Health Information Exchange Case Study
Redwood MedNet
January 30, 2014
Katherine K. Kim
Danielle Gordon
San Francisco State University, Health Equity Institute
Lori Hack, Object Health, LLC
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 Redwood MedNet ............................................................................................................ 2
Redwood MedNet’s Project Goals and Plans............................................................................................ 3
Results .................................................................................................................................................... 5
Participants ......................................................................................................................................... 5
Technology .......................................................................................................................................... 6
Transaction Volume ............................................................................................................................. 7
HIE Expansion Grant ............................................................................................................................ 8
Subproject 1 ERx2G Second Generation Electronic Prescribing......................................................... 9
Subproject 2 Enable Electronic Laboratory Orders and Results Delivery ........................................... 9
Subproject 3. Care Transition Messaging Project............................................................................ 10
Subproject 4 Immunization Reporting ............................................................................................ 10
Subproject 5. DiSTRIBuTE ............................................................................................................... 10
Subproject 6. ADT (Added Later) .................................................................................................... 10
HIE Infrastructure Grant .................................................................................................................... 11
Subproject 1: Lab Results “Laboratory Onboarding” ....................................................................... 11
Subproject 2: Transition of Care Document “Care Transition Messaging” ...................................... 11
Interface Implementation Grant ........................................................................................................ 11
Lessons Learned .................................................................................................................................... 13
Small Organization Managing Large Projects...................................................................................... 13
Sustainability ..................................................................................................................................... 13
Lack of Guidance on Consent for Exchange ........................................................................................ 14
EHR and other Priorities .................................................................................................................... 14
Conclusion............................................................................................................................................. 15
About the Partners ................................................................................................................................ 16
Appendix A: Table of Deliverables in Quarter 6 Expansion Grant Progress Report ................................. 17
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Introduction
California 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 Redwood MedNet (RWMN). This report summarizes
RWMN’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
This case study was conducted by San Francisco State University through a grant from CHeQ. Three
team members reviewed documentation provided by CHeQ including grant proposals, progress
reports, and presentations. CHeQ also made introductions to the grantee’s staff. The SFSU team
conducted in-person interviews with the director and one staff member, as well as a community
stakeholder who is both a user of the HIE and a member of the Board of Directors. 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 Redwood MedNet
Redwood MedNet (RWMN) was established as a non-profit organization in 2005 in Ukiah, CA. It is
led by a nine member Board of Directors of community health care stakeholders. RWMN aims to
enhance the quality of health care for all residents of Mendocino, Lake and Sonoma Counties,
facilitate the individual and collective practice of medicine, encourage adoption of Electronic Health
Records, interconnect all participants in the local health care community and collaborate with
regional, State and Federal health information technology initiatives. They are also currently
providing HIE services to some health care delivery organizations in Napa, Marin, Colusa and
Humboldt counties.
In 2005 RWMN established its first HIE offering, a clinical messaging service for delivery of
laboratory test results. In 2008, RWMN began delivery of electronic clinical data by pushing
outpatient laboratory test results from a rural Critical Access Hospital (CAH) into a chronic disease
registry at a Federally Qualified Health Center (FQHC).
Since then the HIE delivery service has grown. To support its technical solutions, the Board has
established policies and procedures for secure data sharing, and has been a leader in
implementation strategies for the Country. Through their partnership with Mendocino Informatics,
a consulting firm, RWMN has achieved national recognition for its innovation in secure health data
delivery to clinical practices.
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RWMN is the recipient of three grants totaling $755,580 from California Health eQuality (one
originating from its predecessor funding agency, Cal eConnect) in order to expand their existing HIE
capabilities:
•
•
•
HIE Expansion Grant in 2011 for $476,900
HIE Infrastructure Grant in 2012 for $90,000
HIE Interface Implementation Grant in 2012 for $188,680
RWMN hoped to utilize the funds to build the necessary infrastructure and create a solid foundation
from which they would be able to become self-sustaining though subscriptions. They also
participated as a designated service provider in CHeQ’s Rural HIE Incentive Program.
