Joy Grossman, Kathryn Kushner Santoro, and Elizabeth November

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 can’t be made public • Plans pay PMPM fees; start-up grants from other sources

10. Quality Efforts in Four HIEs (cont’d) • 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/