Stakeholder Buyin

1
Stakeholder Buy-in Local Health Information
Exchange Activities Implications for Quality
Reporting P4P

• Joy Grossman, Kathryn Kushner Santoro, and
  Elizabeth November

AHRQ Annual Conference 2008, 9/9/08
2
Health Information Exchanges (HIE) Vision vs.
Reality

• Vision
• Support patient-centered comprehensive medical
  records for treatment
• Leverage clinical data repository (CDR) for
  secondary uses, e.g. quality reporting and
  improvement and P4P
• Reality
• Few operational HIEs no comprehensive CDRs
• Limited research on role of stakeholder
  participation in HIEs

3
Research Questions

• How does stakeholder participation vary across
  HIEs?
• What are the facilitators of and barriers to
  stakeholder participation?
• How are HIEs structured to gain stakeholder
  participation?
• How do stakeholder preferences affect the HIE
  role in quality initiatives?

4
Qualitative Research Design

• Selected four local HIEs
• IHIE and HealthBridge - Mature HIEs with active
  data exchange hospital-sponsored
• CareSpark and Tampa Bay RHIO - Newer HIEs in
  planning/development stage started by
  multi-stakeholder community groups
• 76 discussions held with broad range of
  stakeholders, including participants and
  non-participants, from 2/07-8/07

5
Consistent Concerns Across HIEs About Sharing
Data

• Health care providers and health plans view
  patient data as key strategic asset
• Fear losing competitive advantage by
  relinquishing data
• Concerns about potential data misuse
• Concerns about patient privacy and security

6
Differing HIE Strategies to Engage Stakeholders

• In IHIE and HealthBridge, major hospital systems
  agreed to collaborate rather than compete on HIE,
  providing HIEs with critical mass of data
• Hospitals willing to pay for clinical messaging,
  which replaces hospital results delivery to
  physicians
• HIEs designed to address hospital competitive
  concerns
• With clinical messaging, unlike clinical data
  repository, providers retain control of data
• Legal agreements limit data use, e.g. provider
  performance measurement not permitted
• Governance structure allows hospitals to control
  any changes to HIE

7
Newer HIEs Struggle with Broader Coalitions

• CareSpark and Tampa Bay RHIO had plans to develop
  clinical data repository that aggregates patient
  data
• No critical mass of stakeholders willing to
  provide data or funding
• Struggling to identify initial services and
  financing models that stakeholders will support

8
Minimal Role for Employers and Health Plans
Across HIEs

• Employers are catalysts but few provide financial
  support
• Clinical messaging viewed as provider business
  cost
• Health plans have reduced participation over time
• Local plan mergers with national companies
• Concerns about loss of competitive advantage and
  data misuse
• Development of potentially competing data-sharing
  products

9
Quality Efforts in Four HIEs

• IHIE rolling out Quality Health First (QHF)
• Participants include Anthem and local plans,
  others in discussion Medicare/Medicaid
• Combining claims with some clinical data
• Start with PCPs, add specialists, hospitals
• Physician and patient reports go to physicians
  and plans
• Changed data use agreements to allow comparison
  of physicians but cant be made public
• Plans pay PMPM fees start-up grants from other
  sources

10
Quality Efforts in Four HIEs (contd)

• HealthBridge developing plans for clinical data
  repository to support quality reporting/P4P
• Would need to change data use agreements for both
  purposes
• CareSpark and TampaBay RHIO planning quality
  measurement to track health outcomes but not
  actively considering provider performance
  measurement

11
HIE Role in Quality Initiatives Challenging

• Stakeholders felt HIEs, as central data conduit,
  could address shortcomings of existing quality
  programs
• Combine clinical and claims data for all patients
• Reduce administrative burden
• Facilitate development of common measures and get
  physician buy-in
• Attract employers and plans to provide data and
  funding
• However, more complex/costly clinical data
  repository needed to aggregate patient data for
  quality measurement

12
Provider Views on HIE Role in Quality Initiatives

• Provider competitive concerns heightened with
  clinical data repository
• In IHIE and HealthBridge, requires renegotiating
  data use agreements, etc.
• Providers wary of health plans using data for
  price negotiation/network selection
• Concerns that smaller physician practices
  resistant to P4P might not join HIEs

13
Employer and Plan Views on HIE Role in Quality
Initiatives

• Employers
• Mixed views about provider performance
  measurement/ P4P
• No widespread interest in funding quality
  activities
• Plans
• Value access to clinical data
• Potentially willing to pay fee for quality
  reports
• Concerns about losing competitive advantage by
  sharing data and standardizing P4P programs
• Moving to statewide or national IT and P4P
  strategies

14
Discussion

• Barriers that caused CHINs to fail in 1990s still
  exist
• Health data treated as business assets over which
  health care organizations exert property rights
• Few incentives/substantial disincentives to share
  data
• No stakeholders consistently willing to pay for
  CDRs
• HIEs must balance evolving business relationships
  with maintaining stakeholder participation
• Will niche data exchanges compete with or
  support community-wide HIEs?
• Will HIEs be widespread enough to support quality
  reporting/P4P?

15
Funding Acknowledgement

• Project funded by AHRQ
• Study report Joy M. Grossman, Kathryn L.
  Kushner, Elizabeth A. November, Creating
  Sustainable Local Health Information Exchanges
  Can Barriers to Stakeholder Participation be
  Overcome?, Research Brief No. 2, HSC and NIHCM,
  February 2008, http//www.hschange.org/CONTENT/970
  /