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

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

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?

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

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

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

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

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

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

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

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

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

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

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?

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,