Redwood MedNet’s Project Goals and Plans
In 2011 RWMN received HIE Expansion Grant funds, the first of 3 awards received from CHeQ.
The overarching goal of this project called Meaningful Use Expansion 1(“MUX-1”) was to assist
rural Northern California providers in achieving the Meaningful Use requirements for Stage 1 and
Stage 2. This project proposed to build 73 interfaces for 21 community providers. Their five HIE
service expansion subprojects were:
Second Generation e-Prescribing (eRx 2G) -- Expand RWMN’s e-Prescribing
1.
project to five safety net clinics, and improve medication reconciliation at local acute care
facilities.
2.
Electronic Labs -- Enable hospital laboratories to receive electronic orders from or
deliver electronic test results into certified EHRs at outpatient practices in Humboldt,
Mendocino, Sonoma, Marin, Solano, Yuba and Sutter Counties; enable public health
laboratories to receive electronic orders and post electronic test results to local hospitals.
3.
Care Transition Messaging -- Enable eligible providers building patient centered
medical home (PCMH) services to receive care summaries for their patients from local
hospitals; enable eligible providers with certified EHRs to push patient care summaries to
an electronic patient controlled health record (PCHR); enable providers to use Direct
Project secure SMTP messaging for electronic care summary handoff between unaffiliated
healthcare Facilities.
4.
Immunization Reporting -- Enable eligible providers with certified EHRs to
submit immunization reports to the California Immunization Registry (CAIR).
5.
DiSTRIBuTE -- Enable hospitals to publish daily syndromic surveillance signals on
behalf of their local public health agency to the ISDS DiSTRIBuTE portal (operated under a
contract with the CDC).
Table 1 below shows the 21 proposed project participants and the type of data exchange proposed.
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Table 1. Project Participant and Proposed Interfaces for the HIE Expansion Grant, 2011
Participant
eRx
Msg
IZ
Alexander Valley Regional Medical Center
X
X
Alliance Medical Center
X
X
Anderson Valley Health Center
X
X
Andy Coren, MD
X
Digestive Health Consultants
Labs
X
X
Healdsburg District Hospital
X
Healdsburg Primary Care
X
Jerold Phelps Community Hospital
X
X
Long Valley Health Center
X
X
Mendocino Coast Clinics
X
X
Mendocino Coast District Hospital
X
X
Mendocino Family Care
North Coast Family Health Center
Synd
X
X
X
X
X
X
Palm Drive Hospital
X
Rideout Memorial Hospital
X
X
Robert Rushton, MD
X
X
Santa Rosa Memorial Hospital
X
X
Solano County Public Health
X
Sonoma County Public Health
X
Sonoma Valley Community Health Center
X
Sonoma Valley Hospital
X
X
LEGEND: eRx= electronic prescribing; Labs= receipt of electronic lab results; Msg= receipt of clinical summaries; IZ= push
immunization records to the California Immunization Registry; Synd= push surveillance data to the California Department
of Public Health.
RWMN received a second grant for HIE Infrastructure Expansion (“MUX-2”). The original goal of
this funding opportunity was to focus on two priorities defined by the Office of the National
Coordinator (ONC):
1. Enable electronic laboratory-test results delivery from two hospitals and one outpatient
laboratory operated by the Sutter Health West Bay Region through RWMN to five
unaffiliated health care outpatient practices with certified EHRs, representing
approximately 300 EPs in Marin, Sonoma and Lake Counties.
2. Enable bi-directional exchange of care summaries (supporting patient discharges, referrals,
and health home) between St Joseph Health Sonoma (SJH-S) and safety net primary care
providers in Sonoma County to facilitate transitions of care (ToC).
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Finally, RWMN received a third Interface Implementation Grant to develop 23 interface
deliverables at 16 covered entities participating in the HIE services provisioned by Redwood
MedNet (“MUX-3”).
