Taking HIE Beyond The Enterprise And Into The Community

This article originally appeared in Health IT Outcomes.

Pioneer Valley Information Exchange (PVIX), a community HIE founded by Baystate Health, is fostering clinical collaboration throughout Massachusetts.

Not-for-profit Baystate Health in Springfield, MA is one of the largest integrated healthcare systems in New England and the largest employer in the region. The 131-year-old organization employs 10,000 staff across four hospitals, 60 medical practices, health centers, homecare and hospice services, and other ancillary services. It is a founding member of the Pioneer Valley Information Exchange (PVIX), an HIE formed in 2013 with Sisters of Providence Health System and Baycare Health Partners, a physician-hospital organization that serves three of Baystate Health’s hospitals and more than 200 medical practices in the Pioneer Valley. Joel Vengco, CIO at Baystate Health, explains how implementation of HIE technology has helped PVIX members begin realizing their goal of accessing patient health data when and where they need it.


Q: Why did you decide to implement an enterprise HIE rather than use a public HIE?

A: We’re creating what we like to call a community HIE that includes our enterprise environment and organization, as well as community practitioners and organizations that may not be part of Baystate. We’re looking to have 10 members by the end of our fiscal year, and we have 40 prospective members who are looking to connect at some point over the next couple of years. I like to call PVIX a community HIE because it’s really bringing all of these parties in Western Massachusetts together to exchange health information about patients.

The major reason we went with this more community-focused HIE is that the public initiative, while absolutely terrific in focus, is still very high level. It’s just secure email exchange in many regards right now. We wanted to get more granular and to have more transactions take place. We also wanted to have more discrete and codified data exchanged between practitioners because we share patients much more frequently than we do with anybody on the other side of the state.

It’s also worth noting that development of public exchanges has historically been much slower than what we wanted to do with PVIX. The fact is, we’re running faster than a statewide initiative because we have more focused plans and patient outcomes.


Q: Do you find yourself “competing” with other HIEs in the state?

A: That was certainly one of the challenges we had. There are at least 10 HIEs in the state and what’s called an enterprise exchange around Western Massachusetts. The main idea behind HIE, connectivity and interoperability, gets defeated if you’ve got multiple HIEs in a state or region. We’re trying to figure out where these individual or enterprise HIEs are and how we can connect them to our larger public utility so they don’t lose out on their investment. We believe they can still leverage their investment and the connections they’ve made to their clinician community and then attach that to another larger network like PVIX.

It’s basically connecting networks to networks, such as you might see with Verizon and AT&T. Our message is that “We don’t want to compete with you. We’re trying to connect our region, so if you would like to cooperate, we would love for you to connect as another hub to this larger hub.”

That’s essentially what we continue to communicate to other HIEs in the region. Two HIEs, Holyoke and the Berkshires, have committed to PVIX in this manner. We’ve been in discussions with the North Adams HIE, but it has other priorities for now.


Q: What underlying technology do you leverage for PVIX, and when did you implement it?

A: We use InterSystems’ HealthShare (implemented in August 2013), which was designed for enterprise HIE. Since we’re a community HIE, we’re taking HealthShare beyond the enterprise and bringing members onto it that are outside of a single institution. The main reason we went with InterSystems is that they had a proven track record of being able to scale, and we had a large number of transactions we needed to address.

InterSystems also showed a willingness and desire to innovate with us as a partner. It’s very important to have that, especially when it comes to HIE. People in healthcare believe it will be core to population health, but they’re still a little fuzzy about how to do it successfully, and who really pays for it. Many are still trying to figure out what value-added services to place on top of the HIE to create more value than just pure data exchange.


Q: How does your HIE technology work? What type of data does PVIX collect, share, and access?

A: We are exchanging meds, problems, allergies, lab results, and notes, such as discharge summaries. We are also able to send alerts to individuals within member organizations.

For example, the HIE can send an alert to a primary care physician at one of our member organizations, letting them know when one of their patients goes to the ER or gets admitted to an inpatient setting. We can push that alert out through the provider’s EHR or through the portal they have with PVIX. That’s a great example of a value-added activity for providers who participate in the HIE.

We’re also toying with secure texting so that alerts providers subscribe to can be sent to them via a secure text application on a mobile device or desktop. We’re working with Imprivata to build that application.


Q: What type of staff members use the HIE technology and for what purposes?

A: Right now our target is really clinicians. Through PVIX and HealthShare, they are able to have a holistic view of the patient wherever that person may travel to, whether it’s another practice down the road, in the region, or even across the state. Clinicians will have access to information beyond the local EHR. That’s really the core principle.

