HIEs and the Gateway to Better Care
By Kara Nuzback Texas Medicine April 2015

Committee Advises State to Simplify Meaningful Use Reporting

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Practice Management Feature — April 2015

Tex Med. 2015;111(4):51-55.

By Kara Nuzback

Health information exchanges (HIEs) are becoming a more widely used method for physicians to share valuable patient information. They also can help solve a big headache for physician practices. HIEs can facilitate fulfillment of the meaningful use requirements for physicians to submit certain information to the Texas Health and Human Services Commission (HHSC), including data on cancer and immunizations.

Dallas pediatrician Joseph Schneider, MD, is chair of the HHSC Electronic HIE System Advisory Committee. Dr. Schneider says he is heartened by the fact that many physicians are using HIEs — an electronic source of up-to-date patient data that are shared by physicians and hospitals in a region — to better serve patients. "Certain HIEs are catching on and doing well; other HIEs are still in the development stage," he said.

He adds HIEs are an important step in health information technology that physicians should support. 

"It will help our patients, and in a value-driven heath care system, HIEs become critically important," he said. If physicians don't support HIEs in Texas, cost of care will continue to go up, decreasing the overall value of care physicians are able to provide, he says.

Internist Dwight Mark Toups, MD, cares for patients at CHRISTUS Physician Group, which connects to the HIE Greater Houston Healthconnect. He says he recently saw a patient for a routine appointment, and she revealed to him she had been in the hospital and received a computed tomography scan for abdominal pain, but she did not mention anything else about the hospital visit.

Dr. Toups said he used the HIE to look up the patient and found that physicians at the hospital found a mass on the patient's kidney. When he asked the patient why she didn't mention the mass, she told him, "I just assumed you knew that."

Dr. Toups says he eventually would have found out about the kidney mass through the hospital discharge summary, but the HIE allowed him to find out more quickly and see that his patient received the appropriate care as soon as possible.

"It made it more timely. It also gave a broader safety net," he said. "It saves you from errors of omission."

Dr. Toups says more and more physicians are prioritizing the use of HIEs, but many still worry about the privacy and security of the information. "It's a matter of learning how to trust systems," he said.

There is value in centralizing patient information, Dr. Toups says. When one institution has an isolated patient record, there's no way to verify the accuracy of the information, he adds.

HIEs allow health care professionals to share every physician encounter in addition to data from pharmacies and claims data. "That puts all the info at hand to be analyzed," he said, which in turn improves the accuracy of information because it allows physicians to validate and verify everything from allergies to insurance.

Robin Mansur, chief marketing officer at Greater Houston HealthConnect, says it's telling that Dr. Toups' patient assumed he knew the details of her hospital visit. "We can see planets on our cellphones," she said. "Patients sometimes expect that information technology in the medical community is more advanced."

Ms. Mansur says many physicians already have put so much effort into converting from paper records to electronic health records (EHRs). "We appreciate how much they have invested and can significantly add more value to their investment," she said. 

Connecting to a local HIE is the next logical step in the process, and it's a step that physicians will benefit from by having community-wide access to critical patient information within their EHR clinical workflow, she says.

"We focus very much on value and the kinds of information physicians and hospitals want to see," she said.

Ms. Mansur says Greater Houston HealthConnect has an agreement with three EHR vendors — Greenway, Aprima, and Athenahealth — that offer discounts or in some cases no fee to connect physicians with the HIE. "We'd like to see more EHRs stepping forward and making a commitment to affordable interoperability," she said.

Expanding the Gateway

Dr. Schneider says though many EHR vendors charge physicians to connect to their local HIE, they also charge to connect to each separate government agency that requires data from physicians fulfilling Stage 2 of the Centers for Medicare & Medicaid Services (CMS) meaningful use program. Currently, physicians have to report different data to separate state agencies, including lab results, newborn screenings, immunization data, and cancer cases. 

But the HHSC Electronic HIE System Advisory Committee is asking: What if physicians could report all that data to one source?

The Texas Department of State Health Services (DSHS) currently has a pilot "gateway" that helps physicians report immunizations to the Texas Immunization Registry (ImmTrac) and influenza cases to the Centers for Disease Control and Prevention.

The HIE Advisory Committee requested a cost estimate to expand that into a larger health service enterprise gateway that would give physicians a single place to exchange data with all state health agencies. In other words, instead of a physician reporting immunization data to ImmTrac, cancer cases to the state cancer registry, and so on, physicians would be able to report all relevant data to the state through one portal.

If the enterprise gateway comes to fruition and connects to local HIEs, physicians can pay a single fee to the EHR vendor for the HIE interface, rather than several fees for each state connection, Dr. Schneider says.

The committee says the enterprise gateway would streamline and secure data sharing, and it has the potential to reduce costs and improve health outcomes. Read the HIE Advisory Committee's January presentation, which includes information on the enterprise gateway. 

Dr. Schneider compares the enterprise gateway to a post office — the user can drop off any information they need to send in one place, where it is then sorted and sent to the relevant state department.

Ideally, he says, physicians would enter the information into an HIE, which would then use the gateway to forward the information to the state.

"Instead of having lots of these different connections to and from my EHR … there would be one pipe I can use to send and one pipe I can use to receive," he said.

A Plan for Growth

Sylvia Kauffman, former director of the Office of e-Health Coordination at HHSC, says about 1,400 Texas health professionals use the state's existing gateway, which, she adds, is bidirectional — not only can users send information to the state, they can also receive information from the state.