Results
Participants
RWMN has expanded its operations in rural communities to serve additional providers and offer
new product lines. In total, 30 provider organizations were involved in testing or production use of
the RWMN HIE in the scope of these three grant funded projects. The participants involved were:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Andy Coren, MD
Alexander Valley Healthcare
Alliance Medical Center
Anderson Valley Health Center
Andy Coren, MD
Digestive Health Consultants
Healdsburg District Hospital
Healdsburg Primary Care
J. Nevin Smith, MD
Jerold Phelps Community Hospital
Kent Matsuda, MD
Long Valley Health Center
Lucerne Community Clinic
Mendocino Coast Clinics
Mendocino Coast District Hospital
Mendocino Family Care
North Coast Family Health Center
North Valley Family Physicians
Palm Drive Hospital
Prima Medical Group
Redwood Coast Medical Services
Rideout Memorial Hospital
Robert Rushton, MD
Santa Rosa Imaging
Santa Rosa Memorial Hospital
Sonoma Family Community Health Center
Sonoma Family Practice
Sonoma Valley Community Health Center
Sonoma Valley Hospital
South Health Clinics of Santa Clara
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RWMN acknowledges that their work and deliverables has often shifted during the course of these
grant cycles; as priorities shift for their clients. Due to the number of participants, departments
impacted by the interfaces within the provider facilities, the work under these grants has been
quite challenging.
Technology
RWMN’s current technology supports point-to-point bi-directional data sharing among providers in
the community. See Figures 1 and 2. Each provider has its own interface engine stored at its own
site that allows the provider to securely transmit or receive data from external providers in the
network. RWMN uses open source technology from Mirth that meets federal and state standards.
Figure 1. Point to Point Architecture
(http://www.redwoodmednet.org/news/present/20100722_rmn_oscon.pdf)
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Figure 2. Data Flow Schematic
Transaction Volume
RWMN reports 28,000 clinical messages delivered during October 2013, up from 12,900 in October
2012. These include final lab results and immunization reports send to CAIR. Figure 3 below
shows the tremendous growth in transaction volume since 2009.
Figure 3. Transaction Volume of lab results and immunization reports
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Detailed results from each of the subprojects within the three grants follows.
HIE Expansion Grant
RWMN worked to integrate their established participants into new services and acquire new
participants through the additional offerings. Many of the stated goals of the grant were to provide
for the technical capability of providers to exchange data and test that capability. There is no clear,
comprehensive record of the total data exchange produced through these awards. RWMN was
successful in implementation and testing of interfaces for the exchange of data and has increased
substantially the volume of lab results and immunization messages. More challenging, for a variety
of reasons, was the ongoing participation of partners and their continued use of technology. There
were numerous shifts in the use cases and deliverables identified in the original grant proposals. A
general summary of the status of the subprojects is in Table 2.
Table 2. HIE Expansion Grant Subprojects Summary Findings
Subproject Name
Modification (date and reason)
Final Disposition
1. eRx 2G
Expand the electronic prescribing
and medical reconciliation
capabilities
Abandoned due to insufficient
need
2. Electronic Labs
Enable hospital labs to receive
electronic orders and deliver test
results, includes Public Health
Hospitals
Public Health Hospitals did not
participate but 5 hospitals and
over 200 providers were
reported with more than 33k
transactions
3. Care Transition
Messaging
Eligible Providers receive care
summaries and send to patient
health care record (PHR)
This project was substituted
with the implementation of HIE
Gateways to facilitate the
ability of providers to share
data within the HIE.
Enable DIRECT messaging between
unaffiliated providers
Radiology reporting was added
to this project.
4. Iz Reporting
Enable submission of immunization This project was completed for
date to CAIR using a flat file.
two providers
5. DiSTRIBuTE
Enable hospitals to send syndromic
surveillance data to CDC portal
This project was not completed
and substituted for the HIE
Gateway.
6.ADT
This project was added after
approval of the original grant and
reported as a deliverable of patient
demographic data delivery from
one hospital to RWMN.
Mendocino Coast District
Hospital successfully
completed ADT delivery as a
predecessor for CCD delivery.
