Texas HIEs Close In on Connecting
Practice Management Feature — February 2014
Tex Med. 2010;110(2):39-44.
By Crystal Zuzek
Texas' health information exchanges (HIEs) are closer to being able to connect to one another locally and across state lines. Shkelzen Hoxhaj, MD, a Houston emergency physician, can't wait for the day Texas achieves full interoperability, allowing physicians and patients to benefit from information technology systems' ability to communicate and exchange vital patient data.
"HIEs make it possible for physicians to see everything that's going on with a patient's health — medications they're taking, allergies they have, scans they've received — while reducing cost and improving quality. The exchanges will greatly benefit physicians and their patients, especially once they're interoperable," he said.
While local HIEs are in various stages of development, the future of HIEs in Texas looks bright. Texas Health Services Authority (THSA) is administering HIETexas, a network of shared services that facilitates interoperability. THSA, under contract with the Texas Health and Human Services Commission (HHSC), oversees the development and implementation of HIEs in Texas. THSA Chief Executive Officer Tony Gilman expects four Texas HIEs to connect to HIETexas in the first half of the year. He says HIETexas planned in December to connect to the National eHealth Exchange, which provides local HIEs with a link to federal agencies' health information networks and HIEs in other states.
THSA contracts with Massachusetts-based InterSystems Corporation to help the organization develop HIETexas' shared services.
This year, THSA plans to introduce these four state-level shared services through HIETexas:
- Patient consent management allows HIEs requesting patient information from other HIEs to quickly and easily determine whether the appropriate patient consent has been granted.
- Clinical document exchange provides a secure network health professionals can use to retrieve specific patient data stored outside their HIE.
- The gateway to the National eHealth Exchange is a secured network of HIEs and other health care organizations from other states and federal agencies that allows document exchange to and from these entities.
- The federated trust framework helps ensure information exchanged among HIEs is secure and confidential.
HIETexas plans to eventually offer local HIEs access to state data sources, such as the state's online prescription drug monitoring program known as Prescription Access in Texas, Texas Medicaid, and public health data repositories maintained by the Texas Department of State Health Services (DSHS).
"By more efficiently managing these essential services at the state level, the state's network of regional HIEs can continue to be guided locally while avoiding costs and incompatibilities resulting from the development of separate strategies to cover core services they all need," Mr. Gilman said.
Dr. Hoxhaj is chief medical adviser for Greater Houston Healthconnect, an HIE serving 20 counties that planned to connect to HIETexas last month. He is a liaison between the medical and health information technology industries.
"I provide a physician's perspective of how we expect the exchange to function. I advocate an exchange that facilitates enhanced patient care and works seamlessly in the medical environment. The last thing physicians need is another technological hassle," said Dr. Hoxhaj, director of the Harris Health Ben Taub General Hospital Emergency Center.
For the most part, electronic patient information has resided in separate silos of hospital and physician practice electronic health record (EHR) systems. Dr. Hoxhaj says that HIETexas makes it possible to accomplish the ultimate goal of EHRs sharing data with one another, allowing multiple physicians at the local, state, and national levels to access patient information.
He describes Greater Houston Healthconnect as "user friendly" and says the HIE continues to ramp up operations and recruit participants. The HIE had 23 hospitals and about 4,000 physician users at press time.
"The HIE's community health record shows me the clinics, hospitals, and physicians the patient has seen, as well as testing and labs that have been done. The HIE will become an even more useful tool as more hospitals, labs, clinics, and practices participate," he said.
Funding Winds Down
Developing HIE infrastructure in Texas has rapidly gained traction due to $28 million in federal Health Information Technology for Economic and Clinical Health (HITECH) Act funding. The Office of the National Coordinator for Health Information Technology (ONC) allocated $548 million of HITECH funds among all 50 states. Texas has used its share of the federal money to establish HIEs in local communities.
As of November, HHSC had awarded about $18.8 million in grants to fund the initial planning, development, and implementation of local HIEs in Texas. Mr. Gilman says HIEs used the funding in 2013 to support operations, including hiring personnel, deploying technology, connecting participants to local exchanges, developing marketing materials, and preparing to link to HIETexas. For a map of HIE service areas, click here.
HHSC awarded Greater Houston Healthconnect a $5.6 million grant. James Langabeer, PhD, chief executive officer of Greater Houston Healthconnect, says the exchange received its first grant payment from HHSC in 2011 and its final grant payment late last year. He says the HIE also receives money from private sources.
"We've used about half of the grant money so far to hire employees, purchase and implement technology, and create policies and procedures for patient consent," he said.
Grant funding is winding down and will end for all HIEs next month, Mr. Gilman says. Texas has 11 publicly funded HIEs. (See "HHSC-Funded HIEs.")
"THSA anticipates this figure may change as federal funding winds down in March 2014. Although some HIEs may dissolve or cease to operate in 2014, we do not anticipate any gaps in HIE geographic coverage," Mr. Gilman said.
David Fleeger, MD, recognizes that the cessation of funding could be a big barrier for some HIEs.
"Texas' HIEs are in various stages of maturity," said Dr. Fleeger, an Austin colorectal surgeon who's a member of the Texas Medical Association Board of Trustees and THSA Board of Directors.
The HIE he uses, for instance, provides a community record for several hundred thousand patients in Central Texas, but he's unable to access patient information through his EHR.
"The information must be accessed through a different system, and this can be a bit cumbersome at times," he said, adding that these types of problems need to be addressed.
