Pennsylvania ehealth Partnership Authority Health Information Organization Survey. January 2016

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1 Pennsylvania ehealth Partnership Authority Health Information Organization Survey January 2016 Page 1 of 16

2 Table of Contents Introduction... 3 Key Points and Findings... 4 ehie Technology Models... 5 Technology Vendors... 5 P3N Intentions... 5 Return on Investment... 5 ehie Functions Adoption... 6 Exchange Methods... 8 Structure and Vocabulary Standards... 9 Participating Providers Service Coverage Area Page 2 of 16

3 Introduction The Pennsylvania ehealth Partnership Authority, hereafter referred to as the Authority, conducted a survey in November and December of 2015 of health information organizations (HIO) operating in Pennsylvania. This survey refreshes and adds to information gathered in similar annual surveys completed since Seven organizations participated in this year s survey, five returning from the previous year, and two new organizations: Behavioral Health HIE and Mount Nittany Health Exchange. Two previously participating organizations, MaxMD and Tapestry HIE, have discontinued their HIO activities. This year s survey was truncated compared with previous surveys. In 2015 the Authority, in collaboration with the HIOs, completed efforts to renew the Authority s HIO certification framework. This framework encapsulates consensus views on policy, consent management, and legal issues that were topics for examination in previous years surveys. Those interested in this issue should refer to the HIO certification package, and related policies, available on the Authority s website at We also omitted questions related to communications and outreach and most questions related to finance from this year s survey. Little or no new information emerged in the responses to these questions over the past several years, so they were discontinued. Each section of this report begins with a table summarizing the results, including comparisons with prior surveys where available. Increases in yearover-year results are shown in green, decreases are shown in red. Black indicates unchanged results or changes that appear to be an artifact of the change in the survey participants. Certain information is proprietary and therefore has been omitted from this report, or is presented only in aggregated format. For presentation purposes, several HIOs legal names have been truncated in this report, per the following crosswalk: Health Information Organization Name Crosswalk Legal Name Behavioral Health HIE, powered by Pennsylvania Psychological Association/ Community Data Roundtable ClinicalConnect HIE evantagehealth, powered by St. Luke's University Health Network HealthShare Exchange of Southeastern Pennsylvania Keystone Health Information Exchange Lancaster General Health Mount Nittany Health Exchange Abbreviation BHIE ClinicalConnect evantage HSX KeyHIE LGH MNHX Page 3 of 16

4 Key Points and Findings P3N Participation: Seven organizations participated in the Authority s 2015 HIO survey. One is already connected to the P3N, three are in the process of connecting, and two more expect to be connected by the end of Only one of the responding HIOs, BHIE, is uncertain if they will connect to P3N directly or via another HIO. Technology: As in the past, there remains considerable diversity in the technology models and vendors employed by the participating HIOs. Return on Investment: While some organizations are identifying perceived value in ehie, measurable return on investment for either the HIOs or their member organizations remains elusive. ehie Functionality: Discharge summaries remains the only universally enabled/planned function among the survey participants. Decreases in planned capabilities have occurred for alerts, patient portals, provider-topatient messaging, and referral/consultation request and delivery. Quality/safety analysis and reporting is the only function with increased planned adoption. Exchange Methods: The trend identified in earlier surveys toward adoption of both push and query for most ehie functions continues. Standards Adoption: There has been an increase in adoption for most vocabulary standards, possibly indicating increased industry maturity. Adoption of structure standards is consistent with previous surveys except for C-62, an unstructured document standard, and HPD, a standard for provider directories, which have decreased. Provider Participation: All five survey participating HIOs who also participated last year reported advances in current participation for several provider categories, most notably urgent care centers. Actual and/or planned participation also increased for payers, ambulatory surgery centers, long-term/post-acute care facilities, mental health/substance abuse facilities and physical therapy/occupational therapy practices. The most underserved provider types (current or planned) included in the survey are independent imaging centers and independent reference laboratories. Geographic coverage: Coverage by HIOs has dramatically shifted to a much more regional focus for many HIOs compared with previous reports. There is very little overlap county-to-county for current participation (only eight counties), and only 20 counties have overlapping planned coverage, not counting BHIE, which plans to operate in all counties, but specializes in behavioral health providers. Only a single county, Berks County, does not have planned coverage by at least one HIO, again not counting BHIE. Page 4 of 16