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Of 30 deliverables recorded in the most recent progress report available (Quarter 6 of grant period,
dated November 30, 2012) for the HIE Expansion Grant two were completed, 16 were cancelled,
and 12 were changed. 15 new deliverables were listed as replacing the cancelled or changed
deliverables. Since there was no progress report listing the final disposition of these replacement
deliverables, it is unknown whether they were accomplished. See Appendix A for table of
deliverables.
Subproject 1 ERx2G Second Generation Electronic Prescribing
The eRx 2G project proposed to expand the electronic prescribing and medical reconciliation
capabilities between providers as defined as a core and menu set requirement for CMS Meaningful
Use Incentive program.1 This proposal was made as a result of discussions with the regional
stakeholders and their desire to achieve meaningful use in 2011 and 2012. Because the Meaningful
Use program was not clearly defined at the time of the discussions, this project was to ensure the
ability to meet the MU requirements without consideration of the capabilities of the certified
Electronic Health records subscribed to by the stakeholders. During 2011, as each clinic adopted an
EHR, they migrated away from the eRx service hosted by RWMN. The project provided a learning
experience for how the HL7 data elements work in eRx, but there was no business reason for an HIE
service to be offering eRx to eligible providers who were adopting certified EHR technology. With
regard to medication reconciliation the pure quantity of real-time longitudinal data necessary for
an HIE service to be relevant to a MedRec enquiry exceeds electronic medication history data
streams that are currently available. It was subsequently determined that there is no current
business case to support the cost of acquiring and maintaining real time eRx data streams. No
further action was required on this interface.
Subproject 2 Enable Electronic Laboratory Orders and Results Delivery
The Electronic Labs project was designed to enable hospital laboratories to receive electronic
orders from or deliver electronic test results into certified EHRs at outpatient practices in
Humboldt, Mendocino, Sonoma, Marin, Solano, Yuba and Sutter Counties; enable public health
laboratories to receive electronic orders and post electronic test results to local hospitals. The
development of HL7 interfaces between the laboratories and provider EHRs to allow for the receipt
of results as structured data began with stakeholders already working with RWMN. Among current
EHR or CDMS vendors, RWMN sees two business models for interoperability: simplex interfaces, in
which the EHR or LIS vendor requires the facility to purchase a separate interface license for each
data source (e.g., eClinicalWorks, Meditech); and multiplex interfaces, in which the vendor allows
multiple clinical data streams to share a single interface. By full implementation of the project,
RWMN will operate at least 4 dozen interfaces to certified EHRs.
Documentation of laboratory ordering and delivery results was not available. From interviews, we
gathered that testing had occurred but production exchange was not yet occurring. The intended
participants for lab data exchange were: St. Joseph Health Sonoma, Meritage Medical Network,
Sonoma Valley Hospital, Prima Medical Group, PSC Urology Services, Marin Sonoma IPA (67
providers).
1
RWMN Proposal MU Expansion Part 1, January 31, 2011, pg.1
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Subproject 3. Care Transition Messaging Project
The proposed project included the transmission of clinical care summary records between
providers and to the personal health records of patients affiliated with those providers. This
process was demonstrated as a capability at various conferences and workshops such as HIMSS in
2012, however there were no providers in the community willing/able to test the workflow of
delivery through direct clinical messages. Subsequently, the stakeholders were offered a DIRECT
messaging service solution for transition of care messaging and personal health record updates.
However, data from DIRECT were not integrated into EHRs. Despite offering free DIRECT mailboxes
to multiple partners, no providers availed themselves of this product.
Subproject 4 Immunization Reporting
In 2011, RWMN proposed to enable the submission of Immunization reporting data to the
California Immunization Registry (CAIR) through the transformation of electronic data submitted
from an ONC Certified EHR into a flat file to CAIR. This format was the only viable format in 2011. In
the quarterly reports, RWMN reports successful completion of this project with data currently
being transmitted to CAIR for Dr. Andrew Coren and Alliance Medical Center’s primary care
provider sites. It is the second most used source of data flow behind lab results for RWMN.