She says HHSC, at the HIE Advisory Committee's request, is finalizing a plan and cost estimate to expand the existing DSHS gateway to allow additional data exchange, such as Medicaid claims and clinical data. She says the state already has the funds to support the exchange of electronic lab reporting, newborn screenings, sexually transmitted disease reporting, and clinical summary data exchange between state hospitals and mental health authorities. 

Once HHSC has a cost estimate, Ms. Kauffman says, it will hand it over to the HIE Advisory Committee, which can help others lobby the Texas Legislature for funds to support the project.

"It is a five-year plan," Ms. Kauffman said. "The approach would be to build this in small stages."

In the first year, HHSC would study whether the existing gateway can support a massive expansion. If the state has to chuck the current gateway and start anew, it would use the second year to build a more expansive system from scratch, she says. HHSC also would connect to a master list of health care professionals and organizations as well as a master index of patient records in year two, she adds.

By year three, Ms. Kauffman says, HHSC hopes to set up a helpdesk and make the system operational. HHSC would use subsequent years to make new connections and expand services, she says.

Dr. Schneider says the HIE Advisory Committee recommends connecting the enterprise gateway to HIEs in Texas. Contributing data to the local HIE allows the broader health care community to benefit from additional patient information, he says.

"HIEs serve a very important function, particularly when it comes to things like lab and radiology results," Dr. Schneider said. "We can prevent repetitive testing on patients, and we can speed their care if we know the results from another place."

The existing gateway is not yet connected to any HIEs. Dr. Schneider says the committee recognizes that some hospitals and larger health care systems might opt to connect directly to the state instead of connecting through an HIE.

HIE Oversight

Texas currently has 10 HIEs. (See "HIEs in Texas.") 

"We started with a larger number of HIEs than we have now, and we've whittled down to a smaller number," Dr. Schneider said. "It is conceivable that there might be further consolidation, but the important thing is that if there is further consolidation, we're all working together to make sure access is not eliminated and communities and physicians are supported in any upcoming changes that take place."

In other words, he says, consolidation should not disrupt physician access to patient information.

The Texas Legislature created the nonprofit Texas Health Services Authority (THSA) in 2007 to provide governance, infrastructure, policy development, and oversight of HIEs in Texas. In 2013, THSA created HIETexas — a project designed to connect all regional HIEs in the state.

Last year, two of the largest HIEs — Greater Houston HealthConnect and Integrated Care Collaboration of Austin — connected through HIETexas, allowing thousands of doctors and hospitals in the two regions to quickly and securely share patient health data.

According to THSA's 2014 report, Supporting HIE Growth While Building Trust and Confidence in HIE, "Healthcare Access San Antonio has completed testing and is preparing to conduct final live testing with HIETexas. Leveraging shared services through HIETexas reduces costs because it reduces the number of interfaces and legal agreements necessary for exchange."

THSA is undergoing sunset review in the 2015 legislative session. The Texas Sunset Advisory Commission reviews state agencies to determine whether they are effective and should continue to receive state funding. 

The Sunset Advisory Commission voted in December to recommend that THSA operate without government oversight or funding beginning Sept. 1, 2021. Until then, the commission says THSA should add to its board of directors two members representing state health agencies to act as state data sources and one new member to represent HIEs.

The Sunset Advisory Commission also recommended that THSA's SECURETexas certification remain in place beyond THSA's Sept. 1, 2021, sunset date. SECURETexas is the first state program in the country to offer privacy and security certification for compliance with state and federal laws. SECURETexas is managed by THSA and the Health Information Trust Alliance. 

The commission presented its recommendations to state legislators to consider in the 2015 session. 

Another bill before the legislature would limit the liability of physicians who participate in HIEs. According to the bill, unless a health care professional acts with gross negligence, he or she would not be liable for damages for failure to obtain or disclose information from or to an HIE. The bill would also protect physicians who rely on inaccurate patient data obtained through an HIE as well as physicians who submit patient data to an HIE, which is then used by some other entity in a manner that violates state or federal laws.

The same bill would protect HIEs in similar instances. The Texas Medical Association supports the bill; Rep. John Zerwas, MD (R-Richmond), is a sponsor. 

Kara Nuzback can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

All articles in Texas Medicine that mention Texas Medical Association's stance on state legislation are defined as "legislative advertising," according to Texas Govt. Code Ann. §305.027. That law requires disclosure of the name and address of the person who contracts with the printer to publish the legislative advertising in Texas Medicine: Louis J. Goodman, PhD, Executive Vice President, TMA, 401 W. 15th St., Austin, TX 78701.


HIEs in Texas   

  • Southeast Texas Health Services serves the Panhandle as well as four counties in the Southeast.
  • Paso del Norte serves West Texas.
  • Healthcare Access San Antonio serves Southwest Texas.
  • Rio Grande Valley HIE serves most of South Texas.
  • Rio One HIE serves Hidalgo and Starr counties.
  • Health Information Network of South Texas serves the southeastern most part of the state.
  • Greater Houston HealthConnect serves the Gulf coast.
  • Integrated Care Collaboration serves Central Texas.
  • FirstNet Exchange serves Northeast Texas.
  • North Texas Accountable Health Partnership serves a patch of North Texas bordering Oklahoma.
  • North Central Texas is a white space.  

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Last Updated On

May 13, 2016

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