Vital Connections

HIEs Improve Patient Care 

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Practice Management Feature – October 2012  

 Tex Med. 2012;108(10):43-48. 

By Crystal Conde 
Associate Editor 

In 2006, North Texas Specialty Physicians, a group of Fort Worth doctors, developed a tool to help them manage the increasing complexities of patient care. Their brain child, a privately funded health information exchange (HIE) known as Sandlot Connect, blossomed over the years and now counts among its users more than 2,400 physicians and staff members, along with two national laboratories and 15 Texas hospitals.

Thomas Deas, MD, a gastroenterologist and Sandlot's chief medical officer, says the HIE allows physicians to coordinate care, manage costs, and assess quality of care. He witnessed how an HIE improves the quality, safety, and efficiency of patient care.

"If you talk to almost any physician, you'll hear about how inefficient and tedious the process is for obtaining patient information from another office, hospital, emergency department, or clinic. The HIE makes it possible for me to securely access patient information from many different participating facilities in a matter of seconds," he said.

Dr. Deas is one of many Texas physicians who realize the value of HIEs.

Developing HIE infrastructure in Texas has rapidly gained traction due to $28 million in federal Health Information Technology for Economic and Clinical Health (HITECH) funding. The Office of the National Coordinator for Health Information Technology (ONC) allocated $548 million of HITECH funds for all 50 states. Texas uses its share of the federal money to establish HIEs in local communities.

As of June, the Texas Health and Human Services Commission (HHSC) had awarded about $9.5 million to fund the initial planning, development, and implementation of local HIEs in Texas.

Texas Health Services Authority (THSA) Chief Executive Officer Tony Gilman says HIEs used the funding in 2011 to support the development of business and operational plans and outreach with physicians and other key stakeholders. The grant program requires HIEs to obtain commitments from hospitals and physicians willing to guarantee their support and participation in the local networks. Physicians who wish to participate in an HIE sign a statement of interest. Almost 23,000 Texas physicians have signed a statement of interest to participate in a local HIE. This year, HIEs are using funding to support overall operations, including personnel, HIE technology selection and deployment, development of marketing materials, and planning for future operations. THSA, under contract with HHSC, oversees the development and implementation of HIEs in Texas.

Joseph Schneider, MD, chair of the TMA Ad Hoc Committee on Health Information Technology, says it's important that physicians get involved in their local HIEs.

"Physicians should be investigating how to connect and use the information that is available," Dr. Schneider said.

 HIE Benefits 

Dr. Schneider is chief medical information officer for the Baylor Health Care System, which has an internal HIE that recently connected with another HIE.

"The benefits we experience are knowledge of what tests have already been done for patients so that we don't repeat them, knowing what medications they are taking, and knowing where the patient has been previously," Dr. Schneider said.

For Dr. Deas, Sandlot not only allows him to coordinate care among other physicians, but also helps prevent errors that could jeopardize patient safety.

"I've had patients give me incomplete medication lists," he said.

The HIE gives Dr. Deas quick access to prescription records to accurately reconcile medications, thus lowering the risk of prescribing a medication that could cause an adverse reaction.

Another advantage of participating in an HIE, Dr. Deas says, is reduced cost. A 2009 survey by eHealth Initiative polled 40 operational HIEs that reported cost savings in: 

  • Reduced staff time handling lab and radiology results,
  • Reduced staff time for clerical administration and filing,
  • Less money spent on redundant tests,
  • Decreased cost of care for chronically ill patients, and
  • Reduced medication errors. 

The survey also highlights efficiencies that practices using HIEs experience, including improved access to test results and fewer hassles associated with looking for information.

As part of a strategy to develop the HIE infrastructure in the state, HHSC established a local grant program with THSA.

North Texas Accountable Healthcare Partnership formed in 2009 as a coalition of major physicians, employers, insurers, and hospitals in the Dallas-Fort Worth area. Joe Lastinger, its chief executive officer, says the HIE's mission is to promote and reward coordinated care at the local level.

"Our board recognized that sharing information via an open HIE was a critical first step in achieving our mission," he said.

The HIE's service area includes 13 counties in North Texas with participants from 137 hospitals, as well as roughly 11,000 physicians and records for nearly 7 million patients.

Mr. Lastinger adds that the partnership spends a lot of time working with physicians in the community to address interface, workflow, and privacy and consent policies. (See "10 Questions to Ask HIE.")

