The odds seemed stacked against a new health information exchange in Michigan as it began operating in what had become a precarious business climate. Unsustainable HIEs in District of Columbia, Kansas City and Kingsport, Tenn., were shutting down. An eHealth Initiative report counted just 18 HIEs among hundreds in existence that broke even on operations without depending on grant money.

A $548 million federal grant program was rushing financial reinforcements to the rescue of HIEs, but none of that money was destined for fledgling Michigan Health Connect, which had been hatched in 2009 by three competing health systems in the western Lower Peninsula and went into operation by 2011.

HIE value and sustainability are still debated nationally in 2016. But meanwhile, that same Michigan operation is up to a billion transactions per year among 129 hospitals and 4,000 primary, specialty and allied care offices throughout the state. A merger with an adjacent HIE helped the renamed Great Lakes Health Connect (GLHC) amass 6.5 million unique records in its community health record database. It’s growing 15 percent to 20 percent per year and never ended a year in the red.

For information exchanges looking to gain that kind of scale without running themselves into the ground, GLHC’s brief history is a how-to for gaining impressive size and healthy growth in small increments.

“We didn’t build a big, giant solution in the sky and say, ‘Here’s the price for everything under the sun that you must do with us,’ ” says George Bosnjak, director of business development. “We work to meet our customers where they need it: ‘We have this problem, there’s this financial barrier, it costs us this much, can you solve that problem cheaper than we can?’ And if it’s ‘yes,’ we do it.”

The exchange broke through to the market by having a menu of separable services to select depending on the particular challenge facing a hospital, practice or health plan, “instead of forcing an entire suite of solutions on them,” says Julie Klausing, senior director of operations. The menu itself was accumulated through the process of discussing customer data shortcomings and building services to suit.

Just like any other small business starting out, it was a matter of defining its customers first, then offering them ways to make their operations better, faster and cheaper, says Executive Director Douglas Dietzman.

“To the extent that we’re good at understanding where our customers are needing to go from a business standpoint, what their technology needs are, and ways we can help them achieve those goals in a cost-effective way, then we earn the right to get their business and continue to add solutions.”

Emerging priorities in healthcare delivery around such objectives as care coordination, preventing readmissions and meeting data-movement requirements of meaningful use all presented opportunities to be useful right away. The HIE started out “really boring” with basic solution sets: delivering test results from hospitals to community physician practices that were increasingly acquiring electronic health record systems, says Dietzman.

Hospitals were faced with building a raft of interfaces to EHRs from myriad IT vendors. The alternative, Dietzman says, was to “just give all the results to the HIE and say, ‘You figure all that stuff out, you build the interfaces, you maintain them on our behalf,’ so the hospitals could stay focused on other things that are more important to them.” It was a specific problem across all hospitals that each was trying to solve.

Evidence of success at that one service was the springboard to widespread acceptance of GLHC’s role and potential, says Bosnjak. “At the same time, others that were trying it across the state and country weren’t accomplishing that result delivery and weren’t showing success rates.” The HIE started signing up new healthcare organizations at a rapid clip, and the increasing base of business fed off itself to attract more new entrants and stabilize the business foundation ever further.

That mass of participation created a sense that it had staying power, that health systems would not squander their HIE investment and have to start over in a few years, says Dietzman. “That continual momentum helped us get that trust and have people take the leap to start working with us.”

To make the barrier to participation as low as possible, the HIE sliced services as small as necessary. With meaningful-use-related results, for example, “if a hospital wanted to send immunizations, we would just send immunizations for them,” says Bosnjak. “If they wanted just to have a referral tool to move stuff for their specialists, we would price it to make it work for that.”

“If you do those initial things really well, and you really solve a person’s problem, there’s more problems out there in the world that we’re dealing with in healthcare, in moving data,” he says. “And they say, ‘You did a pretty good job on this, can we maybe send these results? Can we start storing data in the community record? Can you get our information out to these skilled nursing care facilities that we have trouble communicating with?’ ”

The technological undergirding for the business includes an interface engine, developed by InterSystems and called Health Connect (part of the vendor's HealthShare family of products), and a community-level EHR branded the Virtual Integrated Patient Record (VIPR), a longitudinal repository offering both near-real-time data and accruing history on patients of participating providers.