The other type of user is the patient. We’re going to be releasing a patient portal, or what we call a patient engagement platform, to our community this summer. It’s going to sit on top of the HIE. The purpose of having it on top of the HIE rather than our local EHR is so that patients can access their medical records just as the physicians do. They can see any and all orders they’ve been given by physicians in multiple organizations with different EHRs. These may include an allergy list or an immunization list.


Q: How will a patient know what’s better to log into — their primary care physician’s patient portal or this new HIE portal?

A: We don’t want to take out somebody’s technology and say they’ve got to use ours instead. We want the community utility to be as collaborative as possible with technologies that providers have already invested in. The thinking is that those incumbent portals that patients already use with their local providers will have a way to connect to the PVIX platform. We could do things like “powered by PVIX,” so that patients are receiving additional information from PVIX, but they are still using the patient portal that they’ve spent time getting used to over the last year or so.


Q: What problems have you experienced (or do you expect) from your HIE? Were any unexpected?

A: I don’t think any of our problems were unexpected, but the degree or depth of some of these problems was often surprising. For example, one expected challenge has been working with the EHR vendors. We’ve seen between 20 and 25 EHRs so far, including eClinicalWorks, Epic, Greenway, Sage, Allscripts, and Cerner. There are a lot of barriers that tend to arise when implementing EHRs and their connections to the HIE. Some weren’t able to develop a continuity of care document that was conformant. Some of it includes cost, which can be unbelievably high. Thankfully, we’ve got MassTech and the Massachusetts eHealth Institute that have created grants for connecting providers to HIEs. That’s helped out a lot because cost can certainly be prohibitive. The other barrier is that sometimes the vendor community and the vendor culture make it hard for folks to really connect to HIEs. Interoperability is perhaps an enemy to their overall market strategy.

Because of these anticipated issues, we wanted to make sure we connected with EHR vendors up front and created ways that could scale for our membership in terms of price or cost. We tried to mitigate that problem as much as we could by working with them and having the members interact with them up front.

As with all HIEs, we knew there was going to be a trust issue. Many folks believe the data they have in their EHR is somehow intellectual property and that sharing that data will give their competitors an advantage. We have certainly seen that, and the depth of that distrust is something we have to continue to converse about with our community. We help mitigate that from a legal perspective. The contracts we have for our members specifically state that other members won’t be able to aggregate or utilize other members’ data without their consent.


Q: What benefits have you realized through the HIE?

A: We’re still in the early stages of leveraging the HIE, but I’d say the major benefit right now is the ability to get a single record for a patient in front of a physician in a seamless way, where they don’t have to log into another system. They can get it from their local EHR and it connects directly to PVIX. We’re in a day and age now where we really have to collaborate with our providers because our patients will continue to migrate, and reimbursement is increasingly based on quality and outcomes. If we collaborate on a patient’s care, and one of us makes a mistake or causes a readmission, all of us get dinged. The seamless connectivity we’ve realized through the HIE has really helped in continuing to connect and collaborate across our community.


Q: What best practices or strategies would you recommend to other providers considering this type of HIE?

A: I think inclusivity is a big deal. Create an advisory or steering committee and bring as many of those who are motivated, even those who are challengers, to the table. You’ve got to bring multiple stakeholders to the table immediately if you want to create utility adoption and connectivity, even if it’s just enterprise-wide and not necessarily a community effort, because data can be very, very sensitive. Have a sustainability plan as well. It can never be too early to envision sustainability. The grant will run out, much as you’ve seen historically, so it’s imperative to have an idea of how you might pay for this in the future before funds dry up.

Another best practice involves setting the right level of expectation with regard to what your members can expect and in what time frame. People tend to use HIEs as a silver bullet. It’s not a panacea that’s going to solve everything, but if you set the right expectations, then people will appreciate even its most basic capabilities. It’s also important to note that setting expectations from the outset will help you envision more complex, sophisticated ones in the future. That will help members understand the value of it out of the gate, even if it’s basic at the beginning.


Q: How much of an investment is an HIE rollout from a financial, resource, and time perspective?

A: As with all HIEs, there was an initial grant. In this case, the grantor was Baystate Health, and so we put in the first round of investment. It could be a multimillion dollar and multiyear initiative, and ours has certainly been no exception. This is a several million-dollar initiative that requires dedicated resources.

It took us seven months to get the first site up. That’s really, really fast. Many would like to have it done in a few months, but the level of granularity and the level of efficacy that you want from your HIE will determine how quickly it goes up. If you have really good codified data being liberated from systems into this HIE, then that’s going to take some time. If you just do very basic document exchange, which is typically data exchange without the ability to exchange computer-consumable information, then that could be a couple of months. I think most want to be able to have that granular level of exchange, but it does take time.

The first time is always the longest and most painful, but the idea is to continue that effort until it becomes more standard, more efficient, and hopefully quicker for the next several sites that come onboard. The hope moving forward is that the community will fund it via a subscription model, so we really have to drive value.