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May 26, 2008

State Expectations
By Kathryn Foxhall
For The Record
Vol. 20 No. 11 P. 24

The State Alliance for e-Health has mapped out a strategy to increase the effectiveness of HIT initiatives across state lines.

A committee advising state governors about e-health’s future is set to tell them that states should use the programs they pay for—including Medicaid, child health insurance, and state employees health plans—as tools to vigorously advance health information exchange (HIE), employing incentives for providers to participate.

The draft recommendations voted on by the State Alliance for e-Health say that states should establish procurement rules to require the adoption of interoperable HIT applications and set up flexible financing mechanisms across public agencies to support HIE and to allow Medicaid, public health, and state employee health plans to sustain HIE “for purposes of it being a necessary public benefit.”

The State Alliance for e-Health, formed last year under the National Governors Association to explore solutions for state-level electronic healthcare, is composed of 12 state-level officials and cochaired by Tennessee Gov Phil Bredesen and Vermont Gov Jim Douglas. Through five meetings and the work of three appointed task forces, the panel has developed a plan that includes speeding HIE adoption within states, increasing resources, and making a push for universal child health records.

For example, the draft recommendations call for states to review policies and laws for intrastate and interstate data exchange and “remove barriers as appropriate to ensure that public health information systems are interoperable” across local, county, state, and other jurisdictions.

Anthony D. Rodgers, director of the Arizona Health Care Cost Containment System and cochair of the alliance’s HIE task force, said, “We believe that it is critical, as governors look at the responsibility for the overall public health in their states, that they make sure that their systems are interoperable. … And currently what we see [are] silos that cause public health to be disconnected. ... There is also a lack of common architecture even within the states in terms of public health, Medicaid, and other programs.”

Asked to comment on the recommendations, David St. Clair, CEO of MEDecision, praised “the growing state-level understanding that health records are important for their populations and their increasing willingness to use information about their Medicaid and state employee populations as a way to … fuel growth in their markets.”

MEDecision, a provider of technology that connects patients, payers, and providers, works with several Pennsylvania Medicaid managed care plans and has had conversations about doing the same in other states.

The alliance recommends that state Medicaid plans and state employee health plans, in cooperation wherever possible, should create incentive programs, pay-for-performance processes, rate adjustments, and quality motivators to encourage provider IT adoption and HIE participation.

The alliance’s HIE task force acknowledged in a recent report that the price of HIT is a barrier for many providers who serve primarily Medicaid and State Children’s Health Insurance Program beneficiaries. Incentive and reimbursement programs may create the business case for providers to invest in HIT, the report indicated.

It described a vision of the future where “through the different incentive and reimbursement programs, providers are able to earn payments at different points in time—when they adopt HIT, as they use HIT, and once they achieve results related to improving quality of care and health outcomes. Incentive and reimbursement programs also can be leveraged to support better coordination of care for Medicaid beneficiaries with chronic illnesses.”

States should require that public health systems conform to the Health Information Technology Standards Panel interoperability standards as recognized by the secretary of Health and Human Services (HHS), according to the recommendations. Georgia Department of Community Health Commissioner Rhonda M. Medows, MD, FAAFP, cochair of the HIE task force, said that during multiple interviews and site visits with public health officials, “The common theme, again, has been the need for having standards in order to have a common system develop and to have software systems that could actually communicate with each other, regardless of the level of government and regardless of the users.”

Bidirectional for Public Health
The alliance believes that all electronic health record (EHR) systems supported by state funds must have functionalities for bidirectional data exchange between clinical care and public health.

“With electronic health records, many times we are focused on our healthcare delivery system or personal health delivery system. And often times, public health seems to be neglected or at least late to the table,” Rodgers told state alliance members.

He said states should set the direction to ensure that physicians have access to information from public health and, conversely, public health officials can receive reports from providers for population health management. “This will really give us an opportunity once public health is connected through these exchanges,” he noted.

Medows said there needs to be representation from the public health sector whenever executive advisory councils, regional health information organizations, and other governing bodies are constructed. Such strategies will allow public health officials to better understand the value of HIE to providers and the general population.

Child Health
At the behest of the HIE task force, the alliance endorsed the idea that “every child must have a patient-centered electronic health record that is transferable to other providers and accessible to individuals by 2014.”

“The task force was energized and adamant about this particular recommendation and feels that it really jump-starts a life-long important record for the population,” Rodgers said.

According to the recommendation, “At a minimum, the record should include guardianship information, newborn screening, family history, growth, immunization, birth history, problem lists, medications, and allergy data.”