However, because this is a requirement of Meaningful Use, the use of the CAIR interface may grow.
RWMN developed a specification for a Direct-enabled gateway to bridge the gap between these two
incompatible formats in an automated fashion.
As of 2013 CAIR is now able to accept real-time HL7 messages but cannot provide data back to
submitting providers, obviating the need for the file transformation utility RWMN had created.
RWMN has worked to develop HL7 interface capabilities for providers in their region as part of the
HIE Expansion Grant. No additional providers are reported as having completed this process with
RWMN at this time.
Subproject 5. DiSTRIBuTE
This project proposed to enable the reporting of syndromic surveillance data for the local public
health agencies to the CDC sponsored portal. During the course of the project , RWMN reported on
discussions and preparations. For example, in the Quarter 7 (early 2013) progress report
discussions were held with Sonoma County Public Health. Submission of electronic syndromic
surveillance structure data to Biosense II requires a data use agreement signed by the Health
Officer for the local public health jurisdiction that is submitting the data to the CDC. RWMN offered
to create the signals and submit them to Biosense II for no charge to the local agencies. RWMN
proposed this with two local public health jurisdictions of Mendocino County and Sonoma County.
However, each county declined to initiate a syndromic surveillance service from RWMN.
Subproject 6. ADT (Added Later)
This project was added based on an additional request from participants. The project was
substituted for the Care messaging project. RWMN reported that the ADT feed is in production for
Mendocino Coast Hospital.
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HIE Infrastructure Grant
This proposed project would provide funding necessary to expand the current RWMN capabilities
to allow for additional providers in the region to send electronic laboratory results and other
clinical data among key stakeholders.
Subproject 1: Lab Results “Laboratory Onboarding”
The goal was to enable meaningful use eligible providers (EP) to receive structured laboratory test
results in their certified EHRs. Electronic laboratory test results were delivered from two hospitals
and one outpatient laboratory operated by the Sutter Health West Bay Region--Sutter Santa Rosa
Medical Center, Sutter Lakeside Hospital, and Sutter Shared Laboratory--to five unaffiliated health
care outpatient practices with certified EHRs in Marin, Sonoma, and Lake Counties. Sutter backed
out of the project. There was no documentation of the reasons for this.
Subproject 2: Transition of Care Document “Care Transition Messaging”
This project was to enable EPs to facilitate transitions of care (ToC) by sending discharge care
summaries via RWMN bi-directionally between St Joseph Health Sonoma (SJH-S) and safety net
primary care providers in Sonoma County. At the time of this grant, RWMN had existing private
contracts with the hospitals which he’d intended to leverage to fulfill the match requirement for
this grant. In the time lapse between submitting the proposal to Cal eConnect, and the execution of
contract, the business case for the 2 projects changed, and in the end neither one was built.
Interface Implementation Grant
The interface grant proposed to implement 23 of interfaces across 14 community practices. The
intention of this grant was to significantly add to the existing exchange capacity, and to support
local practices to adopt HIE. The specific interfaces proposed for each exchange partner are listed
in the table 3 below.
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Table 3. Exchange Data Type by Practice
Provider
ORU
CCD
Receive
labs
ADT
X
VXU
IZ
1.
Andy Coren, MD
2.
Alliance Medical Center
3.
Alexander Valley Healthcare
X
X
4.
Anderson Valley Health Center
X
X
5.
Healdsburg Hospital
X
6.
Healdsburg Primary Care
X
7.
J. Nevin Smith, MD
X
8.
Kent Matsuda, MD
X
9.