While most HIEs in Texas are up and running and providing some services to physicians and hospitals, Dr. Fleeger says some aren't yet fully functional.
"HIEs have made great strides in the past three years. Unfortunately, federal funding is drying up, and financial sustainability will be a major hurdle for many of the HIEs. It would not surprise me if we see some consolidation among the HIEs of Texas," he said.
Focusing on Sustainability
Once grant funding runs out, HIEs will need to be economically viable to survive. Mr. Gilman says July reports from the HIEs to THSA and HHSC show HIEs are evaluating and fine-tuning their sustainability plans.
"Most HIEs determined their sustainability partners in the last year, and all HIEs have reported progress toward developing a viable business model. HIEs are reaching out to a variety of partners including health professionals, physicians, businesses, pharmacies, nursing homes, federally qualified health centers, county health departments, and labs," Mr. Gilman said.
Many HIEs' sustainability plans include fees for HIE services as a means of staying in business, he says.
"The costs vary by HIE and differ based on the HIE model being developed and services offered," Mr. Gilman said, adding that while HIEs consider physicians significant sustainability partners, they're not charging them or are setting low fees to encourage participation.
TMA policy says "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."
Dr. Langabeer says sustainability is a top priority for Greater Houston Healthconnect, and the HIE plans to require participants to pay an annual fee for services. He says physicians will pay $500 per physician per year.
"We set a five-year plan back in 2012. By year five, we want to have 60 percent of all hospitals connected, and we want 50 percent of the 14,000 physicians in the area to use the system on a daily basis. If we can achieve that level of connectivity, we estimate we'll eliminate 1,350 adverse drug events and 2,400 preventable hospital readmissions every year," Dr. Langabeer said.
Greater Houston Healthconnect will ultimately make medication histories available through the community health record and will develop a patient portal this year.
"The patient portal will be tremendously valuable to patients. They'll be able to access their medical records on any computer, even when they're traveling," Dr. Hoxhaj said.
Dr. Fleeger says HIEs are "well on their way" to providing physicians with accurate and timely patient information so a correct diagnosis and treatment plan can occur efficiently while ensuring patient privacy. He encourages physicians to get involved in their local HIE.
"Although our HIEs have a way to go before they provide seamless health information on every patient in Texas, you'll be surprised at how far they have come and how much information they can provide you," he said.
Participating in an HIE also assists physicians in meeting Stage 2 meaningful use measures that require hospitals and physicians to exchange information with outside organizations using different EHR systems.
For more information, access the Stage 2 Eligible Professional Meaningful Use Core and Menu Measures Table of Contents online.
Additionally, TMA's EHR Implementation Guide, EHR Product Comparison Tool (TMA member login required), Medicare and Medicaid EHR Incentive Comparison, EHR Incentive Program Eligibility Tool, and Medicare and Medicaid incentive program instructions are available on the TMA website.
Addressing Challenges, Concerns
Ensuring access to an HIE for physicians living in Texas' white space, the areas of Texas without local and regional HIE activity, is a priority for THSA. In the past, qualified health information service providers (HISPs) supported white space HIE connectivity through Direct Secure Messaging, a method of exchange that functions much like email with additional layers of security. Direct 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.
Physicians were eligible for a $400 voucher paid to the HISP they select to offset their initial connectivity costs, but the voucher program supporting Direct messaging within the white space region ended last year.
"While we are pleased with the voucher program's success, there is clearly more work to do to ensure connectivity in rural Texas," Mr. Gilman said.
HHSC, in partnership with THSA, has contracted with the West Texas HIT Regional Extension Center to plan for the implementation and development of HIE options in the Texas white space. Last year, the West Texas HIT Regional Extension Center held stakeholder meetings in Wichita Falls, Abilene, and San Angelo to discuss HIE needs in the region and preferences for creating and maintaining connectivity. At press time, the West Texas HIT Regional Extension Center planned to appoint members of the West Texas HIE Advisory Committee to identify options for supporting the technical infrastructure needed to enable HIE in the Texas white space.
More information about the Texas white space strategy and the counties that make up the region is available online.
THSA and HHSC are also working to address Texas physicians' concerns regarding HIE privacy, security, and accountability. THSA is developing an HIE accreditation program and a privacy and security certification program. Mr. Gilman explains that currently, local HIEs must meet certain operations standards under their contracts with HHSC. But when the local grant program ends in March, those standards will no longer be applicable or enforced.
"We at THSA believe in providing a method to improve HIE standards and trust within the field without stifling innovation in this new, growing, and exciting area," he said.
THSA is partnering with the Electronic Healthcare Network Accreditation Commission to establish the Texas HIE accreditation program, which will encompass criteria relating to privacy and security, business practices, and technology.
"Physicians who participate in an accredited HIE will know that the HIE has met best practices with respect to privacy and security as well as other key areas in order to provide them and their patients a level of trust with the HIE," Mr. Gilman said.
THSA is collaborating with the Health Information Trust Alliance to implement the Texas Covered Entity Privacy and Security Certification Program early this year. Mr. Gilman says the goal of certification is to strengthen the protection of Texas residents' health information.
"Texas is the first state to develop a formal approach to certification that incorporates state and federal privacy and security regulations. HIEs and other organizations participating in the program will be able to show they have met state and federal privacy and security standards to manage risk and increase confidence in how they protect health information," he said.
You can access additional information about Texas HIE privacy and security online.
Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.