5 ehie Technology Models Two of the responding HIOs BHIE and LGH are implementing centralized data models, meaning that they are aggregating the data from their constituents in centralized repositories. All other respondents are implementing hybrid models where some information is aggregated, while other data remains federated in repositories maintained by their members (i.e. electronic health record systems). Technology Vendors Six of the seven responding HIOs identified their software and services vendors in their survey responses. A dozen different vendors were identified with minimal overlap. P3N Intentions A key eligibility requirement for Authority HIO certification and connection to the Pennsylvania Patient and Provider Network (P3N) is that an HIO must enable information exchange between unaffiliated organizations. All but one of the responding HIOs indicated that they currently meet this requirement. The exception HIO indicates that they will meet this requirement by the time they are ready to certify and connect. evantage is currently connected to the P3N. Three more HIOs ClinicalConnect, HSX, and KeyHIE are currently in the process of connecting to the P3N. MNHX is in the process of applying for certification and connection, while LGH states they intend to connect in Among the survey participants, only BHIE is still in the process of determining their intentions for connection to the P3N. Return on Investment HIOs were asked whether they had any measurable return on investment (ROI) directly resulting from electronic health information exchange activities, for either the HIO or for the HIO s participants. Two organizations identified indication of such an ROI, but in both cases stated that there was insufficient data to offer more concrete information. Clearly this remains an area for further investigation and development. Page 5 of 16

6 BHIE ClinicalConnect evantage HSX KeyHIE LGH MNHX 2014 Rate 2015 Rate PA ehealth Partnership Authority January 2016 ehie Functions Adoption HIOs were asked which functions they have implemented or plan to implement. Rates include both HIOs who are currently and planning to offer each function. The results of the survey are compiled in Table 1. Table 1: ehie Functional Summary Function Active Care Coordination 17+ O O O 100% 86% Alerts O O O 86% 71% Discharge Summaries 17+ O O O O O O 100% 100% Historical Lists (Medications, allergies, etc ) 16 O O O O O 86% 86% Longitudinal Medical Records 16 O O O O O 86% 86% Meaningful Use Analysis And Reporting O O O O 57% 57% Order/lab results delivery O O O O O O 100% 86% Patient Portal 16 O O O 71% 57% Provider to Patient Clinical Messaging 17+ O O O 86% 57% Provider to Provider Clinical Messaging 17+ O O O O % 86% Quality/Safety Analysis And Reporting O 57% 71% Referral/Consultation Request 17+ O 57% 29% Referral/Consultation Delivery 17+ O 71% 29% Additional Functions Legend Currently Operational O Planned in Planned after HIOs were asked about their current capabilities for two additional functions: All responding HIOs except ClinicalConnect offer functionality that enables providers who do not have EHR systems, or who have EHRs that don t support ehie, to participate in their networks. Only KeyHIE and LGH offer non-standard data transformation and translation services. Note: Several previously reported functions have been dropped from this year s survey: Master Patient Index, Provider Directory/Index, Record Locator Service, registries, and role-based access control. These functions are primarily capabilities associated with the HIOs technology models and are different from the other functions shown in the chart, which are more directly client-facing services. Page 6 of 16

