The Sixth Annual Survey, sponsored by the eHealth Initiative (eHI), shows nearly 200 health information exchange (HIE) initiatives active today in the United States.  Most cover a multicounty area, yet federal ARRA dollars are being distributed through state-designated entities whose constituency is defined as the entire state. How are these newly empowered state HIEs dealing with their smaller regional counterparts that, in some cases, have been at this business far longer?

Deb Bass, interim executive director of the Nebraska HIE www.nehii.org, explained her position this way: “If we can connect to an already functioning local HIE, then that is our preferred option. The federal government is channeling their funding through us to make sure that fully functional and affordable connectivity is available to all providers. And we, in turn, are working closely with state government, which provides administrative oversight and assessment of our operations. With that in mind, we have implemented technology that enables us to achieve our connectivity goals either by connecting with local initiatives or by connecting directly with providers.” 

According to the results of the eHI survey, 20 states have only one HIE and 10 have more than five. New York leads with 14 HIE initiatives. That means most states are wrestling with this issue and, like many issues in health care, this overlap in responsibility can lead to political disputes and arguments about who is best suited to meet the needs of local providers.

The geopolitical dynamics are fascinating. The truism that “health care is local” means that most of us receive our health care within a few miles of our home and work locations. Our families’ physicians, clinics, labs, hospitals and other services are typically located within the same local area. So, for most of our activities, a local HIE would give us the necessary electronic record connectivity. In some cases, when we receive our care from an integrated delivery system such as Kaiser Permanente, Henry Ford Health System, Geisinger Health System or The Cleveland Clinic, our electronic health records never even need to leave the enterprise. It is only when we move, go away to college, have to travel long distances for work or need to leave town to obtain specialized medical care that a larger regional, state and national network becomes useful. 

On another dimension, economies of scale and access to federal funding give the advantage to larger, state-level networks. With widespread broadband and Internet connectivity, a state-level entity may be able to assemble a team of technical specialists and negotiate statewide contracts to provide more services and functionality at a lower cost than those that could be provided by smaller, local initiatives. States with multibillion-dollar health care entities like those just mentioned would be hard pressed to provide greater economies of scale than what are already provided by those entities.However, more rural states, like Nebraska, have the opportunity to provide services and functionality at a better price that would be difficult for a local health care entity to beat. 

Another factor to be considered is local control. As with the greater health care reform discussion, there is great reluctance among Americans to cede control of the health care system to state or federal government. This desire for local control also applies to the larger health care systems that have their own HIE solutions. And it applies to the regional initiatives that have fought long, difficult battles to bring together sometimes competing providers into one interconnected network.  These successful and potentially successful HIEs insist on retaining control and not handing it over to a state-designated entity.

An anonymous IT manager at a major California medical center asked me, “Why would we allow an outside entity to get in the middle of our physician connectivity solution?  Helping physicians with technology adoption and information exchange is a critical component of the relationship we have with our medical staff. Done correctly, you become a trusted advisor and partner with physicians.” She added, “Physician bonding has always been critical to hospitals, but with the advent of bundled payments and care coordination, physician connectivity is now absolutely essential to our hospital’s survival. ARRA funding is a short-term tactic to ‘stimulate’ technology adoption toward the end game of improving the cost and quality of care. We have to work together with our medical staff to achieve those results. What happens to the state HIEs and the regional extension centers when the ARRA funding goes away? Hospitals and physicians were here before, and we will be left after to figure out how to continue to provide care. We are working together with our medical staff to make sure we are both here to meet the future needs of our community. Why would we let another entity, even if it is state sanctioned, get in the middle of that relationship?”

How will state HIEs manage to work with their sometimes rebellious local and regional cohorts? The Colorado HIE, www.corhio.org, says its role is to be the “state-level convener/coordinator and solutions provider/broker of HIE services.” That’s a mouthful, but it describes the multiple roles these state-level organizations need to assume in order to get independent initiatives to play nicely with their big brothers at the state and federal levels.

What does all of this mean for POCP clients?

This dynamically changing landscape means that POCP clients will have to hedge their bets.  As we said in our last article on this topic (see the September issue of HIT Perspectives), the winds are blowing strong behind state -designated HIEs. Since they are responsible for channeling federal HIE funds and have strong influence over state laws and regulations, these HIEs must be reckoned with by working with them and not getting in their way.

However, it is also clear that local and regional HIE initiatives will not go quietly into the night. Regional initiatives have fought hard for their very existence and will maintain their turf. Similarly, health systems with their own HIEs consider this connectivity to be critical to their identity and survival. Moreover, they will not give up control. 