"While we don't have to spend a lot of time persuading physicians of HIE value, we do have to demonstrate to them that we're going about it in the right way," Mr. Lastinger said.

 HIE Sustainability 

TMA policy is that "any costs of supporting systems providing health information technology incentives to physicians should be borne by all stakeholders, clearly defined, fair, simple to understand, accountable, and should support the financial viability of the considered practice."

THSA and HIEs funded through the local grant program have to develop plans to stay in business in the long term next year, according to Mr. Gilman, and many of those plans highlight fees for HIE services to ensure economic viability.

"In their business and operational plans, four of the 12 HIEs indicated they intend to charge either a fixed or a tiered fee to physicians, while seven of the 12 HIEs indicated they intend to charge either a fixed or a tiered fee to hospitals to support sustainability. HIEs also say they plan to charge health plans," he said.

North Texas Specialty Physicians' members don't pay to participate in Sandlot. Hospitals and labs do pay to connect to the HIE.

"Money is brought into the group through capitation arrangements and is being used to sustain the HIE. Physicians don't individually write checks, but there is a cost to the group to keep the HIE running," Dr. Deas said. "Physicians who aren't members of North Texas Specialty Physicians do pay a monthly fee to use the HIE. The fee varies depending on what services the physician wants."

Dr. Deas explains money invested in the HIE improves efficiency and quality of care, generating a return on investment and retained earnings from risk management contracts.

"We have a solid business model that fosters tremendous value for our users, and the HIE is profitable. We're able to return some of those profits back to the HIE," Dr. Deas said.

North Texas Accountable Healthcare Partnership is developing plans to stay in business in the long term that will depend on charging fees to users. Once approved, the partnership will publish the pricing model on its website,

"We're going to charge only what we have to and not a penny more. The partnership has been tasked with working as efficiently as possible," Mr. Lastinger said.

One common theme across all the HIE plans to remain viable is aligning HIE value with the cost so the primary contributors also are the primary beneficiaries, Mr. Gilman says. He adds HHSC and THSA monitor local HIEs' sustainability efforts and plan to initiate communication regarding sustainability later this year.

Eventually, local exchanges will connect across the state and expand connectivity to other states and the nation.

Local HIEs will communicate with THSA using local master indices of patient and physician information from HIEs. THSA will then securely exchange the information with the Nationwide Health Information Network (NHIN), a public-private venture that will connect HIEs, physicians, pharmacies, government agencies, laboratories, health care payment plans, and other stakeholders into a national network.

THSA released a request for proposal in June to support development of state shared technical services. Mr. Gilman says the procurement process started during the summer. THSA plans to select one or more vendors in the fall. The state shared services will support connectivity among Texas local HIEs and to NHIN next year.

 HIE Connectivity 

Mr. Gilman says Texas HIEs are at a critical juncture of moving from planning to implementation.

Sixteen community-based HIEs received federal funding in 2011 through the local HIE grant program. Only 12 continued into the implementation phase this year, and they plan to connect about 86 percent of all active physicians in Texas. (See "THSA-funded HIEs.")

"The operational status of each HIE differs, but almost all of them have selected an HIE technology partner that allows them to move forward with implementation of data exchange services," Mr. Gilman said.

Additional information on the HIEs funded by HHSC is available online.

A majority of publicly funded HIEs now offer Direct Secure Messaging services that support exchange of information, including clinical summaries and lab results.

Mr. Gilman explains Direct Secure Messaging is promoted in Texas' white space, a term referring to the areas of the state without local and regional HIE activity. A list of counties that make up the Texas white space region is available online.

He says Direct Secure Messaging requires physicians simply to have Internet access; they don't have to purchase new hardware or sign a long-term contract. The email messages and attachments are encrypted for security and privacy, as well. Mr. Gilman explains Direct Secure Messaging uses a "push-based" method of exchange that functions much like email with additional layers of security.

"Through 'push-based' HIE, physicians can securely and actively send clinical information to others, enabling delivery of lab results or delivery of a clinical summary upon referral to a specialist or a hospital," he said.

THSA chose qualified health information service providers (HISPs) in January to support white space HIE connectivity through Direct Secure Messaging. Physicians are eligible for a $400 voucher paid to the HISP they select to offset their initial connectivity costs, Mr. Gilman says. 

