Federated-model HIE Connects 16 Unaffiliated Hospitals
When the 16 hospitals of the Western North Carolina Health Network (WNCHN) sat down to create a federated model for a health information exchange (HIE) four years ago, they could find no examples of unaffiliated institutions sharing health data, so WNCHN essentially began with a tabula rasa.
Andrew Well, MD
Dana J. Gibson, MPH, CPHIT, CPHQ
Harold Moore, CIOBuilding on a federation founded to collaborate on quality-improvement goals and, later, to achieve economies through group purchasing, Dana J. Gibson and the 16 member hospitals built an HIE called Data Link, which gives approximately 1,500 physicians in the region access to admission and discharge information and to laboratory, microbiology, and radiology reports, as well as to information on patients’ medications and allergies, discharge summaries, histories and physicals, and other transcribed reports, such as consultative notes. Gibson, MPH, CPHIT, CPHQ, is vice president, Data Link Services, WNCHN, Asheville. The next steps will be to add physician-office electronic medical records (EMRs) to Data Link and, significantly for the radiologists in the network, to provide access to diagnostic-quality medical images. “We are in the process of identifying specifications and identifying companies that would like to participate in that development and deployment,” Andrew Wells, MD, radiologist, Margaret Pardee Memorial Hospital, Hendersonville, explains. How It Works Data Link is surprisingly simple. WNCHN worked with MEDSEEK, a Birmingham, Alabama, software developer, to create a piece of software that sits on the hospital server and communicates with an independently hosted Data Link server. “I envision it as a large electronic card catalog where patients have a record, and the record can occur across any of the 16 hospitals,” Wells says. “The application creates the master patient index and the locator tool that allows any provider with the proper credentials to log in, query a specific patient, and then get the results back from the card catalog saying they have events across two hospitals or six hospitals.” He continues, “At that point, no data are pulled; it’s just that the pointers are identified, so it’s extremely fast to find the events and the history. It’s really important that so far, you haven’t pulled anything out of the host computer system: All you are doing is turning the crank on the card catalog and indexing tool. It’s extremely quick, and it’s not until you say, ‘I want to see this,’ that it actually engages the host repository or host archive to pull it out and then present it. It’s a small question and a small file, and it gets there quickly.” Minimal Hospital IT Requirements From the hospital IT perspective, the HIE required very little effort to implement. As Harold Moore, CIO, Margaret Pardee Hospital, explains,“They developed a little piece of software that we load on our server, which basically allows us to communicate with the hosted Data Link system.” Data Link periodically queries the hospital information system (HIS) for each of the 16 hospitals and receives some basic patient information to populate the index. “Once a user finds the patient at, for example, Pardee Hospital, the user clicks that in Data Link, and Data Link does another query into our hospital system and extracts the appropriate data,” Moore says. “It was quick and easy for us to get up and running. We use the MEDITECH hospital system here, and we just plugged it in and did some testing; it worked out of the box very quickly. We were up and running before we knew it, so there really were very minimal requirements on our part.” It is quick and easy by design, Wells says, because the software developers worked with the requirement that individual hospitals would not need to upgrade their equipment or software to participate. “The thing that makes this powerful is that the umbrella was developed with the clear expectation that no hospital would change its HIS,” Wells explains. “No hospital would have to do some monstrous custom thing to participate in this federated collecting of data. The beauty of it is that the 16 hospitals have multiple HIS platforms, and the work was done to make the hooks into the platforms smart, rather than telling the hospitals, ‘Change your box.’” Roles of the Individual Hospitals The 16 individual hospitals, however, do have both administrative and financial responsibilities to maintain the system. “Each of the 16 hospitals has appointed a member of its staff to be an administrator of Data Link within that hospital, which means they assign who uses Data Link and they also audit the Data Link activity that goes on,” Gibson explains. The 16 hospitals support Data Link by paying a monthly fee; half of the amount is equal for all participants, with the other half based on the size and complexity of the institution. Gibson attributes Data Link’s success to early grant money from the Health Resources and Services Administration (HRSA), a division of the DHHS, and the Duke Endowment, which paid for software development and infrastructure. “We