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The Health Information Exchange Organization (HIEO) was launched several years ago with the goal of helping to lower the state’s staggering healthcare expenses and improve the state’s consistent poor rankings in leading health indicators, including obesity, smoking, diabetes and heart disease. Improving healthcare through the enhanced use of information technology and data exchange is the heart of what we do. We manage one of the country’s largest and most successful health information exchange (HIE) networks, provide advisory services that help healthcare professionals effectively use technology and improve care delivery, and supply health plans and accountable care organizations (ACOs) with valuable data that enhance analytics and population health programs. We’ve been in existence for several years and now have the majority of the state’s hospital providers and have many physicians, reference lab, diagnostic radiology centers, mental health providers and other providers participating in our exchange. All participating organizations send electronic health information to the exchange including hospital transcribed documents (H&Ps, Discharge Summaries, Operative Reports, etc.), lab results, diagnostic radiology results, and other clinical documentation.
As an independent, nonprofit organization, we are dedicated to serving all of the state’s healthcare stakeholders including physicians, hospitals, behavioral health, emergency medical services, public health, long-term care, laboratories, imaging centers, health plans, communities, and patients. We are self-sustaining and our funding comes from a fee-based subscription model. We were previously the recipient of three grants focused on building capacity for statewide health information exchange, including two grants from the American Recovery & Reinvestment Act (ARRA) HITECH program.
Our Mission is: Through information exchange, we improve health and healthcare.
Our Vision is: Patients will be measurably healthier as organizations and individuals that contribute to health and healthcare effectively utilize information provided by the HIEO to continuously improve patient care and population health.
IG Program Description:
In partnership with the communities and people we serve, we have expanded our data use policies with the goal of improving the integrity and quality of the data we store on each patient. We created an HIM Steering Committee, chaired by the CDO, to provide oversight to our IG activities and it is comprised of HIM and IT professionals from our member organizations. This Steering Committee creates a report on a quarterly basis that is presented at the HIEO board’s meeting and a more detailed report presented monthly to the HIEO’s executive team. We have developed policies and procedures to guide our Data Management processes. These policies cover data management oversight, data management responsibilities, types of data management staffing required, staff training requirements, quality assurance processes and reporting, and accountability and authority of the HIEO, the Steering Committee, and the CDO.
We are also a participant in the eHealth Exchange initiative, a group collaborating on and working toward interoperable health information exchange, and DirectTrust, a non-profit, competitively neutral entity created by and for participants in the Direct community, including HISPs, CAs and RAs, doctors, patients, and vendors.
Prior State Analysis:
Participating organizations send interface transactions into the HIEO’s database and contain information such as lab results, diagnostic imaging results, etc. These interface transactions had to meet basic record match criteria such as matching on the Assigning Authority from the sending organization and medical record number (or other unique patient identifiers for that organization.) If the transaction did not meet that first level of record match a demographic data match was attempted. The last name, first name, date of birth and address was used to determine if a record for that patient already existed in the database. If these four elements matched exactly, the transaction was posted to the existing record. If it did not meet these four criteria, a new person/patient level record was created in the HIEO database and the transaction information posted to the new record.
Additionally, transactions were evaluated to determine that minimum record and patient identity data fields were populated including assigning authority, medical record number (or corporate medical record number), patient’s last name, first name, date of birth and gender. If these basic minimum requirements did not exist, the transaction failed to post to the HIEO database.
No communication was sent to the participating organization regarding failed messages. Additionally, no data integrity assessment was done on transactions received to determine whether data values were populated with default data values and therefore no reporting was provided back to the sending organization on the quality of the data they sent.
Describe data management program:
Following the completion of the HIEO’s new strategic plan, the CDO was hired to implement a new data management program. Initially, she had queries run on the HIEO database to identify the volume of records with the inadequate population of key record matching data fields including the patient’s last name, first name, middle name, date of birth, gender, last four of the SSN, address and telephone number. She analyzed the results of these queries to stratify them by members, date ranges of transactions received and each individual data field.