Lucerne Community Clinic
X
X
X
10. Mendocino Coast Clinic
X
X
12. North Valley Family Physicians
X
13. Prima Medical Group
X
14. Redwood Coast Medical Services
X
X
X
X
X(send)
X
11. Mendocino Family Care
MDM
MFN
Receive Provider
directory
Rad
X
X
X
15. Santa Rosa Imaging
X(send)
16. Sonoma Family Practice
X
17. Sonoma Family Community Health
Center
X
18. South Health Clinics of Santa Clara
X
19. Sonoma Valley Hospital
X
X
X
X(send)
Legend: X= interface proposed for indicated practice. ORU= HL7 message type for “Order Result”; CCD=
Continuity of Care Document; ADT= HL7 message type for “Admissions, Discharge and Transfers”; VXU= HL7
message type for “Unsolicited Vaccine Report”; MDM= HL7 message type for “Medical Data Report” (eg
transcription); MFN= HL7 message type for “Master File Update”.
GREEN: COMPLETE, BROWN: IN PROGRESS
Every participating site was able to send or receive laboratory results using the interfaces built
under this Grant. In some cases, funds were expended from prior grants in order to facilitate a
complete solution for the providers noted in the table above. In addition, three of the sites noted are
also transmitting immunization data with the CAIR registry (Dr. Coren, Alliance Medical Center, and
School Health Clinics of Santa Clara County).
There has been difficulty progressing from testing to production for radiology reports. In some
cases the manner in which the EHR is able to render the written reports makes it less useful when
received electronically instead of on paper. For this reason, several providers were unwilling to
move from test to production.
Some sites are testing CCD exchange and the Provider Directory (MFN) with none in production.
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Lessons Learned
Small Organization Managing Large Projects
RWMN is an organization with less than five staff, yet the projects proposed in these grants alone
involved the building of over 70 interfaces and implementation with over 30 provider
organizations.
“I’m constantly juggling to abandon a project that’s two-thirds done and
change to something else. Because the sponsor is gone, the business case is
gone; it doesn’t make any business sense anymore; they decided to adopt a
different EHR... So I’m surfing that issue constantly and trying to envision a
Redwood Met Net service that doesn’t fall prey to going out of business like a
lot of HIE’s have done because they had this business model that was entirely
dependent upon one thing happening.”
While remaining flexible to meet the needs of clients is laudable, the wear on staff is
difficult and organizational stress is the result. Solutions to this challenge are
elusive.
“… we try to do every single thing that he says he can do at whatever expense
that it takes because he hates disappointing them all and he wants to get
everybody you know.”
Sustainability
RWMN does receive some fee payments but relies primarily on grants to cover
salaries, capital investments, development, and operating expenses. Following grant
cycles means staff are consumed with writing proposals, fulfilling overlapping grant
accounting and reporting requirements, and then managing the cash flow until
funds are received. While they achieved some of their goals in terms of building out
interfaces, they haven’t progressed toward sustainability.
“ What Redwood Med Net wanted out of the ARRA funding cycle was to not get
swamped and bankrupted because of chasing something that we could find the
grant money to install, but there would be no recurring revenue to operate.
We wanted to focus on the nuts and bolts of interoperability that affected our
participants at the workflow level. We wanted to help our participants to
understand the implications of their software procurement decisions. At the
end of the ARRA investment we wanted to be standing with more interfaces to
more people running more data types and so we’ve accomplished all of that.”
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Lack of Guidance on Consent for Exchange
There remains a challenge to HIE in that guidance on how to handle consent and authorization for
data sharing is lacking. This causes a burden for patients and a challenge to HIOs who are looking
for solutions to promote the flow of data.
“I was sitting in the waiting room the other day with my son and this lady
came into the doctor’s office and she says, “I need to send my records to you
know several doctors.” She gave her four sheets of paper, she sat down and she
filled in 4 different releases of information. When she finished she went back up
and got one more and says, “Oh I forgot another doctor I had to send it to.” So
she must have spent 45 minutes to an hour filling out the releases of
information. There hasn’t been a lot of guidance I don’t think from the State as
far as electronic you know consent you know and how to do it easily it’s a real
big barrier.”