try to use grant money for any connectivity or startup activities, but we pretty much rely on the 16 hospitals to maintain Data Link going forward,” Gibson says. Maintenance fees cover software updates, HIPAA compliance, Internet activity/server/software (IBM WebSphere), and the hosting fee (Peak 10). Clearing Funding and Security Hurdles One of the greatest hurdles in getting the HIE off the ground was securing the grant money from the Duke Endowment and HRSA to launch Data Link, followed by accessing further funds to add functionality. Gibson believes that CMS American Recovery and Reinvestment Act (ARRA) funds cannot be used to build out Data Link linkages or to create radiology PACS connectivity, and the HIE is not one of the state-designated entities that will receive Health Information Technology for Economic and Clinical Health Act funding through the state. “We do have Office of the National Coordinator (ONC) funding secured to build our National Health Information Network gateway, and we already have HRSA funding secured to link unaffiliated physician offices across western North Carolina,” Gibson says. “Going forward, we will be applying for more funding for both of these goals from the ONC Beacon Community grants program, which is part of the ARRA provision (Public Health Service Act). We also hope to apply for more funding from HRSA and the Duke Endowment to help us achieve these goals, should we be unable to secure the Beacon Community grant.” The other significant challenge was addressing security concerns, particularly the HIPAA requirement that patients consent to the disclosure of personal health data. According to Gibson, there were two choices for patient disclosure: either an opt-in or an opt-out model, and WNCHN went with the opt-out method. “There was a lot of pain in terms of trying to decide how best to do this, and we actually decided to go with the opt-out model,” Gibson recalls. The consent form that a patient signs when entering one of the 16 hospitals contains a section explaining that information will be made available within the Data Link HIE. Patients are given the opportunity to opt out or opt out for a specific medical encounter within that medical record. Each hospital sets its own policy for user access, but once it logs into Data Link for the first time, there is an end-user agreement that it has to sign electronically before it can move into the Data Link stream, and that has to be updated regularly. “We are creating a gentle speed bump for users to be reminded that this is protected health information,” Wells says. “It is not as painful as with some HIS setups that really are Chinese walls, but it is a reminder that you are entering protected patient information, and it asks whether you want to continue. That’s a pretty clear message that somebody’s counting, and somebody is looking at who comes through the door.” Auditable Events Every time a user clicks continue, an alert is sent to Data Link saying that a certain physician has decided to enter into a patient’s record (if he or she does not have an established relationship within the EMR from which the information will be pulled). “We get that count,” Gibson explains. “Emergency-department physicians typically do not have relationships with patients within the EMR system at the hospital. If it’s a primary care physician or an internist looking at an orthopedic patient, though, then we might do a little research into that to find out why he or she needed to be in that particular chart.” Moore acknowledges some initial challenges in educating physicians in the community and reassuring them that using the application would not require any additional hardware, software, or cost. He says, “Once they see how quick and easy it is to use, they say, ‘Wow, this is not really that cumbersome.’ It’s not only physicians in the hospital setting, but physicians in their own rural practices who see the value of this. It bridges care across the whole area.” Wells describes the log-on process: “You just go to the Web site, and when you enter your user name and password it goes to an SSL-encrypted status. You put in the patient-seeking demographics (whether those are last name, first name, date of birth, or whatever), and once a patient list is provided, you select a patient. The user must affirm, ‘I have a relationship with this individual, and I wish to go forward,’ and it is a HIPAA auditable event.” He adds, “You can do this from any browser, desktop, laptop, or netbook that can see the Web. There is no software requirement for the end user. Again, we use a very small footprint and a very low cost expressly to increase ease of access.” While community physicians are currently accessing Data Link free, that will change, going forward, as WNCHN begins connecting ambulatory-physician EMRs and home health agencies to Data Link. “When that takes place, the opportunity for moving documents from the hospital into a physician’s EMR so that he or she doesn’t have to launch Data Link is going to cost some money,” Gibson says. Superusers and Clinical Utility Meanwhile, Data Link has 1,500 