7 ehie Functions Adoption Observations Organizations who participated in last year s survey appear to be consistent in most current capabilities and intentions compared with last year, though in some cases planned implementation time for planned functions has been extended. evantage has gone live, as previously planned, with provider-to-patient clinical messaging reporting. They appear to have dropped previously reported plans to implement alerts and referral/consultation requests and deliveries. HSX has gone live, as previously planned, with alerts, historical lists, longitudinal medical records, meaningful use analysis and reporting, and order/lab results delivery. They appear to have dropped previously reported plans to implement a patient portal, provider-to-patient clinical messaging, and referral/consultation requests and deliveries. There has been some pull-back in rates for several services, but in all cases of year-over-year decreases the decrease is the result of changes in planned, not currently operational capabilities. The year-over-year decreases in order/lab results delivery is the result of new HIOs joining the survey, not a change in status for previous participants. There has been an increase in adoption of quality/safety analysis and reporting, but as in this past, this rate, in most cases, reflects plans more than currently operational capabilities. Discharge summaries is the only universally enabled/planned function among the HIOs participating in the survey. LGH reports the highest number of operational functions, while ClinicalConnect and MNHX report the most narrowly focused initiatives. In last year s survey, the function with the most significant decrease in current or planned adoption was referral/consultation request. The move away from both this and referral/consultation delivery continues, as now only LGH reports this function operational, and only one other, BHIE, reports plans in this regard. KeyHIE noted in their survey response that they also offer sensitive data scanning services. Other HIOs were not asked this question. Page 7 of 16

8 BHIE ClinicalConnect evantage HSX KeyHIE LGH MNHX PA ehealth Partnership Authority January 2016 Exchange Methods Survey participants were asked which methods they planned to use for sharing data. Table 2 summarizes the data collected from the survey. Table 2: Exchange Methods Summary Function Active Care Coordination Q,P (Q,P) (Q,P) Q,P D Alerts D(Q,P) D,P P Discharge Summaries P Q,P D(Q,P) Q,P Q,P P(Q) Historical Lists (Medications, allergies, etc ) Q,P Q,P Q,P Q,P P(Q) Longitudinal Medical Records Q,P Q,P Q,P Q,P Q,P Order/lab results delivery P Q,P Q,P Q,D,P Q,P P(Q) Provider to Patient Clinical Messaging D D Provider to Provider Clinical Messaging D D(Q,P) D D (D,P) Quality/Safety Analysis And Reporting (Q,P) (Q,P) Q,P Referral/Consultation Request D(P) Referral/Consultation Delivery D(P) Note: Not Planned means that the HIO did not convey intentions to adopt this function in Table 1. No Response means that the HIO reported current or planned adoption in Table 1, but did not provide information about exchange methodology. Exchange Methods Observations Legend Query Q DIRECT D Push (other than DIRECT) P Not Planned No Response Parentheses () indicate future plans There is an evident trend, continuing from prior surveys, toward use of both push and query across virtually all functions, except for the two clinical messaging functions. As in previous surveys, all HIOs providing responses to this question offer or plan to offer query for at least one function. Page 8 of 16

9 Vocabulary Structure BHIE ClinicalConnect evantage HSX KeyHIE LGH MNHX 2014 Rate 2015 Rate PA ehealth Partnership Authority January 2016 Structure and Vocabulary Standards Survey participants were asked whether or not they were adopting various structure or vocabulary standards. Blanks indicate no response or a no response. Table 3 summarizes the data collected from the survey. Table 3: Structure and Vocabulary Standards Adoption Standard HL7 Yes Yes Yes Yes Yes Yes Yes 100% 100% C-32 Yes Yes Yes Yes Yes Yes 86% 86% C-62 Yes Yes 57% 29% CCD Yes Yes Yes Yes Yes Yes Yes 100% 100% CDA Yes Yes Yes Yes Yes 86% 71% C-CDA Yes Yes Yes Yes Yes Yes Yes 100% 100% HPD Yes 43% 14% LOINC Yes Yes Yes Yes Yes Yes Yes 86% 100% SNOWMED CT Yes Yes Yes Yes Yes Yes Yes 71% 100% OID Yes Yes Yes Yes Yes Yes 86% 86% ICD-9 Yes Yes Yes Yes Yes Yes 86% 86% ICD-10 Yes Yes Yes Yes Yes Yes Yes 86% 100% RxNorm Yes Yes Yes Yes Yes Yes 57% 86% NPPES Yes Yes Yes Yes Yes 14% 71% Structure and Vocabulary Standards Observations Adoption of structure standards has remained consistent with last year s survey, except C-62 and HPD have declined. The decline for CDA is due to changes in survey participants rather than changes by returning survey participants. C-62 is a standard for unstructured documents, and the decline is likely due to the universal adoption of C-CDA which includes provisions for unstructured documents. HPD is a standard for the structure of provider directories. While it is not a new standard, it has been subject to recent revisions, and it has probably not been a priority for HIOs to undertake efforts to update their provider directories to the latest version of the standard. We anticipate that we may see migration back toward this standard in the future. Page 9 of 16