The interface engine, says Klausing, enables GLHC to bring in data from all the varied sources across the state, normalize the data, create statistics, and pass the data along to wherever it needs to go: the VIPR, out to provider EHRs, to the state for health reporting requirements.

For its first and most basic service, results from hospitals get out to physicians via a C-CDA document. A link to admission/discharge/transfer information systems monitors and informs physicians that an event involving a patient occurred. But the ADT notification “isn’t the end anymore, just the beginning,” says Dietzman. “The next question after notice of a patient discharge is, ‘Well, what the heck happened?’ ”

The VIPR, with more than 6 million people in its master patient index to date, and more than 12 million clinical messages a month flowing into it, is the future for solving the challenges of information for care coordination activities, Dietzman asserts. By setting it up as the central go-to for information continually assembled and updated on patients, a proliferating corps of case managers, care coordinators, social workers and other professionals can see what’s relevant to their setting and situation, pull out what they need and move on.

At the Center for Integrative Medicine, an initiative of Spectrum Health in Grand Rapids, continual awareness of recent or developing problems is crucial to managing its caseload of people with multiple and highly complex medical problems, says Cara Poland, MD, who directs the center. Among her duties is a daily planning meeting to get up to date on patient status, and logging in to the HIE gives her comprehensive information on any recent medical encounters, including at the other two major hospitals in the area.

“It’s the fastest and easiest way to get information about a patient from another facility,” says Poland. “I can see last night’s lab work, I can see last night’s ER visit, I can see today’s imaging [reports].” The center’s information users include social workers placed there by a community mental health center, and case management and community workers provided by Priority Health, the region’s major health insurer.

Other customers are using the information to broaden their understanding of patients to encompass behavioral, physical and socioeconomic aspects. For example, Washtenaw County Community Mental Health, Ypsilanti, contracts to have physical-health information on its clients transferred from the GLHC repository directly into a behavioral-health information system, says Michael Harding, deputy director.

The impact of medication information on behavioral healthcare is coming into focus as accountable care and clinical integration force clinicians to take stock of people’s overall health and well-being. Current care details from hospitals and physician offices are having a financial as well as physical impact at the Washtenaw County facility, says Harding. “Our partnership with Great Lakes Health Connect, and our strategies, are helping to reduce healthcare costs.”

For example, many of its clients have to undergo a panel of metabolic tests before they can be prescribed certain medications. For years, the mental health facility had to order the panel of tests, draw the blood for it, and wait for the results before it could prescribe, says Harding. Now it can check to see if a physician had ordered that panel a week or two earlier, not an uncommon occurrence. If so, it saves the cost and the “poke” of a duplicate test, and the recipient can get the script before leaving the center.

The norm has become “real-time prescribing based on lab results that have come in from external sources through the HIE,” he says.

Use of the HIE also has significantly reduced unnecessary utilization of resources at the Center for Integrative Management, says Poland. Patients in the Spectrum system who have logged more than 10 emergency department visits in two of the previous three years are referred there, and complicated medical issues continue to make ED monitoring essential, she says.

One 42-year-old woman already with a pacemaker and suffering from hypertension, heart failure, diabetes and asthma--and who smokes, is morbidly obese and has alcohol-use issues--is a constant risk for complications and can end up in at least three different EDs as she travels among several family locations. Occasionally she travels to Flint to visit a cousin. “One of the great things about the health information exchange is, I wouldn’t see the trip to Flint with the information I currently receive [from Spectrum],” says Poland.

Another patient in her 20s, after suffering a fall, “ended up going to three different ERs over four different days in three different hospital systems,” she recalls. Each site did a CT scan. Then the patient presented to Poland with the same complaint, and denied having gone elsewhere to be seen. “And so if I didn’t have that health exchange, I wouldn’t have been able to see the information from the other resources, to know that I didn’t need to do a fourth CT scan on the poor woman.” Incidentally, no injury was ever detected.

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