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September 17, 2007
Buoyed by an uncompromising spirit of cooperation, Indiana has become a national leader in medical information exchange. Because states are payers, regulators, and representatives of their populations, the concept that they are natural coordinators of health information exchange is garnering a good deal of attention. Although perhaps only a dozen or so have active health information exchanges (HIEs), the Office of the National Coordinator for Health Information Technology (ONCHIT) is promoting states as a focal point of the push for interoperability. As a result, state governments themselves have more actively explored the potential in the last year. Amid all the discussion, Indiana may be mentioned more often than any other state as a model for how to develop a successful HIE. Like many places, the Hoosier state probably has less than 20% of its physicians using an electronic medical record. But the Indiana Health Information Exchange (IHIE) has implemented, among other services, a clinical messaging system that serves roughly one third of the state’s population by delivering 35,000 electronic documents per day to physicians’ computers from 25 hospitals and other facilities. The system, known as DOCS4DOCS, delivers lab and radiology reports, electrocardiogram results, transcriptions, and images, among other information, to roughly one half of the state’s doctors—a total of approximately 5,000. For most physicians, the system has become integral to their practice, according to J. Marc Overhage, MD, PhD, IHIE’s president and CEO. Most messaging is being conducted within the Indianapolis area. However, other areas are in the process of setting up the IHIE system to get doctors connected. “We really started in central Indiana and have been building outward from there,” Overhage says. And even more information is on the way. “We're starting to build as many sources of information flowing into the system as possible,” says Thomas Penno, IHIE’s chief operating officer. Clinical Messaging But the doctors aren’t rebelling now that they know they can look for most of their results in one place, and their office personnel are free to provide billable services rather than answering phone calls and helping find misplaced or undelivered documents. Kenny Stall, MD, an obstetrician and state medical association representative to IHIE, says he cannot think of one physician who does not like the messaging. Indeed, he says, doctors are asking when IHIE can take the system to the next level, with more and more sophisticated communication. It’s the Revenue,
Stupid IHIE has been the beneficiary of a lot of “sunk costs” in prior work during the previous 30 years, including medical informatics research and a processor physicians network, says Penno. Nevertheless, he asserts, “I become even more convinced every day that clinical messaging is that component that a community can get started doing and then start to build from there.” Valuable Incremental Steps Some communities, Overhage says, have tried to go too fast, getting money from various sources, and then had those funds cut off when they couldn’t perform everything they had hoped. On to Electronic Health
Records (EHRs) Penno believes the IHIE has now achieved such a critical mass in Indiana that vendors feel they should be working with the organization. Public Health Functions Something of a public health landmark happened recently, says Gamache, when incoming ED data alerted state officials to two different disease outbreaks even before any doctor had contacted the agency. “We have to be able to not only receive information from [hospitals] but to also process that information and provide feedback,” says Gamache. Currently, he says, the system is working with the visualization department at Purdue University to allow officials to make speedier decisions concerning public health issues. Surging Into Quality Overhage says area physicians have agreed on measures that should improve community health. Captured information on those measures will be used to generate quality reports to all physicians, starting with primary care doctors, as well as payers. For example, the IHIE could analyze data from diagnosis or A1C tests to determine that a physician’s practice has approximately 100 diabetics. The report, sent via DOCS4DOCS, could further break down the data to inform the physician that only 50 of those patients have had a recent A1C test. “It’s just a really neat thing to see this whole package come together,” says Overhage, particularly in light of estimates that a minority of physicians can generate their own list of diabetic patients. According to Penno, payers are prepared to reward primary care doctors who improve the quality of care to diabetes patients by roughly $15,000 to $20,000 per year. Grants support this “Quality Health First” operation, but IHIE hopes it will be self-sustaining within 18 to 24 months of its start-up, a goal it sets for all its services. Why Indiana? One huge advantage is the presence of the Regenstrief Institute, a prominent, 38-year-old informatics and healthcare research body affiliated with the Indiana University School of Medicine. Not only did Regenstrief offer longtime experience in medical records applications, including the development of Health Level Seven, but its presence gives five local hospitals something to agree on. In the end, it only made sense for the community to use the DOCS4DOCS clinical messaging system that Regenstrief had developed and continues to develop, says Penno. Overhage, who serves as Regenstrief’s director of medical informatics, says that, ironically enough, Indiana’s medium size helps. There is one medical school in the state and not many nearby large medical communities: “There was less bickering and competition than in some markets.” That one medical community also made for some helpful connections, he says. For example, one physician would call another who he had trained under or been in a fraternity with 20 years before. But there was also enlightenment about health connectivity in the other segments of the community, Overhage says. For example, he says the leaders of the Indianapolis company Eli Lilly understand HIT’s value, talk about it, and use it. The company’s employee health clinic has had an EHR for years. Overhage cites the contributions of Indianapolis Mayor Bart Peterson, who is on the IHIE board and regularly attends meetings, as another factor. “There are not many mayors who can talk about potential savings from physician order entry for both ambulatory and hospital patients,” Overhage says. He also says there is a “coherence” on HIT from local foundations, the state heath department, an economic development initiative called BioCrossroads, and universities. “We are not all one big happy family by any means,” he says, but there is a level of understanding that helps them move forward. Can Other Communities
Do It? But does that mean communities without that atmosphere and lacking the other factors working in Indiana’s favor can’t build a similar model? Says Stall: “Not now that Indiana has shown the way. As with many other impossible innovations, somebody [Indiana] didn’t listen and did it anyway. Now, people elsewhere will say, ‘Well, I guess that it can be done.’” Indeed, Penno says IHIE is now talking to different parts of Indiana and to communities elsewhere in the nation to see if they share this vision of clinical messaging, emergency room data sharing, and quality programs. — Kathryn Foxhall is a freelance writer in
the Washington, D.C., area. She covers health informatics, public health,
health policy, reimbursement, mental health, and other issues.
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