Ross D. Martin, MD, MHA
Program Director, Integrated Care Network | CRISP
Ross Martin shares his insights on why Health Information Exchange is in many ways the reason that Electronic Health Records (EHR) need to exist.
Can you explain where Health Information Exchange fits into the overall federal mandate for Meaningful Use?
Health Information Exchange can take many different forms. It can be the point-to-point kind of exchange, which is simply connecting to another provider and sending them records, such as a referral letter, but that’s just duplicating what we do in the paper world. But now, the Meaningful Use program recognizes the value of having a more systematic approach to exchange and that is why the HITECH Act was created as statewide Health Information Exchange (HIE) approaches. So, HIE is in many ways the reason that Electronic Health Records (EHR) need to exist.
If we just create EHRs to do documentation, we’ll get more legible documents and content but it’s not worth the pain really of moving into the digital space without having exchange. The main reasons we’re doing all this is to get good data liquidity and good data flow. The true value of adoption of EHR comes when there is more data liquidity and tools and services that you can place on top of that – they are very transformative. And we’re not experiencing the benefits nearly to that level yet, because it’s just part of that evolution.
From your vantage point, can you describe the importance of Health Information Exchange and how it is reinventing healthcare?
Initially, I think we get some efficiencies in having a better awareness in what is happening in the overall health system. Early on, in CRISP (Maryland’s state-designated HIE, which also serves the District of Columbia and the region) we created an Encounter Notification Service (ENS). A primary care provider or an individual practitioner who subscribes to ENS sends CRISP a list of his or her patients. We match up those patients to our master patient ID. Whenever that patient is admitted to the hospital or is seen in the emergency department, that practice receives a notification of the encounter – either in real time if preferred or in batches once or twice a day. This Encounter Notification Service has had a big impact on how people are able to follow up on someone’s care. When you build on this and do things like provide care plans for care coordination, provide more in-the-moment lab results and imaging results — things like that, you can avoid unnecessary utilization and improve quality. You can interpret repeated tests more effectively if you’ve got the old one. Because we’re such a fragmented healthcare system, we need those connection points.
Patagonia Health serves local health departments, community health centers and behavioral health agencies. How can HIE specifically help these agencies and why should they connect to HIE?
Electronic Health Records (EHRs) need to be in place. You need electronic content on the other end for exchange to happen. Here’s just one example: I attended the American Medical Informatics Association (AMIA) symposium in San Francisco last November (2015), and I went to a session on public health electronic case reporting. They’re really making some progress in this area. They’ve got a pretty good plan to make public health reporting something that can be done in a much more structured way to electronic health records, and in a fairly automatic way. So providers who were notoriously bad at reporting can do it without really having to lift a finger. This electronic case reporting approach uses a common report for all of the different reportable conditions.
It makes it very easy for the EHR vendor to comply with that simply because it is using Consolidated Clinical Document Architecture (CCDA) standards that the EHRs already have to use. They can already generate them so you’ve got an opportunity to leverage this standard to use electronic case reporting. This represents an opportunity to do something much more efficiently and much more comprehensibly than is currently being done and really increase the level of public health reporting.
How would you advise a health agency about when they should connect to HIE and are there best practices you would recommend for those that are just beginning?
CRISP has a philosophy and a number of guiding principles that we try to work within, and one of our top principles is incrementalism. We try to do these things in a thoughtful step-wise approach. Even though there’s lots of pressure to do things quickly, we try to start with a modest goal, understand something that will be of real value and not try to boil the ocean if you will. I think that is a good approach for Public Health.
For the HIE, every state, every region is doing things a little bit differently and in the Maryland case I think we’re very interested in trying to pilot solutions for public health. For example, Maryland is already doing ImmuNet connectivity right now so people can report on immunizations and get immunization records in a common way. We’re very interested in exploring other opportunities for supporting public health cases.
What about timing? How can agencies share information with other providers when many others are not yet connected to HIE?
Public Health, while it should be a driver, never really is the kind of driver that you want it to be. It’s not exactly an afterthought because a lot of this is mandated by the Centers for Disease Control and Prevention (CDC) and by state regulations, but it’s not the first thing that people jump to. So, I think there is a real opportunity for public health but you’re never going to drive the marketplace with a public health imperative. People are not going to adopt electronic health records, for example, so that they can fulfill their public health obligations, but once they are connected and once they are doing other things of value, they can help support care coordination.
Right now CRISP is connected to all the acute care hospitals in MD, but we have a fairly limited penetration in the much more fragmented ambulatory provider market. As we connect to ambulatory providers, the opportunity for public health is much more significant and we can take advantage of the fact that they are doing this for other things to kind of piggyback. There is an element of having to be patient for the market to adopt more comprehensively.
With the changing landscape of healthcare, how do you see HIEs evolving in the future and the role it plays with EHR use?
I think some of this is going to get a little bit worse before it gets better. The value you get from adoption is going to come more in the next phase than right now, so there will be a little bit more pain before the gain, if you will. I think exchange is going to become increasingly vital in the way that we expect healthcare to work.
I don’t think it’s going to move that quickly and, even when it does, we’re going to have a need for it because of the mobility of our population, because of our aging population, and because the level of knowledge and data that we are accumulating continues to increase. We’re going to need a more complex systemic approach to this so I think we’re going to see a lot more HIE. It’s going to be a brave new world. I do think that we will see more dramatic changes in the next ten years than we’ve seen in the previous thirty.
Dr. Martin is responsible for all aspects of building and deploying next-generation care coordination tools and services that build upon CRISP’s existing data delivery and reporting services as Maryland’s state designated health information exchange. Dr. Martin’s passions for the benefits and advantages of Health Information Exchange are powerfully expressed in his video production of Flow – A spoken-word piece about health information exchange.