Health Information Exchange Case Study
Northern California Health Information Network
January 30, 2014
Katherine K. Kim
Danielle Gordon
San Francisco State University, Health Equity Institute
Prepared for California Health eQuality
University of California Davis
Institute for Population Health Improvement
http://www.ucdmc.ucdavis.edu/iphi/programs/cheq/
Copyright © 2013 The California Health and Human Services Agency (CHHS). All rights
reserved.
This publication/product was made possible by Award Number 90HT0029 from Office of the
National Coordinator for Health Information Technology (ONC), U.S. Department of Health
and Human Services. Its contents are solely the responsibility of the authors and do not
necessarily represent the official views of ONC or the State of California
Contents
Introduction ..................................................................................................................................... 2
Methods .......................................................................................................................................... 2
Description of North Coast Health Information Network (NCHIN) ................................................. 2
NCHIN’s Project Goals and Plans ..................................................................................................... 3
Results ............................................................................................................................................. 4
Participants .................................................................................................................................. 4
Technology .................................................................................................................................. 7
Lessons learned ............................................................................................................................... 9
Sustainability ............................................................................................................................... 9
Practice Workflow ..................................................................................................................... 10
Working with EHR Vendors ....................................................................................................... 10
Interface Implementation ......................................................................................................... 11
Relationship Building ................................................................................................................. 11
Conclusion ..................................................................................................................................... 12
About the Partners ........................................................................................................................ 13
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Introduction
Callifornia Health eQuality (CHeQ), a program of the Institute for Population Health
Improvement at UC Davis, engaged San Francisco State University’s Health Equity Institute
to develop a case study on one of its HIE Acceleration awardees, the North Coast Health
Information Network (NCHIN). This report summarizes NCHIN’s grant goals, the progress
made towards those goals, and lessons learned along the way. We hope that this
information will be of assistance to other organizations who are seeking to launch or
sustain their HIE efforts.
Methods
Two team members reviewed documentation provided by CHeQ including grant proposals,
progress reports, and presentations. CHeQ also made introductions to the grantee’s staff.
SFSU team conducted in-person interviews with three leadership and staff members, a
board member and medical provider, and had one telephone interview with another
community medical provider. Interviews were audiotaped and transcribed for analysis.
The research was conducted from June to December 2013. The protocol was approved by
San Francisco State University Institutional Review Board prior to conducting research.
Description of North Coast Health Information Network (NCHIN)
The North Coast Health Information Network (NCHIN) began as a project of the HumboldtDel Norte IPA and Foundation (HDN) in Eureka, CA. It serves as a data information hub,
receiving health data from labs and hospitals, and routing it to local primary and specialist
medical providers in Humboldt and Del Norte Counties.
Prior to forming NCHIN, HDN initiated the North Coast Referral Network, aimed at
facilitating the electronic transfer of patient clinical data between referring and specialist
physicians. Based on the success of this project, and the commitment of the community to
health information exchange, a decision was made to pursue the formation of a health
information organization (HIO).
NCHIN’s mission statement is to…“provide secure and appropriate sharing of electronic
health and clinical data among diverse organizations facilitating access and retrieval of data
for health care purposes, and to use that, individual, aggregated and comparative clinical
data to improve health outcomes for clinicians and citizens of Humboldt County and
Northern California.”
NCHIN was incorporated as a separate legal entity in 2010. NCHIN is a “virtual”
organization, and utilizes the employees and physical offices of the HDN. There are four
permanent employees who provide services to the Medical Foundation, the IPA and to
NCHIN, designating hours as needed to each entities’ projects.
It is the recipient of four grants from California Health eQuality (one originating from its
predecessor funding agency, Cal eConnect): an HIE Expansion Grant in 2011, an Interface
Grant in 2012, an Immunization Interface Grant in 2013 and a grant to participate in CHeQ’s
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California Trust Framework Pilot in 2013 . The receipt of the Expansion Grant
corresponded with the initial foray into health information exchange (HIE) for NCHIN, and
marks the start of their work in this area. NCHIN also received funds to participate in the
Western States Consortium project, now called National Association for Trusted Exchange
(NATE). In this case study we focus on NCHIN’s work related to the Expansion Grant and
Interface Grant only.
NCHIN’s Project Goals and Plans
NCHIN’s goals in the Expansion and Interface Grants were to lower barriers to community
provider’s ability to meet Meaningful Use requirements by completing the following:
1. Create a conduit for our region to send and receive electronic lab data between
practice offices and lab facilities at the local hospitals.
