Delaware established the first statewide clinical health information exchange (HIE) in 1997. Compared with other states, it has taken more of a public sector approach to HIE governance, though this strategy may be shifting. Its HIE, the Delaware Health Information Network (DHIN), is a public–private partnership that operates under the auspices of the Delaware Health Care Commission, which the state created in 1990 with the goal of moving toward basic, affordable health care for all residents.
DHIN began as an effort to create a state administrative data exchange, which would have allowed providers and payers to share claims and encounter data describing the use of specific services. However, as health plans increasingly took on the responsibility for electronic use of administrative data, and as HIEs gained attention at the federal level, DHIN shifted its focus in 2003 to clinical information that providers could use at the point of care to improve patient outcomes and increase efficiency. DHIN began distributing clinical laboratory test results, radiology reports, and admission face sheets from hospitals and laboratories statewide in 2007, and since then has been expanding its functionality, number of users, and data contributors. DHIN Executive Director Gina Perez said, "The process has centered around getting everyone to the table, reaching consensus on priorities for what we're building and how we're implementing it, and maintaining a focus on the patient."
The exchange currently provides laboratory results; hospital admission, discharge, and transfer data; and radiology reports, using the Web-based ProAccess application developed by Medicity. Radiology images, electronic order entry, and transcribed reports will be added in coming months, and a medication history search function will soon be piloted in emergency departments to evaluate its performance and cost. More than half the providers in Delaware now use DHIN. Over 85 percent of lab transactions in the state go through the system, and more than 80 percent of hospitalizations are reported in it. Clinical information from laboratory and hospital participants is automatically delivered through DHIN in real time to the ordering provider at the point of care. Six hospitals currently participate and two more are considering joining, out of a total of nine in the state.
Perez highlighted DHIN's ability to work with providers at all levels of technology adoption as a strength of the exchange. Providers access DHIN by logging into an online "inbox," where results for their patients are delivered. If they already use an EHR, the data links to patients' electronic records. If the office uses paper records, the provider can schedule the program to regularly print out patient results in a standardized format, to be integrated with paper files. DHIN will also soon add an EHR Primer, an intermediate step between paper-based and fully electronic records, which will help providers who would otherwise be unlikely to purchase an EHR meet federal "meaningful use" criteria to qualify for incentive payments offered as part of the American Recovery and Reinvestment Act (ARRA).1
For patients, participation in DHIN is on an opt-out basis. Patients receive information about the exchange at the point of care, and can decline to participate. DHIN's consumer advisory committee, composed of a wide range of individuals and organizations (including advocates for people with disabilities, mental health advocates, cancer survivors, community health centers, AARP, and others) plays a strong role in the program's governance, and worked extensively to develop its privacy policy. According to Perez, the opt-out structure has not proved a major challenge as the system has expanded. "The focus has always been on the system's ability to ensure that providers have the right information at the right time and place in order to provide better care, and that this is a patient and physician decision," she said.
Governance Model
DHIN was established in 1997 under the umbrella of the Delaware Health Care Commission, but governs itself. Its board of directors consists of representatives from the hospital, physician, state, employer, consumer, and insurance worlds, of whom roughly 70 percent are from private organizations and 30 percent are from the public sector (Figure 2). Perez anticipates that the DHIN governance structure will change over time, likely shifting more toward the private sector. The board is considering whether and how it could retain the liability protections and state funding established in the legislation that governs it, but operate more extensively in the private sector. At the same time, DHIN is attempting to diversify its sources of revenue as part of an evolving strategy to ensure its financial sustainability over the long term.
Figure 2 (click to view)
Financing
DHIN is currently funded in roughly equal amounts through federal contracts, state funding appropriated by the legislature, and private-sector funds to match the state contribution. Ninety-five percent of this private-sector funding is contributed by hospitals and laboratories that are using DHIN to replace their current paper-based systems, while about 5 percent consists of grants from private foundations and funding from health plans. The federal funding DHIN currently receives through a contract with the Agency for Healthcare Research and Quality under its State and Regional Demonstration Projects ends in September 2010. This contract provides $5 million in funding from 2005 to 2010. DHIN also participates in the Nationwide Health Information Network, receiving contractual funds from the Office of the National Coordinator for Health Information Technology, and funding from ARRA is expected to begin in January 2010. Perez said the availability of stimulus funding may accelerate DHIN's timeline for implementing new features over the next several years.
The program is currently developing a long-term financial sustainability strategy that will diversify its revenue sources and move it toward heavier reliance on fees or subscriptions from providers and other types of participating organizations. The costs to the various entities now using the system will be based on the relative value of the exchange to them, which DHIN is currently determining how to evaluate. It expects to implement a new financing model at the start of the next fiscal year. In developing the new strategy, DHIN aims to balance expanding its capabilities with the goal of cutting its operational costs, a tension that is particularly acute in the current economic environment.
Key Lessons
The program's vision is to develop a network among all health care providers to "improve patient outcomes and patient–provider relationships, while reducing service duplication and the rate of increase in health care spending." A strong, inclusive strategic planning process and involvement of all stakeholders to build consensus and tailor implementation to the particular needs and capabilities of participants have been important factors enabling DHIN's progress so far. The network started with a foundation of basic functions, rather than trying to be "all things to all people" immediately. The long-term commitment of its organizers and an active planning process have allowed it to build on those capabilities gradually, while remaining responsive to the needs of those who will be using and paying for it. Perez noted that the challenges and importance of collaboration are similar regardless of a state's size, although Delaware's small size was an advantage once the exchange was operational. "The legislation was enacted in 1997, and DHIN went live in 2007, so we didn't just snap our fingers and make it happen," she said. "The common thread over the course of DHIN's development was the strong commitment of people who wanted to improve the health care system and truly have an impact on quality, access, and cost."
DHIN is also participating in discussions with nearby states about how to share information and address privacy issues, and how to approach public health reporting and quality measurement from a regional perspective as the use of health information technology continues to expand.
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Note
1. This EHR primer would include an electronic calendar, the capability to view and update chart information, electronic prescribing and test orders that interface with DHIN, an internal e-mail system to be used within a practice, the ability to automatically merge demographic and clinical information to generate letters to be sent to outside organizations, and the ability to create custom electronic forms. It would support expected ARRA meaningful use goals of storing patient demographic information and care preferences, and maintaining updated information about health problems and treatments. However, the primer does not have all the functions of an EHR; for example, it allows only limited documentation, and does not include electronic submission of bills.