EHR and other Priorities
Though not unique to RWMN, they faced the difficulty that adopting EHRs poses to a medical
practice. Because of the rapid timeframe for HIE deployment required by ARRA funding
opportunities, EHR deployment was often occurring simultaneously with HIE testing and
implementation. As a result, providers may not have been ready to take advantage of HIE. For
example, one practice was unsuccessful in adopting their EHR, eventually abandoning the system,
which then impacted RWMN’s ability to accomplish the HIE goals:
“…we were simply involved in one aspect of it (the EHR implementation), we
were there to turn on the interface for lab results. And we were the straw that
broke the camel’s back, because that turned out to be the workflow
inconvenience that they were unwilling to accept. But that wasn’t the only
problem with that EHR; it was that those three providers were done with their
first attempt at electronic health records.”
In addition, many providers have multiple conflicting priorities that interfere with the
ability to implement HIE.
“The things that give me nightmares as far as sustainability is as far as
sustainability of this clinic number one is the ICD-10 that’s coming in next year.
Training providers. To see if they’ll be able to deal with that and the insurance
companies’ capacity to be able to deal with that. And the changing role of
reimbursement you know Patient Centered Medical Home. I mean there’s got
to be a shift somewhere in there that is going to be able to compensate
providers and the clinics for all this extra work in reporting that they’ve
having to do but at the same time getting reimbursed at the same you know
fee for service you know thing. So that’s going to have to come.”
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Conclusion
RWMN is a seasoned HIO. They are active in promoting HIE in their region, and have pursued many
opportunities for funding which have facilitated development of needed infrastructure.
While the goals were laudable, the complexity of the proposed technical projects fell prey to
common technology problems. Taking more than 8 months to develop stakeholder interest,
negotiate, fund and launch the project then obtain the software and ready the test environment was
a significant issue. By the time the software is ready for testing and implementation, the
stakeholder has lost interest, lost their job or lost this project priority.
The ability to sustain technology projects from proposal through implementation and to
achievement of value requires leadership vision, champions within the organizations involved,
excellent ongoing project management and communication skills, and the ability to demonstrate
interim progress to keep stakeholders involved.
While RWMN attempts to be ‘”agile and responsive” to the needs of the rural, safety-net community,
they were challenged by delivery of promised outcomes for a variety of reasons. The required
events for successful launch of health information exchange include establishing a shared priority
and resources among a variety of stakeholders ranging from clinicians, financial staff, IT staff,
administrative leadership and sub contractors and vendors. These stakeholders must agree and
adhere to complex and lengthy timeline crossing departments, budget cycles and staff changes. As
a small, under-resourced organization, they may not have vetted the projects adequately with
partners, accurately budgeted the resources necessary to accomplish the goals, or had the full
complement of skills needed within the team.
The RWMN case study shows that HIE is not for the faint of heart. It takes passion and dedication
from the team to stick with these efforts in the face of many challenges. While many of the goals
were not accomplished, RWMN did implement a number of interfaces and have also grown
substantially their clinical transaction volumes, indicating that HIE has been expanded in the rural
communities they serve.