10 Structure and Vocabulary Standards Observations (Continued) There have been increases in adoption for most vocabulary standards included in the survey. Of note, HSX, KeyHIE, and LGH now report adoption of all vocabulary standards included in the survey. The increases in adoption rates for vocabulary standards may be an indication of maturation of the industry in this aspect of health information technology. Page 10 of 16

11 BHIE ClinicalConnect evantage HSX KeyHIE LGH MNHX 2014 Rate 2015 Rate PA ehealth Partnership Authority January 2016 Participating Providers The HIOs were asked with which types of providers they are currently connecting, and which types they planned for future connections. Table 4 shows the results. Rates include both those currently connected and those planned to connect. Table 4: Participating Providers Participant Type Payers P P C C C P 57% 86% Hospitals C C C C C C 100% 86% Ambulatory Surgery Centers C C C C P C 86% 86% Long-Term/Post-Acute Care Facilities C P C C P P 86% 86% Mental Health/Substance Abuse Facilities P P C C P P 71% 86% Outpatient Cancer Treatment Centers C P C C C 86% 71% Urgent Care Centers C C C C C 86% 71% Physical Therapy/Occupational Therapy Practices C C C P C P 86% 86% Community Clinic/FQHC P C C C P P 100% 86% Other Ambulatory Practices (includes primary care) C C C C C C 100% 86% Independent Imaging Centers P P P 71% 43% Independent Reference Laboratories P P P 71% 43% Ambulance/EMS services P P C P 71% 57% Home Health Agencies P P C C P 86% 71% Participating Providers Observations Legend Current Planned No Response or Not Planned While 2015 survey rates appear to have decreased in many categories, these changes are attributable to the change in the population of HIOs participating in the survey, most notably the addition of BHIE which is focused specifically on mental health/substance abuse facilities and payers. Among those HIOs participating in last year s survey, rates remained unchanged for most categories, while actually increasing for payers, ambulatory surgery centers, long-term/post-acute care facilities, mental health/substance abuse facilities, urgent care centers, and physical therapy/occupational therapy practices. Similarly, all five HIOs participating in last year s survey reported advances in current participation for several provider categories. Most notably, all five repeat participants report current status for urgent care centers, whereas in 2014 four HIOs reported planned status and one reported no plans. C P Page 11 of 16

12 Participating Providers Observations (Continued) Other notable increases in current participation status include ambulatory surgery centers and physical therapy/occupational therapy practices. They only provider types not currently participating with any HIO are independent imaging centers and independent reference laboratories. In the case of the labs, this represents a small regression, since evantage has reported independent lab participation in past surveys. All participating HIOs have plans to expand the types of participants in their networks. Some indicated that they would be willing to discuss participation by any provider type, and that their responses to the survey only reflect concrete plans, but other HIOs were not specifically asked this question. KeyHIE also reports plans to incorporate dialysis centers and certain social services, but other HIOs were not asked these questions. Note: Previous surveys asked HIOs to provide details on how many of each type of provider were participating in their networks. Tabulation of results of these questions was complicated by different interpretations applied by different respondents, as well as by the fact that not all HIOs responding to the survey were willing to answer these questions. For this reason, and because the Authority intends to commence required, well-defined participation reporting by certified P3N-participating HIOs in the near future, these questions were omitted from this year s survey. Page 12 of 16