"Although THSA has issued eight voucher numbers, no voucher payments have been made at this time. THSA's qualified HISPs, physicians, hospitals, and others report various factors that may be hindering adoption, including lack of familiarity with HIE, HISPs, and the voucher program; lack of knowledge of federal meaningful use requirements; not wanting to be a first adopter; and not understanding the value of adopting Direct-based secure messaging services," he said.

THSA worked on marketing and outreach efforts in conjunction with TMA, the Texas Hospital Association, the regional extension centers, the Texas Organization of Rural & Community Hospitals, and county medical societies to get physicians in the white space connected. In coordination with TMA, THSA also conducted conference calls with medical societies in the white space area and is working on a direct mail campaign to further promote the program.

Mr. Gilman encourages physicians in Texas' white space to take advantage of the Direct Secure Messaging voucher program because once the $400 in voucher funds run out, they have to pay for the services. Physicians practicing in the white space can request a voucher number online.

Pricing for HISPs is available online. Click on the White Space tab to access the HISPs' profile sheets with pricing.

Jump Into HIE 

Mr. Gilman says Texas has made tremendous progress in implementing HIEs.

"Through the local HIE grant program and the white space program covering rural Texas, all physicians and hospitals in Texas have an HIE option. Privacy and security guidance, including a state-level trust agreement and model business associate agreement for use by local HIEs, has been developed in collaboration with TMA and other key stakeholders," Mr. Gilman said.

These documents help shape the legal framework for private, secure exchange of health information in Texas. Additional information on HIE privacy and security and interoperability guidance can be accessed online.

As much progress as Texas has made in developing HIEs, challenges to full connectivity still exist, says Dr. Deas.

"Getting physicians to change the way they've always done things is a constant uphill battle," he said. "Some of us have this ingrained resistance to change."

Dr. Deas encourages his colleagues to take the HIE plunge if they haven't done so already. "Once physicians get past that point of initial resistance and try it out, they recognize the value of HIEs. The exchanges reduce redundancy of care, improve patients' health, and lower costs," he said.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email. 


10 Questions to Ask HIEs 

Before committing to a local health information exchange (HIE), physicians need to ask questions. Physician health information technology experts recommend physicians consider the following: 

  1. What information will the HIE share? Some share only laboratory data, while others allow access to discharge summaries, notes, test results, and more.
  2. How can physicians determine the source, date, and time of the data? Physicians will need to reconcile contradictory information they may encounter, such as a "penicillin allergy" for a patient pulled from one electronic health record but "no known allergies" pulled from another.
  3. What are the HIE's privacy and security mechanisms? Physicians should find out how the HIE will obtain patient consent for using the data. If a patient chooses to exclude some data from being shared, the physician should make sure the HIE discloses that fact.
  4. Does the HIE include the patient populations, referral networks, and the hospitals and other physicians the doctor works with? Make certain the HIEs connect to the local hospitals, labs, radiology services, and other facilities.
  5. Will the HIE be financially viable in the future? It's not simple to move from one HIE to another. Physicians should ensure the HIE has a thorough business plan with strategies for long-term success and should ask their colleagues about the exchange's track record and functionality.
  6. Is there a fee to participate? Many HIEs are free initially, but physicians should ask about potential future fees.
  7. Who is on the HIE's board of directors?
  8. What are the computer system requirements to connect to the HIE?
  9. Does the HIE use a centralized or decentralized model? A centralized model obtains a patient's permission to have their records and information stored in a database. Physicians can query the database for patient information and share it with others. A decentralized model permits access only by authorized personnel and entities.
  10. Are there opportunities to provide feedback on HIE operations?  

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THSA-Funded HIEs  





FirstNet Exchange 



(800) 328-1638 

Greater Houston Healthconnect 


(832) 564-2599 

Healthcare Access San Antonio 

San Antonio 


(210) 233-7079 

Integrated Care Collaboration 


(512) 804-2090, ext. 30213 

Health Information Partnership of Southeast Texas (formerly Montgomery County HIE) 


No website 

(936) 537-9240 

North Texas Accountable Healthcare Partnership 


(817) 274-6300 

Paso del Norte Health Information Exchange 

El Paso 

(915) 544-7636 

Rio Grande Valley HIE 


(956) 622-5801 

Rio One Health Network  


(956) 362-3087 

Southeast Texas Health System 


No website 

(361) 645-1762 

iHealth Trust 


(713) 622-4300 

Health Information Network of South Texas 

Corpus Christi 

(504) 838-1550 

 Additional information on the HIEs funded by HHSC is available online.

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