New policies and procedures were then developed to describe minimum data requirements for patient identity, record matching guidelines, duplicate record validity decision-making, interface requirements related to minimum data and data mapping, interface test plans with scenario use cases and testing scripts, data integrity evaluation and maintenance processes, record correction/merging procedures, reporting of data integrity issues and duplicates to provider members and data integrity reporting. These policies and procedures were presented by the CDO to the executive team. Following the initial approval by the executive team, the CDO presented the program and the policies to the full board and they were approved. The data management program was now official.
Eighteen months ago the CDO began presenting to the executive team monthly reports on member data integrity and quality. A high-level data integrity report was provided a year ago to the HIEO board which showed by members (anonymously) the percent of transactions the HIEO received with blank or default values on key demographic data values. Additionally, research into new record matching algorithm and data integrity products was completed and a product was selected that can be integrated into the existing HIEO platform. After receiving the data integrity report and the financial proposal for the record matching/data integrity product (“identity management” product), the board approved the acquisition of this new technology. This new product utilizes an advanced record matching algorithm that is error-tolerant of typical data discrepancies across multiple records for the same patient. It also has a workflow tool that allows for efficient review of possible duplicate records, error queues for data integrity issues and the evaluation and reporting of such and to support management reporting needs. It was implemented six months ago.
Additionally, in the past year, the CDO began hiring data integrity staff to monitor the daily error logs and aggregate results from these error logs weekly and provide this data to the CDO. Initially, these specialists were only able to monitor and aggregate results from the error logs. Subsequent to the implementation of the new identity management product the specialists are now reviewing the potential duplicate queue in addition to working the transaction error queues. One specialist was appointed as Data Manager and she is responsible for compiling the reports to each member organization regarding the summary of data integrity issues on a monthly basis. Additionally, she provides a list of the data integrity issues for the applicable member’s records. Another responsibility she has is to summarize the intra-facility duplicates sent to the HIEO by each organization and provide that report monthly to the CDO. She also provides each member with a list of their intra-facility duplicates in order for the member organization to resolve these possible duplicates in their source system.
The CDO designed dashboard reports for presentation to the executive team and the board generated from the identity management product. These reports will address the HIEO’s strategic initiatives and goals set forth by the executive team, HIM steering committee, and board.
After the implementation of the identity management product, a data analysis of the entire HIEO EMPI database was completed. This analysis identified a 30% cross-organization duplicate rate, intra-organization duplicate rate of 8% and several data integrity issues including 35% of the records having a blank value in the last 4 digits of the SSN, 70% of the records missing a middle name value and 10% having a default value in the date of birth field. All of these data integrity issues severely compromise the HIEO in successfully matching records for the same patient from different member organizations. The HIEO set a goal of reducing cross-organization duplicate rates to less than 5% which was approved by its board and communicated to its members.
The CDO created a plan to resolve the duplicates, work with member organizations to improve patient identity data capture processes in each organization and begin a monthly reporting process to the members, the executive team and the board. The plan included creating a data dictionary with definitions of key patient identity demographic data elements to be shared with all members, documenting the HIEO’s EMPI data model, working with the HIEO technical team to ensure appropriate data mapping of values in transaction messages sent into the HIEO, contracting with an identity management cleanup company to resolve cross-member duplicates, providing members with their intra-organization duplicates and summary reports. Summary reports included data integrity statistics and data patterns, member duplicate rates and overall cross-organizations duplicates with the HIEO database created due to incomplete or discrepant data.
Following the initiation of the reporting and post the cleanup, the HIEO was able to reduce the cross-organization duplicate creation rate to less than 10%, and an improvement in data capture of SSN, middle name and date of birth. Intra-organization duplicate rates only dropped to 6%. These results allowed the data integrity team to successfully manage these issues and provided the needed information for the CDO to continue to work with member organizations on data integrity improvements in each organization. The number of complaints filed by member organizations and providers dropped 50% and it is expected they will continue to decrease as subsequent efforts by the HIEO and member organizations continues.
The HIEO began to get complaints from participating physicians and other organization members regarding four major issues:
As specific examples were researched, a fifth challenge was identified. This was related to the HIEO’s system having immature tools to identify, resolve duplicate records and pull apart data from an overlaid record.