2. Add 5 new HL7 laboratory interfaces for additional EHRs to route results from local
hospitals to primary care practices and public health.
3. Build an interface to deliver documents and reports from hospitals and public health.
4. Add functionality to the existing IRIS referral system to exchange standard
Continuity of Care Document (CCD) formatted referrals with specialists.
5. Transmit referral data electronically from IRIS to participating practices with EHRs.
6. Extract demographics data from EHRs on a real-time basis to keep the demographic
data in IRIS synchronous with that stored in the EHRs.
7. Continue to provide existing data exchange services such as IRIS to non-EHR-enabled
offices.
Table 1 below summarizes the originally planned activities by category of data as outlined
in the initial project proposal and describes the goals and methods for development.
Table 1. Technology Development Plan
Data
Category
Laboratory
Data
Goals
Planned development methods
1. Create a hub and spoke system
1. EHR vendor will build 3
with NCHIN at the hub and
interfaces
practice offices, tele-health visiting 2. NCHIN will build systems to
specialist centers, specialist offices,
accept lab data from 2 existing
county public health, and local
hospital interfaces and route it
chronic care and other state-wide
to practices.
registries being the spokes.
3. NCHIN will create a channel
with Public Health to receive
lab results
Demographic 1. EHRs will forward demographic
1. EHR vendors will build 3 of the
Data
data to IRIS on a regular basis.
process and message channels.
2. Establish real-time exchanges of
2. NCHIN will build the other 2.
HL7 demographic data between
EHRs and IRIS
Referrals
1. Create a channel for Referral
1. EHR vendors will build 4 of the
Status messages to be routed to
process and message channels.
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Data
Category
CCD
Goals
Planned development methods
the referring provider’s EHR.
1. Provide an HITSP C32 CCD
Component to the specialist
provider at the time of referral.
2. Archive a copy of the CCD in the
NCHIN repository.
2. NCHIN will build the other 1.
1. EHR vendors will build 3
systems to send the CCDs to
NCHIN.
2. NCHIN will build the other 2.
3. NCHIN will build a web portal
to provide access to archived
CCDs to vetted ER providers.
Results
Participants
The intended exchange participants included hospital labs, IPAs, community and Indian
Health clinics, physician practices, and public health. NCHIN exceeded their goals for
interfaces as well as the number of participating organizations. As of May 2013, they
completed implementation of:
 5 active inbound lab feeds
 10 inbound document sources,
 13 outbound feeds to individual practices
 Bi-directional feed for the internet-based referral system.
 Dictated document interfaces
 ADT outbound and ADT inbound from 1 of the local hospitals
 Processed 1.3 million data transactions from March to May, 2013
There was little community interest in building a CCD repository and this deliverable was
cancelled.
Figure 1 shows of the hub and spoke organization of NCHIN as of April, 2013. On the left, in
boxes, are the data sources, organized by provider. On the right are the various practices
that draw data through the NCHIN network. The chart is color coded to indicate the origin
of each interface providing data to a provider site.
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Figure 1. NHCIN Hub and Spoke Data Flows
Table 2 below shows the interface, source, destination and status of each interface as of Dec.
2013 at the completion of the grant.
Table 2. Interface Development
Interface
Dictated documents
Source Entity
Mad River
Community
Hospital (MRCH)
St Josephs Health
System (SJHS)
MRCH
Dictated documents
MRCH
Dictated documents
MRCH
Dictated documents
MRCH
Dictated documents
SJHS
A/D/T messages
A/D/T messages
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Destination Entity/EHR
Current Status
NCHIN
LIVE
NCHIN
Development
NCHIN
United Indian Health
Services/NextGen
Open Door Community
Health Centers/EPIC
Redwood Family
Practice/eClinicalWorks
NCHIN
LIVE
LIVE
Testing
LIVE
LIVE
Interface
Source Entity
Dictated documents
SJHS/MRCH
Dictated documents
SJHS/MRCH
Dictated documents
MRCH
IRIS Interface demographics
IRIS Interface demographics
IRIS Interface –
demographics
IRIS Interface referral status
messages
IRIS Interface referral status
messages
IRIS Interface referral status
messages
Destination Entity/EHR
Fortuna Family Medical
Group/eHealthLine
Eureka Family
Practice/Practice Partner
United Indian Health
Service/NextGen
United Indian
Health Services
IRIS
(UIHS)
Humboldt Medical
Group