individual users, with 440 considered routine users with multiple log-ons per month. Those 440 users, however, are logging on about 6,500 times per month. “Our urgent care has recently gone gung ho in using it as well, because these patients just show up and we don’t necessarily know a lot about them,” Moore says. Emergency-department physicians are another category of superusers. “They want to know if this person who is complaining of pain has legitimate pain or is a drug seeker,” Wells explains. “If emergency-department physicians are concerned about drug-seeking behavior, then they can open Data Link, identify themselves, identify the patient, and see whether, in the last six months, this patient has been through one or six emergency departments with similar abdominal pain, each time ending up with a narcotic prescription or therapy.” He continues, “That provides a tremendous information asset that the patient might be withholding or, in a different patient category, unable to provide adequately; perhaps the patient is debilitated, or perhaps the patient has had a stroke. For example, the record might show that those 10 different emergency-department visits are because of falls, and the patient has pain because of falling a lot. The physician wants to be able to get to relevant information quickly and then get out and do the treatment.” Wells says that Data Link also has tremendous clinical utility outside the hospital setting. He offers the example of an internist whose patient was in the hospital for colon-cancer surgery. When the internist sees the patient back in the office two months after surgery, the patient doesn’t have a copy of the operative report, the pulmonary-complication notes made when the patient had a problem, or the report from the infectious-disease consultation. “That physician could get on the phone, call medical records, and have it all faxed—or open Data Link, look into those things, and print them out in the office,” Wells notes. “The Holy Grail is being able to pull that stuff electronically into an office EMR. That’s great, but we have a lot of baby steps we can take before we get to that. Access to information quickly, at the point of care, is really the goal.” Radiologists and the Missing Link Wells also uses Data Link in his own practice, particularly when he sees an abnormality on a study, but there is no prior exam in his PACS. “I wonder whether there is a prior study somewhere: What did it show, what did the report say, and what did the image look like?” Wells says. “I need those answers so I can make a better report for my current chest radiograph, CT, or MRI. Is it better, worse, or the same?” Even greater clinical and economic benefits will be gained when WNCHN adds a regional tool for viewing images to the Data Link platform. Currently, if Wells has no access to a prior study, he dictates, “If a prior exam were obtained elsewhere and made available, I would happily issue an addendum comparison.” He is currently working with the Data Link team to prepare a request for proposal designed to identify companies interested in participating in the development of a solution. “It would mean greater efficiency for the patient, greater specificity in the reports, and greater satisfaction for the referring physician who is taking care of the patient and wants a question answered,” Wells says. “It’s got to be quick, point-of-care delivery, however.” For the radiologist, that means that the solution would be available at the PACS workstation (at Pardee Hospital, from FUJIFILM, Stamford, Connecticut) and usable across multiple PACS workstations via Internet connection. In describing how such a system could create economies and efficiencies in the cost of care, Wells explains that every time he dictates, “If comparison available,” the next line recommends a follow-up study, medical therapy, or surgical treatment, if no prior study exists. “If we could eliminate the add-on imaging because we could actually come to a definitive answer, that would decrease cost,” he says. “There’s clearly an opportunity to decrease the follow-up imaging, but you have to know what was done before.” Other benefits to be derived from federated access to images include the potential for telemedicine use in rural areas and for work shifting within (and perhaps between) practices that would allow them to provide service to each other over an electronic platform. In summing up the value of Data Link, Wells terms the platform an empowering step in what physicians can do for patients in a current episode of care. “The problem for physicians is how far afield they have to walk, go, or type to get to that information to answer the question,” Wells explains. “If they have to go to a dedicated PC that is sitting in the corner of the emergency department and they are in the operating room, that will never happen. The information has to be delivered at the point of care, and that is why secure access to the card catalog with validation is such a wonderful tool.”Cheryl Proval is editorial director of Radinformatics and ImagingBiz.com and editor of Radiology Business Journal.