IG Program Structure:
The Executive Vice President (EVP) for HIE Network Integration serves as the accountable executive for the exchange program. S/he shall have the authority to delegate strategic alignment to other accountable executives in the HIEO. The Chief Data Officer (CDO) is the strategic executive charged with the strategic development of the IG program as noted previously.
As a clinical data repository (CDR), our HIE is structured as a “centralized” exchange model. Participating organizations shall sign a Business Associates Agreement (BAA) which outlines the accountabilities of the HIEO and the participant. Our organization has established an infrastructure and IT governance process that manages and keeps secure all data contained within the CDR. The HIEO is accountable for assuring version control of software, DURSA requirements for exchange, any necessary dispute resolution. The CDR meets all of the Direct Trust requirements for interoperability. The exchange of information is done via continuity of care documents (CCD’s) and a subset of information from each participating organization’s electronic medical record (EMR). All organizations must have attested to meaningful use and have a fully functional EMR which can interface with the HIE; a “common” EMR is not a requirement. The participant organization is responsible for managing all IT interface connection testing while incorporating the HIEO testing standards and “build”. Participating organizations are responsible for managing their consent and authorization process consistent with state/federal requirements, maintaining appropriate auditing processes for users, maintaining secure log-on requirements and complex password maintenance. The HIEO and the provider organization will work in a collaborative manner to resolve any security threats or breach events that might result. The HIEO shall stipulate to “good maintenance” requirements as a part of their oversight and administrative duties. Servers with maintaining the CDR data is maintained off-premise in the organization’s data center with redundant servers located in a separate location.
The HIEO has an established information governance (IG) program to support the EMR and the CDR. The framework for IG follows the tenants described by the American Health Information Management Association (AHIMA) and the American Record Management Association (ARMA).
The IG program has established a HIM steering committee as its governing body. At the time of development, a project management (PM) approach was taken in order to ensure stakeholder involvement and strategic alignment. This organization has a centralized approach to IG within the organization. There is a centralized authority led by the EVP and CDO with a secondary group of leaders from across the organization that provides control and decision-making authority for information obtained at the enterprise level. There are subgroups with responsibilities for data within their respective business areas, and additional staff can be brought into the program to design workflows. (from AHIMA IG toolkit).
Project components in establishing our IG program included: (from AHIMA toolkit)
The IG program has created new synergy in managing information that supports care delivery for HIEO participants. The project plan, once implemented, created a standard for information maintenance and accountability. During the implementation period, there was significant focus on “quick wins” for the program and notably, there were several challenges that were positively impacted.
After initiation of the project and a period of normalization, identified gaps in some of the types of analytic reports, a deeper understanding of consent management, operational accountability for contributing partners for consent values and managing problem lists and medication reconciliation were identified. The initial project plan had identified “accountability” but did not describe specific requirements and analysis needs. This has unfortunately resulted in unresolved redundant data in the EDW which has created dissatisfaction and concerns of data accuracy and integrity. Audit tools exist within the HIE process but the reports are difficult to interpret and need to be re-tooled to be more user-friendly. Patient matching has worked well, however, the process for individual organizations to manage respective EMR transactions has been problematic. Consideration is underway by the CDO to implement a new project plan to identify gaps and mediation strategies, specifically related to contributing partner consent management.
IG Challenges Resolved:
Following the implementation of the IG program and its related activities, the HIEO gained knowledge regarding key data quality initiatives needed to effectively manage its record matching. The staffing required to manage error queues and duplicates was able to be maintained with increases, even as the HIEO membership grew and volume of EMPI records increased. This was a direct cost savings to the organization. The HIEO’s reputation within the state improved and additional member organizations joined.
The IG program has created new synergy and partnership in managing information that supports care delivery for HIEO participants. Providers have a broader clinical profile that supports population health and works to decrease costs. Patient matching tools and initiatives have been implemented which has significantly improved the provider experience, patient experience, decreased the need for redundant testing and improved the care continuum for the patient.
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