Stressing that the health record goal is for every child and not only those whose care is paid for by public programs, Rodgers said many states could probably achieve the goal earlier. But the task force believed that 2014 was a realistic target date while also providing a sense of urgency.

Personal Health Records
According to the recommendations, states should ensure that Medicaid and state employees have access to portable, private, and secure personal health records. In its report last fall, the HIE task force pointed to Shared Health’s Clinical Health Record model in which all Tennessee Medicaid providers and patients can access records through an Internet-based server.

Based in part on claims-based data, Shared Health receives praise from St. Clair, who touts its approach as a way to jump-start electronic records. He said state employee health plans and Medicaid agencies have historical health claims data for their populations available for use today, with no additional data collection.

States are discovering that valuable EHRs can be created with claims data and used to improve the quality of care within a matter of months, according to St. Clair.

Flexible Funding
The alliance plans also call for flexible HIE funding across public agencies and state jurisdictions, including pooled and bridge funding between federally funded programs.
The HIE task force noted in last fall’s report that HIT/HIE initiatives are often hindered because state agencies are prohibited from distributing resources across programs or sharing assets with other agencies.

According to the task force, grants and federal-matching funds for investments in Medicaid management information systems permit those funds to be spent only on Medicaid enrollees, and other federal programs have similar procedures. In a survey commissioned by the task force, Medicaid leaders said such rules are “inadequate to support the complexity and scope of HIT/eHIE efforts.”

The committee said governors should make funding available in state budgets to allow public health agencies to secure staff educated in public health informatics and train the existing workforce on the latest technology. Also, states should consider multistate collaborations that network and share expertise to increase workforce capacity.

Medows emphasized that there needs to be “some degree of cultural change and general education,” and staff financing needs to be at a level that will permit public health agencies “to compete for new talent with our brethren in the private sector.”

Executive leadership and programmatic management also needs a new set of core competencies, the alliance said. It calls on governors to provide resources and seek outside expertise for skill development in “public health informatics, change management, project management, [and] health IT provider and consumer communication.”

Urging the governors to make sure their executive leadership “understands how to accomplish these very significant changes,” Rodgers said, “I often see system failures—significant system failures—that cost states significant dollars, both in terms of time and budget and suboptimize the result.”

Privacy Rules
Tackling an issue that is one of the biggest impediments to HIE, the alliance said states should educate executive and legislative leaders on the importance of privacy protection alignment and should sustain efforts to reduce variability within and across states “in a manner that ensures appropriate consumer protections are in place.”

“There is great interest in having the states cooperate,” St. Clair said. “We just, as vendors, all have to be a little concerned about what that means because of the politics around privacy.”

Today, he said, state laws are a patchwork of different privacy requirements about delivering clinical information for use by a patient’s physician. A patient who lives in New Jersey may have insurance in Delaware and get care in Pennsylvania.

“So when we have to filter out, based on state law, certain information about the history of drug abuse or HIV status or mental health issues of one sort of another, whose states laws do we use? We essentially have to go with the most restrictive, even if that might not be to the patient’s benefit,” he said.

If information can only be shared “with explicit, real-time patient consent, then the critical mass goes away,” St. Clair said. “Then all of the infrastructure that we are trying to build can’t be paid for. It’s the equivalent of trying to build the interstate highway system for eight cars.”

The state alliance’s task force on information protection issues agreed, saying the confusion is not just about sending records across state lines. State privacy laws, it said, have not kept up with rapidly advancing technology. “In many cases privacy requirements are scattered into different chapters of state legislation and regulation. Some are likely outdated or written for a paper-based system,” the task force noted.

The state alliance will also tell the federal government it has work to do to straighten out federal privacy requirements. Its task force report said the variability of federal privacy requirements conflicts with the government’s stated vision of interoperable exchange. For example, consent requirements for substance abuse and student health information vary significantly from HIPAA requirements.

The draft recommendations also call on states to promote certification of new EHRs and recognize the Certification Commission for Healthcare Information Technology (CCHIT) or other certification bodies recognized by HHS. However, it also calls on the federal government to designate a single certification body, such as the CCHIT, for use by all federally funded programs, grants, and contracts for new products or network components.

Finally, in a move likely to stir both excitement and consternation among providers, the alliance recommends that a convention of state and territorial medical boards be called to create a licensure system that permits open doctor-to-doctor consultation and doctor-to-patient interaction across state lines. It will call for a similar arrangement for pharmacists and for support of the currently existing Nurse Licensure Compact that allows cross-state recognition of nurse licenses in some states.

— 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.