustainability model, including how the HIE will be funded;

— the clinical value of participating in a HIE. "The ability to successfully collaborate with HIE stakeholders is an important critical success factor. It is just as important as HIE finance," says Mr. Rhodes.

Change is biggest challenge

Beth A. Nagel, health information technology manager for the Michigan Department of Community Health, says the biggest challenge with HIEs "is the fact that it fundamentally changes the way that many clinicians do their daily business."

"The technology is not the challenge," says Ms. Nagel. "The technology for HIE exists today and has been tried in many other industries. The biggest challenge will be getting clinicians to change their workflow to accommodate new processes while treating their patients."

Ms. Nagel adds that nationally, a big obstacle is funding sustainability. There is national debate on who should pay to plan, implement, and sustain the technology and organizational structures that are needed to support HIE.

"Many believe that the stakeholders who benefit from HIE should pay for it," says Ms. Nagel. "But it is very difficult to determine who it is that benefits. There are many benefits that reach many different stakeholders, including citizens."

Ultimately, providing the right information to health care providers at the moment of treatment is expected to reduce costs and improve quality. If a provider can see all of the diagnostic tests that have been previously run on a patient, then he or she may not choose to order the same tests.

"This will reduce the amount of redundant testing, which saves costs," says Ms. Nagel. "It will also allow the clinician to plan a course of testing and treatment for a patient in fewer visits, improving quality and health outcomes."

Contact Ms. Dierker at 312-233-1599 or lynn.dierker@ahimafoundation.org, Ms. Nagel at (517) 241-2064 or nagelb@michigan.gov, and Mr. Rhodes at (312) 233-1119 or harry.rhodes@ahima.org.