“At the time we were developing this, there were no HIEs that were being built among disparate systems, so a lot of this we set with a blank piece of paper.” —Dana J. Gibson, MPH, CPHIT, CPHQ, vice president, Data Link Services, WNCHN, Asheville, North Carolina
Andrew Well, MD
Dana J. Gibson, MPH, CPHIT, CPHQ
Harold Moore, CIOBuilding on a federation founded to collaborate on quality-improvement goals and, later, to achieve economies through group purchasing, Dana J. Gibson and the 16 member hospitals built an HIE called Data Link, which gives approximately 1,500 physicians in the region access to admission and discharge information and to laboratory, microbiology, and radiology reports, as well as to information on patients’ medications and allergies, discharge summaries, histories and physicals, and other transcribed reports, such as consultative notes. Gibson, MPH, CPHIT, CPHQ, is vice president, Data Link Services, WNCHN, Asheville. The next steps will be to add physician-office electronic medical records (EMRs) to Data Link and, significantly for the radiologists in the network, to provide access to diagnostic-quality medical images. “We are in the process of identifying specifications and identifying companies that would like to participate in that development and deployment,” Andrew Wells, MD, radiologist, Margaret Pardee Memorial Hospital, Hendersonville, explains. How It Works Data Link is surprisingly simple. WNCHN worked with MEDSEEK, a Birmingham, Alabama, software developer, to create a piece of software that sits on the hospital server and communicates with an independently hosted Data Link server. “I envision it as a large electronic card catalog where patients have a record, and the record can occur across any of the 16 hospitals,” Wells says. “The application creates the master patient index and the locator tool that allows any provider with the proper credentials to log in, query a specific patient, and then get the results back from the card catalog saying they have events across two hospitals or six hospitals.” He continues, “At that point, no data are pulled; it’s just that the pointers are identified, so it’s extremely fast to find the events and the history. It’s really important that so far, you haven’t pulled anything out of the host computer system: All you are doing is turning the crank on the card catalog and indexing tool. It’s extremely quick, and it’s not until you say, ‘I want to see this,’ that it actually engages the host repository or host archive to pull it out and then present it. It’s a small question and a small file, and it gets there quickly.” Minimal Hospital IT Requirements From the hospital IT perspective, the HIE required very little effort to implement. As Harold Moore, CIO, Margaret Pardee Hospital, explains,“They developed a little piece of software that we load on our server, which basically allows us to communicate with the hosted Data Link system.” Data Link periodically queries the hospital information system (HIS) for each of the 16 hospitals and receives some basic patient information to populate the index. “Once a user finds the patient at, for example, Pardee Hospital, the user clicks that in Data Link, and Data Link does another query into our hospital system and extracts the appropriate data,” Moore says. “It was quick and easy for us to get up and running. We use the MEDITECH hospital system here, and we just plugged it in and did some testing; it worked out of the box very quickly. We were up and running before we knew it, so there really were very minimal requirements on our part.” It is quick and easy by design, Wells says, because the software developers worked with the requirement that individual hospitals would not need to upgrade their equipment or software to participate. “The thing that makes this powerful is that the umbrella was developed with the clear expectation that no hospital would change its HIS,” Wells explains. “No hospital would have to do some monstrous custom thing to participate in this federated collecting of data. The beauty of it is that the 16 hospitals have multiple HIS platforms, and the work was done to make the hooks into the platforms smart, rather than telling the hospitals, ‘Change your box.’” Roles of the Individual Hospitals The 16 individual hospitals, however, do have both administrative and financial responsibilities to maintain the system. “Each of the 16 hospitals has appointed a member of its staff to be an administrator of Data Link within that hospital, which means they assign who uses Data Link and they also audit the Data Link activity that goes on,” Gibson explains. The 16 hospitals support Data Link by paying a monthly fee; half of the amount is equal for all participants, with the other half based on the size and complexity of the institution. Gibson attributes Data Link’s success to early grant money from the Health Resources and Services Administration (HRSA), a division of the DHHS, and the Duke Endowment, which paid for software development and infrastructure. “We try to use grant money for any connectivity or startup activities, but we pretty much rely on the 16 hospitals to maintain Data Link going forward,” Gibson says. Maintenance fees