13 BHIE ClinicalConnect evantage HSX KeyHIE LGH MNHX Current Planned BHIE ClinicalConnect evantage HSX KeyHIE LGH MNHX Current Planned PA ehealth Partnership Authority January 2016 Service Coverage Area HIOs were asked to identify the counties in which their current and planned participants are located. Table 5 shows the results, with coverage maps provided on pages 15 and 16. Table 5: Service Coverage Areas County County Adams P P 0 2 Lackawanna P C 1 2 Allegheny P C 1 2 Lancaster P P C 1 3 Armstrong P C 1 2 Lawrence P C 1 2 Beaver P C 1 2 Lebanon P P C 1 3 Bedford P C 1 2 Lehigh P C C 2 3 Berks P 0 1 Luzerne P C 1 2 Blair P C C P 2 4 Lycoming P C 1 2 Bradford P P 0 2 McKean P P C 1 3 Bucks P C 1 2 Mercer P C P 1 3 Butler P C 1 2 Mifflin P C 1 2 Cambria P P C 1 3 Monroe P C C 2 3 Cameron P P P 0 3 Montgomery P C 1 2 Carbon P C P 1 3 Montour P C 1 2 Centre P P C C 2 4 Northampton P C C 2 3 Chester P C 1 2 Northumberland P C 1 2 Clarion P P 0 2 Perry P C 1 2 Clearfield P C P C 2 4 Philadelphia P C 1 2 Clinton P C P 1 3 Pike P P 0 2 Columbia P C 1 2 Potter P P 0 2 Crawford P C 1 2 Schuylkill P C 1 2 Cumberland P C 1 2 Snyder P C 1 2 Dauphin P C 1 2 Somerset P C 1 2 Delaware P C C 2 3 Sullivan P C 1 2 Elk P P P 0 3 Susquehanna P C 1 2 Erie P C 1 2 Tioga P C 1 2 Fayette P P 0 2 Union P C 1 2 Forest P P 0 2 Venango P C 1 2 Franklin P C 1 2 Warren P P P 0 3 Fulton P C P 1 3 Washington P C 1 2 Greene P C 1 2 Wayne P C 1 2 Huntingdon P C C P 2 4 Westmoreland P C 1 2 Indiana P P C 1 3 Wyoming P C 1 2 Jefferson P P 0 2 York P C 1 2 Juniata P C 1 2 Total Current Planned No Response Legend C P Page 13 of 16

14 Service Coverage Area Observations This year s survey changed the focus of this section of the survey. In the past, some HIOs responded based on where they were willing to provide services instead of actually where they were providing services. This year we clarified that we were asking about actually having clients in a given county, rather than an assertion of ability and willingness to provide services. This clarification produces results that are a better indication of actual, rather than aspirational, HIE coverage. Though not specifically asked, several HIOs stated that they are willing to provide services to any county in Pennsylvania. HIOs are currently providing services to participants in over 80% of Pennsylvania counties, with multiple HIOs currently providing overlapping service in only eight counties. Even discounting BHIE, which plans to connect providers in every county, albeit with a particular provider type focus (see Participating Providers Section), there is planned connection in every county of the state except one, Berks County. The two HIOs who participated in last year s survey but not in this year s survey both intended to offer statewide services, but only actually had current clients in a handful of locations. ClinicalConnect has moved from planned to current participation in Blair, Clearfield, Fulton, and Huntingdon counties, while adding planned participation in Cameron County. evantage has removed current participation in Bucks County, but added current participation in Carbon and Monroe counties. HSX participation has remained unchanged from last year s report. KeyHIE has added planned participation in Adams, Fulton, Lancaster, and Lebanon counties. LGH previously reported current coverage in all counties, but this year LGH has clarified that they currently have clients in Lancaster and Lebanon counties. Interstate and Federal Connectivity Two HIOs report that they currently exchange data with organizations in other states. evantage has a participating hospital in New Jersey, and LGH has connections to hospitals in Delaware and Maryland. All but one responding HIO, BHIE, stated that interstate connectivity via P3N is important to them, though four HIOs are independently planning connections, or additional connections, to organizations in other states. Five of seven responding HIOs reported that they currently exchange or are planning to exchange information with federal-level entities such as the Veterans Administration and Social Security. Page 14 of 16

15 HIOs Currently Operational in the Commonwealth Note: Pennsylvania counties shown in gray indicates no current connections by any HIO responding to the survey. Page 15 of 16

16 Planned HIO Connections in the Commonwealth Number of HIOs: Note: Includes BHIE which plans coverage in all counties, but limited to Mental Health/Substance Abuse Facilities and Payers Page 16 of 16

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