In 2009, when the Office of the National Coordinator for Health IT (ONC) began doling out hundreds of millions of dollars in federal funding to states and territories to enable health information exchange (HIE) within their jurisdictions, New Hampshire was one of the last states to receive money. And when the ONC did give money to the state, the amount granted was one of the smallest of any public HIE.
As such, since its inception, the New Hampshire Health Information Organization (NHHIO) has had a “survival of the fittest” mindset and is continuously looking to finding creative solutions to legislative and financial barriers for successful statewide data exchange. Jeff Loughlin, executive director of NHHIO, recently spoke with Healthcare Informatics about these specific barriers and what’s new with the HIE, now in its third year of operations. Below is Part one of that interview, edited for length.
Tell me about NHHIO’s HIE journey, and how it got to where it is today?
We’re at a turning point in the lifecycle of NHHIO in a few ways. From an operations standpoint we are now coming into our third year of operations and moving data around, and our fourth year in existence. After we got funding from ONC to get our operations running and build the infrastructure, we have been turning towards the side of sustainability which is becoming more of a struggle than we initially thought. We decided not to build a mass centralized repository, which I think is still the right answer, especially for New Hampshire, and we’re now focusing more on the transport aspect of it. We are also now bumping into issues with interoperability between vendors, or vendor-driven solutions, which in many cases is right way to go. But it leaves us in a quandary of where do we fit and what is our true value proposition? And that is the question for many organizations like us—how do you maintain that value proposition?
What’s the latest with NHHIO, in terms of member participants?
We have more than 75 organizations across New Hampshire that are members of NHHIO, and that represents close to 100 geographical locations. NHHIO spends a lot of time raising itself up as a facilitating and convening organization for these members. Out of those 75, only about a dozen or so are physically plugged in and directly connected to our infrastructure, and are dependent on us for technical services for Direct messages to remain meaningful use compliant, or for public health reporting. Another dozen or so are connected to us using our web mail product, because they either have an immature electronic health record (EHR) or none at all. The remaining organizations are connecting to us via another vendor, so we’re connected through DirectTrust on some cases, for example. So we have these three flavors of connectivity, and as we’re coming in to the end of our third year of contracts with clients, there are questions about continuing to pay for consulting services if they’re not getting technical services. And that answer varies depending on how the organization is connected to us.
How much data is being exchanged?
Depending on how you want to carve it out, taking out the acknowledgement messages that go around our network, we’re sending about 300,000 public health messages per month from our organization to state, so a lot of syndromic surveillance and electronic lab reporting is happening. Between providers, about 2,000 to 3,000 Direct messages or transfer of care (TOC) summaries are going across the NHHIO network. There are about 10 other HISPs [Health Information Services Providers] in the state, so if you multiply that out, there are a really good number of transfer of care [summaries] happening.
Compared to other public HIEs, NHHIO didn’t receive a ton of federal funding. How has this impacted your operations?
We received just under $5.5 million in federal funding, which was our original grant, and that was pretty small compared to a lot of other states. But that helped us build the infrastructure and pay for a lot of our upfront costs. We had a really good relationship with Orion Health, our technology vendor, to make the cost structure meet our capabilities. So because we didn’t have any state funding on top of that, we had to go to our clients for membership fees. Now, we have a revenue-based fee scale to determine how much each organization pays. In some cases, higher end hospitals will stay with us for a few years since they are dependent on us for the services, but for those organizations who are using vendor-driven technologies, you may see a reduction. We are taking a close look at our staffing model to make sure we’re not overstaffed, and if anything I would say that we’re understaffed for what we’re trying to accomplish.
We are also starting to look at other revenue opportunities, such as more grants. We were just rewarded an ONC grant to expand the use of Direct across the state, which was worth about $1.7 million. Also, we are keeping a close eye on MACRA funds to support rural and small practice providers from a technology standpoint. We’re also applying for the Section 1115 Medicaid waiver for experimental, pilot, or demonstration projects.
The other route would be a vendor-driven model. We’re not a centralized repository, and there are legislative restraints on us in terms of what we can and cannot do in terms of data storage, so we’re looking at vendor opportunities that meet the needs of our organizations. Again, we are putting on that facilitating hat, finding one vendor to universally support this [initiative] to drive down the cost and maximize the efficiency. But there are some flow-through funds for NHHIO since there will vendor members of our organization that use some of our infrastructure to support their activities—things such as event notification, secure texting, things that providers want, but don’t want to go off and buy individually.