Pennsylvania changes HIE strategy with ARRA funds

By Patty Enrado
12:38 PM

The Pennsylvania Governor's Office of Health Care Reform released a request for proposal in early April for an IT vendor to build its statewide health information exchange (HIE) and expects to make a selection in the fall.
In the meantime, the office will ask legislators to create a quality-type entity to manage the HIE and patient-centered medical home (PCMH) activities, said Philip Magistro, deputy director of program implementation.

"We're going to focus on meaningful use, such as clinical messaging to share results and clinical summaries among providers," Magistro said.

Another activity being considered is creating continuity of care document exchanges among several existing organizations that have basic exchange capabilities. The commonwealth hopes to tap into the activities of large integrated healthcare systems such as the University of Pittsburgh Medical Center and Geisinger Health System, which operates a regional HIE. Pennsylvania will also try to leverage the work being done by community hospitals that have HIE-like connectivity with community providers, including Doylestown, Pinnacle, Washington and Heritage Valley hospitals, which are sending results to their providers.

Nearly three years ago the commonwealth was attempting to include financial assistance for electronic medical record and e-prescribing adoption as part of its healthcare reform package, but had no funds, said Magistro.

HIE activities did have funding.

The office conducted outreach and worked with stakeholders and HIE experts at the state, regional and local levels to put together a requirements-based document.
The original strategy was to connect existing regional health information organizations (RHIOs). In regions where there were no RHIOs or HIEs, Magistro's office was planning to act as a consultant, creating a team that would help develop a governance structure and local efforts with implementation. Approximately seven to 10 regions were slated to be connected by a statewide utility.

ARRA changed everything

When the American Recovery and Reinvestment Act (ARRA) was passed in February 2009, everything changed. Pennsylvania will receive approximately $17.1 million for its statewide HIE efforts. ARRA's tight deadlines, however, made the commonwealth switch its plans.

 "It forced us to look at picking the low-hanging fruit by connecting what's out there today and then offering a safety net for providers or hospitals that aren't part of a large health system or academic health system to have some level of support," Magistro said. "We wanted to be that safety net so they could connect and share information without having the benefit of a regional effort to help them."
The changes increased the scope and cost of what had to be accomplished in order to be successful.

In the statewide utility, Pennsylvania was looking to develop an enterprise master patient index (EMPI), record locator service and provider directory, among other things.

"The only difference now is that in addition to these cross-referencing indices, we have to look at how to hook up community hospitals," he said.

Earlier on, Pennsylvania was looking at continuity of care document (CCD) exchanges between entities or leveraging repositories or edge servers that entities already had in place. "Now we're looking at perhaps having to go to a number of community hospitals and offering edge-server capabilities, which drives up costs and extends implementation time," he said.

Pennsylvania is hoping the $17.1 million from ARRA will build the infrastructure. At the same time, the commonwealth is engaged in discussions with payers to discuss validating ROI and getting a commitment for voluntary contributions. There are some 17 to 20 significant insurers that have market presence in Pennsylvania. It is also working on finding revenue streams for sustainability and ongoing implementation and maintenance from a combination of hospitals and providers, and perhaps even consumers, he said.

Finding revenue for sustainability

Finding revenue streams for sustainability is in its early stages. However, Pennsylvania's Chronic Care Initiative has a tie-in with HIE efforts and offers a potential model, Magistro said. Sixteen payers committed to $30 million of supplemental payments to providers over a three-year period to fund the initiative. Although the office didn't have ROI to show, the PCMH concept is viewed favorably, he said.

Learning collaboratives are operating in seven regions, with four funded by payers. Begun in May 2008, the learning collaboratives are the largest PCMH pilot in the country, with 800 primary care physicians and 1.1 million patients participating, Magistro said.

Getting the information electronically from hospitals or doctors to other providers offers some level of benefits, but making that information actionable offers exponentially more value, he said.

Last year, the reporting body Pennsylvania Health Care Cost Containment Council estimated that $2.5 billion of hospital charges for readmissions were attributable to 20 reportable conditions.

Four chronic diseases accounted for $4 billion of potentially avoidable hospital charges.

"There is a lot of money sitting out there in the chronically ill and readmission sides," Magistro said. "We know from the work done at Geisinger Health System and the University of Pennsylvania that if a PCP gets a care manager in front of a patient within 48 hours of discharge, you can have a significant reduction in readmission rates, maybe 40 percent or more."

The transformation of how care is delivered can positively impact those numbers and costs, he said. The savings could potentially be split three ways: Fund health IT activities; provide incentives to hospitals and other providers to continue working with health IT; and give money back to the payers, which ultimately would come back to the patients, he said. Bottom line: "The savings could be phenomenal," Magistro said. And HIE could be the mechanism to achieve the transformation.