IRIS
(HMG)
Fortuna Family
Medical Group
IRIS
(FFMG)
Current Status
LIVE
LIVE
Cancelled due to
funding issues
LIVE
LIVE
LIVE
IRIS
United Indian Health
Services/NextGen
LIVE
IRIS
Fortuna Family Medical
Group/eHealthLine
LIVE
IRIS
Humboldt Medical
Group/Practice Partner
LIVE
Laboratory results
Eureka Internal
Medicine (EIM)
NCHIN
LIVE
Laboratory results
SJHS/MRCH/EIM
Laboratory results
SJHS
Laboratory results
SJHS/MRCH/EIM
Laboratory results
MRCH
Laboratory results
SJHS/MRCH/EIM
Laboratory results
Humboldt County
Department of
Health and
NCHIN
Human Services
(PH)
Laboratory results
SJHS/MRCH/EIM
Laboratory results
SJHS/MRCH/EIM
Laboratory results
SJHS/MRCH/EIM
Laboratory results
SJHS/MRCH/EIM
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North Coast Surgical
Specialists/Allscripts Pro
NCHIN
Eva Teresa Marshall,
MD/Synamed
NCHIN
Humboldt Medical
Group/Practice Partner
Margaret Grossman,
MD/Athena
Fortuna Family Medical
Group/eHealthLine
Redwood Family
Practice/eClinicalWorks
Eureka OB-GYN/Prime
Clinical
LIVE
LIVE
LIVE
LIVE
LIVE
LIVE
Cancelled due to lack
of provider interest
(no cost interface)
LIVE
LIVE
LIVE
Interface
Laboratory results
Single normalized
multi-source feed
Laboratory results
Single normalized
multi-source feed
Laboratory results
Laboratory results
Source Entity
SJHS/MRCH/EIM
PH
PH
Development
LIVE
Laboratory results
SJHS/MRCH/EIM
Laboratory results
MRCH/PH
Immunization Data
UIHS
A/D/T
LIVE
Cancelled due to
funding issues
SJHS/MRCH/PH
Dictated documents
Eureka Family
Practice/Practice Partner
Current Status
SJHS/MRCH/EIM/ United Indian Health
PH
Service/NextGen
Laboratory results
Laboratory results
Destination Entity/EHR
St Josephs Health System
Eureka Pediatrics
Eureka Internal
Medicine/AllScripts
Enterprise
McKinleyville Family
Practice
HSU Health Center/Orchard
LIS
California Immunization
Registry (CAIR)
SJHS/MRCH/EIM/
Redwood Pediatrics/Intergy
Public Health
SJHS/MRCH
Redwood Pediatrics/Intergy
Redwood
NCHIN
Pediatrics
LIVE
LIVE
LIVE
Development
LIVE
LIVE
LIVE
Technology
NCHIN uses Mirth Connect as their core technology for HIE. They have implemented VPN
tunnels, web-based security certificates, or an SFTP file drop system to transmit data,
depending on the capabilities of the sites involved. They have also implemented DIRECT
standard to push data to participants with NCHIN acting as the health information service
provider (HISP). In addition, they support HL7 interfaces as shown in Table 2.
To maintain provider data, NCHIN has a dedicated web portal for participating practices to
access and update their provider data. Changes made to the provider directory are
automatically emailed to the IT department and the NCHIN internal database updates Mirth.
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Figure 1 shows NCHIN’s overall technical schema.
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Lessons learned
The NCHIN team learned many lessons through the grant-funded activities related to
startup and ongoing management of the HIO, working with partners, and technology issues.
Sustainability
NCHIN’s HIO business model includes charging data suppliers a set fee per transaction, and
data recipients a set fee per provider. At the time of the interviews for this report,
participants in the HIO were reviewing a revised Participation Agreement that outlined this
payment structure. It remains to be seen whether customers will accept the pricing model.
Indications from the interviews conducted for this report seem to point toward this being
an acceptable model.
NCHIN is structured in a unique way to leverage existing staff and physical resources. By
contracting existing staff from the IPA, as needed, it has been possible to maintain a highly
experienced, skilled, permanent workforce, even as grant funding for the HIE ebbs and
flows. This has allowed NCHIN to develop additional marketable services, which in turn
contributes to the sustainability of the organization. NCHIN also made a key decision to
assign one administrator to development of revenue generating products/services and
sustainability. At the time of this report, NCHIN was providing a full package of IT support
to three local medical practices.
“[We] know more about people’s EHRs; we know more about their systems,
their IT infrastructure than they do and we needed to learn that to do this
work, to build the interfaces. And so we’re easily the most skilled IT shop in
town by far…And so practices don’t have to get their systems from
somebody, their EHR from somebody, their HIE from somebody, their, you
know HEDIS measure aggregation from somebody. You know my goal is
to have all of that be provided from here.”
