Lessons Learned: Implementing a Low-Cost Structure Health Information Exchange

Slide Presentation from the AHRQ 2008 Annual Conference

On September 8, 2008, Frank Richards made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (3 MB).

Slide 1

Lessons Learned: Implementing a Low-Cost Structure Health Information Exchange

Agency for Healthcare Research & Quality
September 8, 2008

Frank Richards
Chief Information Officer
Geisinger Health System

KeyHIE (Keystone Health Information Exchange™)

Slide 2

The colored photograph shows the Geisinger Medical Center complex in Danville, PA—which is the main campus of the Geisinger Health System.

Slide 3

About the Geisinger Health System

Founded in 1915, the Geisinger Health System is an integrated delivery system including hospitals, clinics and an insurance company serving Northeast and North Central Pennsylvania.

• 4 Inpatient Facilities.
• Service area—2.6 million residents.
• Serves 43 of PA's 67 counties.
• 700 employed physicians & 270 Residents.
• 41 community practice sites; ~200 primary care physicians.
• Approximately 2 million outpatient visits per year.
• Rural and aging population.
• Tertiary/quaternary care medical centers and specialty hospitals.
• Insurance Operations—Covers 220,000 lives.

Slide 4

Geisinger Health System (GHS)

Screen shot of a drawn map of Pennsylvania and its counties. The counties in the Geisinger system's service area are highlighted blue. The service area is mainly in the northeastern and central portion of Pennsylvania. A large pink, blue, green, and yellow star designate a major clinical hub. Individual hospitals and medical centers are labeled on the map.

Below the map is the following legend titled: Geisinger Hospitals "Hubs"—Provide Primary/Secondary/Tertiary Care. The different colored stars and other symbols on the map are described as:

• Pink star: Centre.
• Blue star: Geisinger Medical Center.
• Green star: Geisinger Wyoming Valley.
• Yellow star: Geisinger South Wilkes Barre.
• A large pink, blue, and green circle encompass the counties serviced by each hub.
• The GHS Service Area is outlined in black on the map.
• Smaller Geisinger clinic sites are designated with small red stars.

Slide 5

Geisinger's Electronic Health Record (EHR)

• Major investments over 10 years in electronic health records.
• Implemented a full ambulatory EHR system-wide by 2002.
• Began providing access to referring providers and patients in 2000.
• Currently have over 250 non-Geisinger practices on-line.
• Over 100,000 patients on-line.

Slide 6

What is KeyHIE?

• Keystone Health Information Exchange—a group of provider organizations that believed broader access to clinical information could improve care.
• Started with a survey of 53 hospitals in northeast and central Pennsylvania.
• Initial meeting of 20 interested organizations.
• Ongoing group of 7 healthcare organizations, including a medium sized physician group.
• Subgroup of 3 organizations that initially implemented technology for the Exchange.

Slide 7

KeyHIE Milestones

• 2004 AHRQ Planning Grant.
• 2005 Regional Survey/Symposium.
• 2005 AHRQ Implementation Grant.
• 2005 Memorandum of Understanding (MOU) to establish Central Penn Health Information Collaborative (CPHIC).
• 2007 PA Dept of Health Grants.
• 2007 Renamed to KeyHIE be more inclusive.

Slide 8

KeyHIE Proposed Service Area

Screen shot of a small map of Pennsylvania which projects another larger map of the specific counties within the Keystone Health Information Exchange's proposed service area.

Information highlighted includes:

• 31 counties.
• 53 hospitals.
• 9,000 physicians.
• 2.6 million residents.

Slide 9

Participants for the AHRQ Grant

The slide shows three logos: Shamokin Area Community Hospital; Bloomsburg Hospital (A member of the Bloomsburg Health System); and Geisinger Health System. There is an footnote for Bloomsburg Hospital indicated that it replaced Sunbury Community Hospital in 2005.

Slide 10

Participants for the AHRQ Grant (continued)

Shamokin Area Community Hospital (small clipart image of a hospital):

• 70 Beds.
• 27 Active Staff Physicians
• 342 Employees (4 full-time-equivalent physicians [FTEs] in information technology [IT], incl mgr.).

Geisinger Health System (small clipart image of a hospital):

• 917 Beds (4 Inpatient Facilities).
• 700 Employed Physicians (plus non-Geisinger physicians).
• 14,000 Employees (520 FTEs in IT).