cover software updates, HIPAA compliance, Internet activity/server/software (IBM WebSphere), and the hosting fee (Peak 10). Clearing Funding and Security Hurdles One of the greatest hurdles in getting the HIE off the ground was securing the grant money from the Duke Endowment and HRSA to launch Data Link, followed by accessing further funds to add functionality. Gibson believes that CMS American Recovery and Reinvestment Act (ARRA) funds cannot be used to build out Data Link linkages or to create radiology PACS connectivity, and the HIE is not one of the state-designated entities that will receive Health Information Technology for Economic and Clinical Health Act funding through the state. “We do have Office of the National Coordinator (ONC) funding secured to build our National Health Information Network gateway, and we already have HRSA funding secured to link unaffiliated physician offices across western North Carolina,” Gibson says. “Going forward, we will be applying for more funding for both of these goals from the ONC Beacon Community grants program, which is part of the ARRA provision (Public Health Service Act). We also hope to apply for more funding from HRSA and the Duke Endowment to help us achieve these goals, should we be unable to secure the Beacon Community grant.” The other significant challenge was addressing security concerns, particularly the HIPAA requirement that patients consent to the disclosure of personal health data. According to Gibson, there were two choices for patient disclosure: either an opt-in or an opt-out model, and WNCHN went with the opt-out method. “There was a lot of pain in terms of trying to decide how best to do this, and we actually decided to go with the opt-out model,” Gibson recalls. The consent form that a patient signs when entering one of the 16 hospitals contains a section explaining that information will be made available within the Data Link HIE. Patients are given the opportunity to opt out or opt out for a specific medical encounter within that medical record. Each hospital sets its own policy for user access, but once it logs into Data Link for the first time, there is an end-user agreement that it has to sign electronically before it can move into the Data Link stream, and that has to be updated regularly. “We are creating a gentle speed bump for users to be reminded that this is protected health information,” Wells says. “It is not as painful as with some HIS setups that really are Chinese walls, but it is a reminder that you are entering protected patient information, and it asks whether you want to continue. That’s a pretty clear message that somebody’s counting, and somebody is looking at who comes through the door.” Auditable Events Every time a user clicks continue, an alert is sent to Data Link saying that a certain physician has decided to enter into a patient’s record (if he or she does not have an established relationship within the EMR from which the information will be pulled). “We get that count,” Gibson explains. “Emergency-department physicians typically do not have relationships with patients within the EMR system at the hospital. If it’s a primary care physician or an internist looking at an orthopedic patient, though, then we might do a little research into that to find out why he or she needed to be in that particular chart.” Moore acknowledges some initial challenges in educating physicians in the community and reassuring them that using the application would not require any additional hardware, software, or cost. He says, “Once they see how quick and easy it is to use, they say, ‘Wow, this is not really that cumbersome.’ It’s not only physicians in the hospital setting, but physicians in their own rural practices who see the value of this. It bridges care across the whole area.” Wells describes the log-on process: “You just go to the Web site, and when you enter your user name and password it goes to an SSL-encrypted status. You put in the patient-seeking demographics (whether those are last name, first name, date of birth, or whatever), and once a patient list is provided, you select a patient. The user must affirm, ‘I have a relationship with this individual, and I wish to go forward,’ and it is a HIPAA auditable event.” He adds, “You can do this from any browser, desktop, laptop, or netbook that can see the Web. There is no software requirement for the end user. Again, we use a very small footprint and a very low cost expressly to increase ease of access.” While community physicians are currently accessing Data Link free, that will change, going forward, as WNCHN begins connecting ambulatory-physician EMRs and home health agencies to Data Link. “When that takes place, the opportunity for moving documents from the hospital into a physician’s EMR so that he or she doesn’t have to launch Data Link is going to cost some money,” Gibson says. Superusers and Clinical Utility Meanwhile, Data Link has 1,500 individual users, with 440 considered routine users with multiple log-ons per month. Those 440 users, however, are logging on about 6,500 times per month. “Our urgent care has recently gone gung ho in using it as well, because these patients just show up and we don’t necessarily