In an effort to develop sustainability for the organization, NCHIN also offers a bundle of IT
services to community providers including workflow consulting, hardware and software
consulting, selection, installation and maintenance. In the future, they are considering
adding disaster data recovery as an additional fee-based service. For example, from their
experience as a meaningful use adoption service provider, they created a “Practice Liaison”
position that provides services such as workflow consulting. This service is offered for a fee
to practices needing support around integrating new workflow systems to become aligned
with meaningful use requirements.
“…as practices have come along they’re finally starting to hear that you
can’t put an electronic record system on top of a broken paper
workflow…And so you really need to step back and look at that all over
again. So we can teach them process mapping and quality improvement
and PDSA [plan-do-study-act] cycles...”
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As both a free community service and a marketing strategy, NCHIN offers educational
sessions on topics pertinent to Meaningful Use and HIE. By recognizing the need for expert
training on the technology and regulations, NCHIN has built its relationships and credibility
among community providers. One internal medicine provider said,
“And they sort of distilled things down to okay, these are the bullet
points, these are the changes you’re going to need to make to go to
upgrade to Meaningful Use stage 2. And you know and then we’re going
to rely on their help in order to do that to qualify.”
Practice Workflow
For a practice to engage in HIE, they must first have enabled an electronic health record,
and successfully transitioned their staff and workflow systems to the new technology.
NCHIN staff identified multiple barriers to the adoption of EHR technology, including
financial, cultural, conflicting priorities, and workflow.
“They need to know how resistant people are to change their existing
workflows; how the present EHRs how poor they are, how bad they really
are. They need to understand that a lot of the barriers to using health
information are cultural barriers around how clinicians deal with the world;
they’re not really around providing information or not providing
information.”
As discussed in the Sustainability section above, NCHIN is addressing this challenge by
providing workflow and meaningful use consultations to their HIE clients.
Working with EHR Vendors
One of the major challenges NCHIN reports is that often EHR vendors are uninterested
in building desired interfaces. They reported multiple occasions when their work
plan was delayed due to an inability to get the project on the vendor’s calendar.
NCHIN was able to put centralized resources toward the relationships with vendors,
keeping on top of the issues and communicating regularly, until resolution was
reached. This is a commonly reported issue and one which individual provider offices
would have even greater difficulty managing on their own.
“In some cases we found that the EHR vendors were impacted by the need
for all of these interfaces. And they didn’t have staff that were capable.
And so we felt a couple times that our job here was to train EHR vendor
staff to build interfaces. We have one EHR vendor that never built an
interface. We were their first.”
“The Iris interfaces were really difficult because we found that a lot of the
EMR vendors do not want to write referral interfaces for referrals…They
just said no, no, we don’t do referral interfaces. It was really amazing. So
we ended up writing 3 or 4 of them.”
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Interface Implementation
NCHIN developer staff report that much of the job of implementation requires relationship
building with staff on both the sending and receiving ends of the interface. There is much
work that goes in to standing up a new interface, and at times it is difficult for the practices
to spare personnel for those tasks. One of the more challenging is to organize the
individuals involved in testing a new interface. Project management and communication
are key skills for implementers.
“To make a lab interface work with the [hospital system] it takes an active
person in the lab who usually is a med tech, somebody who actually knows
how their system works and they have to generate test messages; those
test messages them in their system go to their data center… and then they
go across an interface to their interface company. And then the interface
company if you will massages them in some particular way and sends them
to us. And then we send them on to the practice. And each of these steps
there is often some sort of programming responsibility and then there’s
some sort of testing responsibility at the end of it. So you need somebody
in the lab, you need somebody on the interface company’s side, you need us
and then you need someone in the practice and you need the practice
vendor. So you’ve gotta get 5 people working on this for it to really work.
And I think that nothing could be harder really on some days. And so those
people have to be scheduled; those people have to have the time to work on
it.”
Relationship Building
NCHIN staff expressed that in some ways they are at the mercy of the administrative
decisions that are made at the medical practices and hospitals. They reported several
circumstances in which it was necessary to change or even cancel planned projects because
the partners’ priorities had shifted.
“St. Joe has a relationship with us to do all of their exchange but they could
make a political decision that they want to do exchange another way and
that decision would be made in Orange [system headquarters]. And they
would just drop off our map…So having large multi-county, multi-state
organizations work with local community HIEs the power is so
disproportionate.”