Bloomsburg Hospital (small clipart image of a hospital):

• 72 Beds.
• 64 Active Staff Physicians
• 317 Employees (7 FTEs in IT, incl mg.r).

Slide 11

Goals

• Improve quality of care and patient safety (regardless of which partner's services the patient may be accessing).
• Provide basic clinical information services.
• Improve communication among patients, practices, and hospitals.
• Provide access to an expanding set of HIT services—including a high-performance EHR—which would not otherwise be available.
• Improve local practice and hospital viability.
• Meet project time frame and budget constraints.

Slide 12

Approach

• Initially researched products to permit storage of information in a common format. Discarded due to cost.
• Developed an approach to leverage existing technologies:
  • Existing Patient Index.
  • Existing Clinical Information Systems at each organization.
• Developed a portal to access the information residing in the disparate systems.
• Start in the emergency departments (EDs) as a proof of concept to show value of information sharing where lack of information can be most acute.

Slide 13

Challenges

• Ability to identify patients reliably across multiple information systems.
• Financial incentives do not encourage information sharing.
• Concerns about information ownership.
• How do we pay for this? Access to capital limited for rural healthcare providers.

Slide 14

Challenges (continued)

• Coordinated planning may be difficult due to lack of regular, face-to-face contact among rural hospitals and providers.
• Small and financially vulnerable rural providers may tend to feel threatened by provider organizations large enough to have the resources necessary to be helpful.
• Rural providers may have fewer organization-change skills than other providers.
• Concerns about the privacy and confidentiality of patients' information.

Slide 15

Screen shot of a high-level diagram of the KeyHIE information exchange showing Registration Flows, Master Patient Index, and Chart Locator Service on the left and User Portal with Authentication Activity Log and Data Retrieval on the right. The diagram depicts an information architecture where patient encounter lists are built via registration interfaces from the participating organizations, and information is retrieved via a portal that supports single sign-on to each organization's system.

Slide 16

Year 1 Objectives & Deliverables

Slide 17

Year 1 Findings

• Community hospital resource constraints:
  • Limited resources, especially IT staff.
  • Local vs. Shared Priorities.
• Hospital management turnover can affect project commitments. (e.g., Sunbury Community Hospital).
• Larger organization needs to take more of the lead.

Slide 18

Year 2 Objectives & Deliverables

Slide 19

Year 2 Findings

• Additional funding available from PA Dept of Health:
  • Provide regional Logical Observation Identifier Names and Codes (LOINC) education.
  • Deploy single sign-on for Exchange.
• First lab site interface operational—requires an ongoing support model.
• Funding needed for non-IT services (e.g., legal services to develop Bloomsburg Hospital access agreement).
• Collecting patient authorizations for participation was a rate limiting factor to access of information and adoption.
• Combined phase 2 portal with phase 3—still limited use.
• National Environmental Policy Act (NEPA)-Regional Health Information Organizations (RHIO) disbanded.

Slide 20

Year 3 Objectives & Deliverables

Slide 21

Year 3 Findings

• Increased usage is occurring, although the need to navigate multiple systems is still a barrier.
• The document store is expected to address many of the issues of needing to access multiple systems.
• Real-time events such as transfers or consults may be the first compelling business case for data exchange.
• There is still some skepticism about test results external to one's own organization.
• Everything costs more, takes more effort than first planned.

Slide 22

Screen shot of the KeyHIE system showing how patient information is displayed for the various sites. A fictitious patient record is displayed.

Slide 23

Screen shot of the KeyHIE system showing how patient information is displayed for the various sites and a sub-screen entitled "Encounters" displays the encounters the patient has had at each organization.

Slide 24

Lessons Learned

• Small hospitals have a difficult time providing even minimal time to efforts outside their immediate domain.
• The need to share information for care and respect patients' privacy is an ongoing challenge.
• Use of any system must be integral to the care process.
• Leadership and commitment are key to accomplishing anything.

Slide 25

Discussion

Note: This project was supported by grant number UC1HS016162 from the Agency for Healthcare Research and Quality, and in part, under a contract with the Pennsylvania Department of Health. Basic data for use in this study were supplied by the Pennsylvania Department of Health, Harrisburg, Pennsylvania. The department specifically disclaims responsibility for any analysis, interpretations or conclusions. Edward G. Rendell, Governor.