know a lot about them,” Moore says. Emergency-department physicians are another category of superusers. “They want to know if this person who is complaining of pain has legitimate pain or is a drug seeker,” Wells explains. “If emergency-department physicians are concerned about drug-seeking behavior, then they can open Data Link, identify themselves, identify the patient, and see whether, in the last six months, this patient has been through one or six emergency departments with similar abdominal pain, each time ending up with a narcotic prescription or therapy.” He continues, “That provides a tremendous information asset that the patient might be withholding or, in a different patient category, unable to provide adequately; perhaps the patient is debilitated, or perhaps the patient has had a stroke. For example, the record might show that those 10 different emergency-department visits are because of falls, and the patient has pain because of falling a lot. The physician wants to be able to get to relevant information quickly and then get out and do the treatment.” Wells says that Data Link also has tremendous clinical utility outside the hospital setting. He offers the example of an internist whose patient was in the hospital for colon-cancer surgery. When the internist sees the patient back in the office two months after surgery, the patient doesn’t have a copy of the operative report, the pulmonary-complication notes made when the patient had a problem, or the report from the infectious-disease consultation. “That physician could get on the phone, call medical records, and have it all faxed—or open Data Link, look into those things, and print them out in the office,” Wells notes. “The Holy Grail is being able to pull that stuff electronically into an office EMR. That’s great, but we have a lot of baby steps we can take before we get to that. Access to information quickly, at the point of care, is really the goal.” Radiologists and the Missing Link Wells also uses Data Link in his own practice, particularly when he sees an abnormality on a study, but there is no prior exam in his PACS. “I wonder whether there is a prior study somewhere: What did it show, what did the report say, and what did the image look like?” Wells says. “I need those answers so I can make a better report for my current chest radiograph, CT, or MRI. Is it better, worse, or the same?” Even greater clinical and economic benefits will be gained when WNCHN adds a regional tool for viewing images to the Data Link platform. Currently, if Wells has no access to a prior study, he dictates, “If a prior exam were obtained elsewhere and made available, I would happily issue an addendum comparison.” He is currently working with the Data Link team to prepare a request for proposal designed to identify companies interested in participating in the development of a solution. “It would mean greater efficiency for the patient, greater specificity in the reports, and greater satisfaction for the referring physician who is taking care of the patient and wants a question answered,” Wells says. “It’s got to be quick, point-of-care delivery, however.” For the radiologist, that means that the solution would be available at the PACS workstation (at Pardee Hospital, from FUJIFILM, Stamford, Connecticut) and usable across multiple PACS workstations via Internet connection. In describing how such a system could create economies and efficiencies in the cost of care, Wells explains that every time he dictates, “If comparison available,” the next line recommends a follow-up study, medical therapy, or surgical treatment, if no prior study exists. “If we could eliminate the add-on imaging because we could actually come to a definitive answer, that would decrease cost,” he says. “There’s clearly an opportunity to decrease the follow-up imaging, but you have to know what was done before.” Other benefits to be derived from federated access to images include the potential for telemedicine use in rural areas and for work shifting within (and perhaps between) practices that would allow them to provide service to each other over an electronic platform. In summing up the value of Data Link, Wells terms the platform an empowering step in what physicians can do for patients in a current episode of care. “The problem for physicians is how far afield they have to walk, go, or type to get to that information to answer the question,” Wells explains. “If they have to go to a dedicated PC that is sitting in the corner of the emergency department and they are in the operating room, that will never happen. The information has to be delivered at the point of care, and that is why secure access to the card catalog with validation is such a wonderful tool.”Cheryl Proval is editorial director of Radinformatics and ImagingBiz.com and editor of Radiology Business Journal.
Cheryl Proval,
Vice President, Executive Editor, Radiology Business
Cheryl began her career in journalism when Wite-Out was a relatively new technology. During the past 16 years, she has covered radiology and followed developments in healthcare policy. She holds a BA in History from the University of Delaware and likes nothing better than a good story, well told.