NCHIN administrators and staff are acutely aware that the ability to mitigate this risk and to
continue progress toward full HIE in their community rests on the organization’s capacity to
build relationships with the various stakeholders. They have been successful because they
have built those relationships and strive to be responsive to the needs of those partners.
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“Again it’s relationships, talking to people. And you know the hospital
hasn’t spent any money to get its results into all of these practices so you’d
think that they’d like that. And so I think that you know our strongest tool
there is to do good work.”
“I think existing relationships are usually the most important part of it
…we’re not interested in being an HIE, we’re interested in having an HIE
here in the community for our clinicians, our providers. And so we had
relationships with practically everybody that we built an interface for.
And that is part of the overall organizational theory and I guess goals is
for all of our projects they all have the same aim to make it work in
Humboldt County. Now we’ll have some of the same techniques, you know
relationships and being in the practices and having some idea about
workflow. So all of that you know it’s true for the quality projects is true
for the HIE projects; it’s true for utilization management.”
They also acknowledge that some of their greatest barriers come about due to a lack of
relationship with the other entity. They believe that excellent communication and
responsiveness can help mitigate the inevitable challenges that come up in technology
projects. For example, in building interfaces for practices the following barrier was
described:
“But I never hear him say, ‘Boy that was hard code to put together you
know I really struggled with that.’ He doesn’t say that at all, he says, ‘I can’t
get them to return my phone calls.’”
Conclusion
NCHIN provides a very interesting case study. Their strategy of leveraging human and
physical resources of an existing IPA to initiate a new organization, was successful. This
strategy reduced the hurdles of a startup, allowed efficient use of funds, and jump started
the pulling together of existing relationships within the community to accomplish HIE. This
approach put the organization in a strong position to meet the current and future HIE needs
of their community.
Although a small team, the staff and leadership of the HIO seem well suited to their roles. In
addition, as a team, they were adept at business planning, project management, technical
development, and operations which are important functions that an HIO must fulfill.
Through the interviews conducted for this case study, several lessons learned were
identified that may be useful to other HIOs. The fact of shifting priorities for current and
potential participants is a universal reality for HIOs working toward interoperability. This
theme is significant, since it can have a real financial impact on an HIO. Also the need to be
strategic and proactively work to ensure that planned projects proceed is valuable to
recognize.
The experience around workflow changes is similarly important, because if a medical
practice is unable to implement adequate changes to their workflow systems, they will not
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reap the benefits of HIE, and may become discouraged from pursuing electronic data
exchange at all.
The critical importance of building relationships with all stakeholders in the HIE
development and implementation process, and of being perseverant is extremely valuable
to underscore. It is important for all organizations involved in HIE to expect that resources
are needed for project management to coordinate the data providers, data receivers, and
EHR developers, for any given interface. While HIE implementation is largely technology
focused, it is the human factors involved that can contribute the most to the success of the
projects and ongoing benefit HIE can provide to provider practices and their patients.
About the Partners
About California Health eQuality (CHeQ)
California Health eQuality (CHeQ) is a program of the UC Davis Institute for Population
Health Improvement that administers statewide health information exchange (HIE) projects
for California. Funded by the California Health and Human Services Agency, under the
auspices of the Office of the National Coordinator for Health IT State HIE Cooperative
Agreement, CHeQ is promoting coordinated and integrated care through health information
exchange. Programs including a trusted exchange environment, improved public health
capacity for electronic reporting, HIE acceleration funding opportunities, and the
monitoring of HIE adoption lay a foundation for improved quality of care for all
Californians. Please visit CHeQ at http://www.ucdmc.ucdavis.edu/iphi/programs/cheq/.
About Institute for Population Health Improvement (IPHI)
The UC Davis Institute for Population Health Improvement (IPHI) is working to align the
many determinants of health to promote and sustain the well-being of both individuals and
their communities. Established in 2011, the institute is leading an array of initiatives, from
improving health-care quality and health information exchange to advancing surveillance
and prevention programs for heart disease and cancer.
About Health Equity Institute at San Francisco State University
The Health Equity Institute of SFSU seeks to foster innovation and community engagement
towards a vision of a truly healthy society. The mission of the Health Equity Institute (HEI)
is to create an intellectual environment that encourages diversity of perspectives,
challenges conventional approaches, and produces innovative action-oriented research in
the biomedical and behavioral sciences in order to improve health, eliminate health
disparities, and establish equity in health. San Francisco State University (SFSU) is a public
university affiliated with the California State University system. Located in San Francisco, it
offers 118 different Bachelor's degrees, 94 Master's degrees, and 5 Doctoral degrees.
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