In cases like this, when the giants are fighting, the best strategy is to stay well informed of their next moves and to work with them at all levels in an inclusive ― not exclusive ―manner.

POCP is monitoring the plans and actions of state-designated, regional and local HIE initiatives and is leveraging its management and HIT expertise to help both HIEs and the organizations that interact with them.

HIT Included in House Bills

In our last issue of HIT Perspectives, we highlighted some key HIT-related provisions tucked away in the Senate’s health reform bill. Since then, the House of Representatives has been working on two pieces of legislation, both of which contain HIT provisions that could affect POCP clients.

The first is the Affordable Health Care for America Act (H.R. 3962), that passed on November 7, 2009. It weighs in around 2,000 pages and includes numerous HIT-related provisions amid its voluminous health reform provisions, which have been the focus of so much national debate and media attention. These provisions have been relatively under the radar and include:

• Conducting a study examining methods to increase EHR usage

• Integrating meaningful use reporting with PQRI reporting requirements

• Creating accountable care organizations that will incorporate requirements, incentives, and penalties related to EHRs and ePrescribing

• Creation of Independence at Home demonstration practices, which will require electronic health systems

• Establishing a "Center for Comparative Effectiveness Research" and defining its methods and outputs

• Requiring approved medical residencies to incorporate meaningful use of EHR training

• Requiring the Center for Quality Improvement tol align best practices with meaningful use standards

• Establishing a new Assistant Secretary for Health Information within the Department of Health and Human Services (HHS), which will coordinate with the Office of the National Coordinator regarding optimal use of HIT

• Creating grant requirements for community-based collaborative care networks to include meaningful use of HIT

• Requiring that the HIT policy and standards committees work on a unique medical device identifier in certified EHRs

H.R. 3962 also would create grant programs aimed at promoting medication management therapy (MTM) services. The bill provides for: (1) grants to eligible entities to establish community-based, multidisciplinary teams to support primary care practices with the provision of "pharmacist-delivered medication therapy management services (including 'medication reconciliation’), ” as a component and (2) grants to eligible entities for the specific purpose of implementing pharmacist-delivered MTM services in the treatment of chronic diseases.

The second piece of pending legislation of interest to POCP clients is the Small Business Financing and Investment Act of 2009 (H.R. 3854). It includes a section (Title VI) called the "Small Business Health Information Technology Financing Program," which is a part of previous legislation that was folded into the bill. If enacted, this would provide low-interest, deferred loans to small practices and solo providers to support the adoption and installation of electronic health records that are capable of supporting meaningful use requirements.

The section also would create a new Small Business Administration (SBA) loan program that would guarantee up to $10 billion in loans. Individual providers would be eligible for up to a $350,000 loan, and a group of affiliated professionals would be eligible for up to $2 million. Loans would carry a deferral period of one to three years. Each individual loan would be guaranteed by the SBA for up to 90% of the total amount, though no loans could be guaranteed before the meaningful use requirements are finalized in 2010. After meaningful use is finalized, the SBA would only guarantee loans for seven years.

Eligible recipients of the loans would include (as long as their office could be classified as a small business):

• A physician or other qualified practitioner

• A physical or occupational therapist or a qualified speech-language pathologist

• A qualified audiologist

• A qualified medical transcriptionist

• A state-licensed pharmacist

• A state-licensed supplier of durable medical equipment, prosthetics, orthotics or supplies

Needless to say, these are busy times in Washington and 2010 promises more of the same.  POCP continues to monitor legislation and other events in Washington, so we can help our clients understand what is happening and how they can be positioned strategically to capitalize on new programs, funding opportunities and requirements that will be coming down the road.  Call us or shoot us an e-mail. We’re here to make it work for you.

ePrescribing Still in the Federal Regulatory Spotlight

by Tony Schueth, Editor-in-Chief

While much of the focus these days in Washington seems to be on electronic health records (EHRs), ePrescribing is still very much a front-and-center issue at the federal level. As we reported in the August issue of HIT Perspectives, the Centers for Medicare and Medicaid Services (CMS) has expanded the criteria it will use to determine for which eligible professionals the ePrescribing incentive applies and has relaxed reporting requirements for 2010 under the Physician Quality Reporting Initiative (PQRI). Details are in the physician fee schedule final rule, which will appear in the November 25 Federal Register. Once CMS publishes the final rule, it will accept comments on designated provisions (mostly related to payment policies) until December 29. However, we expect no changes to the ePrescribing requirements under PQRI. The rule’s provisions become effective on January 1, 2010. A copy of the final rule is available at http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf.