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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 at San Francisco State University (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. 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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Appendix A: Table of Deliverables in Quarter 6 Expansion Grant
Progress Report
Grant
Quarter
6Q
Due
Date
Deliverable
Install HIE gateway at 3 (three) RWMN participants
1
§ Southern Humboldt Community Healthcare District
OSWPlug @ SHCHD
2
§ Solano County Public Health M-1000 @ SOLANO
6Q
Push lab orders from 2 (two) RWMN participants
3
§ Healdsburg Primary Care --> Healdsburg District Hospital
4
§ Mendocino Coast Clinics --> Quest Diagnostics
6Q
Push lab results to 7 (seven) RWMN participants
Date
Completed
(mo/yr)
Disposition
Dec-16
COMPLETED
12/1/16
CHANGED
12/1/16
CHANGED
CANCELLED
12/1/16
5
§ St. Joseph's Hospital --> Anderson Valley Health Center
CANCELLED
6
§ SHWBR --> Lucerne Community Clinic
CANCELLED
7
§ Palm Drive Hospital --> Santa Rosa Endocrinology
6Q
Push radiology reports to 1 (one) RWMN participant
8
9
6Q
§ Mendocino Coast District Hospital --> Mendocino Coast
Clinic
11
§ Santa Rosa Memorial Hospital
7Q
§ Sonoma County Public Health
7Q
CANCELLED
12/1/16
CHANGED
12/1/16
V-1000 @ SONOMA
Push lab orders from 1 (one) RWMN participant
14
CHANGED
§ Mendocino Coast Clinics --> California Immunization
Registry
Install HIE gateway at 3 (three) RWMN participants
13
12/1/16
SJH-S > AMC
Push IZ reports to CAIR from 1 (one) RWMN
participant
7Q
12/1/16
CANCELLED
10
12
CANCELLED
§ Alliance Medical Center --> RWMN
Push visit summaries from 2 (two) RWMN participants
6Q
COMPLETED
12/1/16
§ Healdsburg District Hospital -->Healdsburg Primary Care
Push medication history from 1 (one) RWMN
participant
6Q
Dec-16
CHANGED
3/1/17
§ Mendocino Coast Clinics --> SDRL
Push lab results to 7 (seven) RWMN participants
CANCELLED
3/1/17
15
§ PINC --> Andy Coren, MD
CANCELLED
16
§ Mendocino Family Care
CANCELLED
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17
§ Healdsburg District Hospital -->Richard Andolsen, MD
CHANGED
18
§ SJH-S --> Northern California Medical Associates
CHANGED
19
§ SJH-S > Marin Sonoma IPA (remane MMN)
CHANGED
20
§ SJH-S > Prima Medical Group
CHANGED
21
§ SJH-S --> Pacific Specialty Care
CHANGED
7Q
Push radiology narrative to 1 one) RWMN participant
22
§ Healdsburg District Hospital -->Alliance Medical Center
Push visit summaries from 3 (three) RWMN
participants
7Q
3/1/17
CHANGED
3/1/17
23
§ Long Valley Health Center --> PDI
CANCELLED
24
§ Southern Humboldt Community Healthcare District to
where?
CANCELLED
25
§ Robert Rushton, MD to where?
CANCELLED
Push ELR messages to CalREDIE from 3 (three) RWMN
participants
7Q
3/1/17
26
§ Healdsburg District Hosptial
CANCELLED
27
§ Mendocino Coast District Hospital
CANCELLED
28
§ Sonoma Valley Hospital
CANCELLED
Push syndromic surveillance from 2 (two) RWMN
participants
7Q
29
§ Healdsburg District Hosptial
30
§ Mendocino Coast District Hospital
7Q
Replacement deliverables for cancelled tasks
3/1/17
CHANGED
CANCELLED
3/1/17
R1
§ Install HIE Gateway
M-1000 @ SOLANO
R2
§ Install HIE Gateway
OSWPlug @ AVH
ADDED
R3
§ Install HIE Gateway
OSWPlug @ MFC
ADDED
R4
§ Install HIE Gateway
SFTP @ RWMN
ADDED
R5
§ Install HIE Gateway
OSWPlug @ PATHS
ADDED
R6
§ Install HIE Gateway
OSWPlug @ RRMD
ADDED
R7
§ Push Lab Orders Healdsburg Primary Care-->
Healdsburg District Hospital
CHANGED
R8
§ Push Rad Report Healdsburg District Hospital -->
Alliance Medical Center
CHANGED
R9
§ Push Rad Report
SRI --> Alliance Medical Center
CHANGED
ADDED
R10
§ Push Visit Summaries Mendocino Coast District Hospital -> Mendocino Coast Clinic
CHANGED
R11
§ Push IZ Reports to CAIR Mendocino Coast Clinic >
California Immunization Registry
CHANGED
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R12
§ Push Syndromic Surveillance
Hospital
R13
§ Push ADT Messages
RAMD > RWMN
R14
§ Push ADT Messages
RWMN
Healdsburg District Hospital-->
R15
§ Push ADT Messages
Hospital--> RWMN
Mendocino Coast District
7Q
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FINAL PROJECT REPORT
Healdsburg District
CHANGED
ADDED
ADDED
ADDED
5/1/17