ePrescribing will be the focal point for other upcoming CMS rulemaking. The agency is expected to issue an interim final rule requiring the use of NCPDP SCRIPT 10.6 for Medicare Part D ePrescribing beginning May 1, 2010. We understand CMS will also issue a rule in December that will include ePrescribing requirements in the definition of “meaningful use.” This will be key for physicians and hospitals hoping to obtain the significant EHR adoption incentives that will be made available through Medicare and Medicaid under auspices of the American Recovery and Reinvestment Act (ARRA). Under ARRA Medicare adoption incentives, hospitals could receive $2 million plus discharge bonuses, with a payout totaling some $10 million, and physicians could earn $41,000 and over five years if they are utilizing a certified EHR in 2011 ($15,000 in year 1, then $12,000, $8,000, $4,000 and $2,000 in subsequent years). Similarly, Medicaid will offer payment for 85% of EHR-related purchasing costs for qualifying physicians, who must meet qualifying volume and practice site criteria. Payments are $25,000 in year 1, $10,000 in year 2, and up to 5% for no more than 5 years, with maximum of $63,750. 

Meanwhile, additional ARRA-funded grants are beginning to be awarded to states.  Vermont recently received a $1 million federal grant to expand ePrescribing adoption. The money will go toward helping doctors and pharmacists purchase ePrescribing software.

However, ePrescribing still has far to go. The Office of the Inspector General (OIG) assessed the use of ePrescribing by all Medicare Part D plan sponsors between August and September of 2008. Its findings indicate that nearly 80% of plan sponsors at that time were at least partially connected to prescribers, that few of them reported complete connectivity, and that a handful (5%) reported no connectivity. Participating plan sponsors additionally reported problems implementing the NCPDP Formulary and Benefits Standard 1.0 because of systems incompatibility. CMS responded that, among other actions, it will continue to educate plan sponsors about ePrescribing requirements. If necessary, enforcement options might be used to bring plan sponsors into compliance. The study’s findings were released in two reports, which can be accessed on the OIG Web site. Medicare Part D E-Prescribing Standards: Early Assessment Shows Partial Connectivity (OEI-05-08-00320) is available at http://www.oig.hhs.gov/oei/reports/oei-05-08-00320.pdf  and the Medicare Part D Plan Sponsor Electronic Prescribing Initiatives (OEI-05-08-00322) are available at http://www.oig.hhs.gov/oei/reports/oei-05-08-00322.pdf .     

What can we make of all this federal regulatory activity?

First and foremost, it reinforces what POCP has been telling clients in 2009: ePrescribing is alive and well and the lynchpin to successful compliance with upcoming federal requirements and funding opportunities. That said, we all know the devil will be in the details.  When I spoke with an OIG representative during the early phases of its study, I noted that the survey may be premature because the major ramp-up to the adoption of ePrescribing standards was going to occur closer to the April 2009 compliance date. One of our clients added 80% of Part D plans that month. We believe this to be the case across the industry, and it is unfortunate that there is not a more representative study of industry readiness at the compliance date. POCP monitors federal activities, helps clients understand regulatory and statutory requirements, and translate them into action. POCP can help you make sense the CMS regulatory requirements and align them with your business needs.

The OIG reports also underscore the need for education and training. We agree with CMS that education and training will be imperative for successful ePrescribing use by Part D plan sponsors. The same is true for physicians and hospitals, whether it be for ePrescribing or EHRs.  For more than two years, POCP has had a successful track record in developing and implementing successful ePrescribing outreach and education campaigns.   We are currently doing just that for the Southeastern Michigan ePrescribing Initiative. Let us do it for you.

Ed Daniels joins Point-of-Care Partners

Ed Daniels, a healthcare information technology consultant with extensive experience assisting companies during startup, development and transitional situations, has re-joined Point-of-Care Partners, LLC (POCP).  He will be working in the company's chronic care management in the context of electronic health records (CCM) practice, working on health information exchange (HIE) and related initiatives, and running the mobile health (mHealth) group.

"I couldn't be happier to have Ed rejoin us," said Tony Schueth, CEO and Managing Partner.  "I have known Ed for nearly 15 years, learning from him in the early years and observing his successes from afar more recently.  His experience with HIEs and mHealth nicely complements our core ePrescribing and CCM expertise."

Prior to joining POCP, Ed consulted with Healthagen, a developer of healthcare information software that empowers patients to make better decisions and gives healthcare treatment facilities improved access to additional patients.  In June, the company launched an iPhone application called iTriage, which helps consumers evaluate their symptoms, lists potential diagnoses and provides access to appropriate locations for treatment.