California Health eQuality Project Summary
HIE Rural Incentive Program
January 2014
AREA/PROJECT
The HIE Rural Incentive Program was an eight month program to encourage providers in ambulatory
offices, clinics and hospitals in Rural and Frontier areas of California to adopt health information
exchange (HIE) in order to improve care coordination. Rural and Frontier MSSAs of California form
approximately 80% of the geography and 17% of the population of the State as defined by OSHPD.
Most such areas are medically underserved, resource-poor, and had not yet adopted HIE – often still in
the process of adopting EHR which proved expensive, complex and resource-consuming. CHeQ also
included 11 full counties in the scope of the Rural Incentive Program given populations with profiles
similar to the Rural/Frontier MSSAs, and their need for stimulus to help launch HIE. They are:
Butte, Fresno, Kern, Merced, Napa, San Joaquin, Shasta, Solano, Stanislaus, Tulare, Yolo.
PROBLEM
One problem California faced in expanding HIE through out the State was how to encourage providers
in Rural and Frontier areas to adopt HIE. It is not as easy to form close-knit communities of medical
practitioners for planning and implementing HIE when distances are so great, precluding easy travel to
meetings. Yet the need for HIE was clear given long distances patients also had to travel for transitions
of care from one provider to another, increasing the likelihood of providers not having complete records
for a patient, resulting in fragmented and inefficient, less effective care.
Rural and frontier areas have a greater number of small and solo physician offices than urban areas
increasing the need for better coordinated care and optimization of all levels of medical staff.
Rural/frontier areas tend to have lower socio-economic populations with fewer resources. Very few
HIEs/HIOS were serving rural/frontier areas, yet those areas are the majority of California’s
geography. The issue: how to jumpstart the spread of HIE and HIOs into rural and frontier areas in an
effective manner that can build sustainably while improving care coordination.
SOLUTION
CHeQ chose strategically to fund a Rural Incentive Program which paid for a major portion of one-time
costs to connect to an HIO, as well as year 1 maintenance fees, to jump-start the launch of effective
exchange among a disparate provider population with few discretionary financial and labor resources.
Through a competitive process, CHeQ chose five strong HIE Service Providers with extensive experience
California Health eQuality Project Summary
HIE Rural Incentive Program
January 2014
who could offer services beyond only the technology, helping guide HIE-novice providers effectively
through the staffing needs, trust agreements, and decision-making to create a trusted community of
referring providers welcoming this improvement in areas where care can improve markedly with such
HIT.
In detail, CHeQ funded 65% of all connectivity costs for any eligible provider, including interfaces,
SaaS, software, hardware, license fees, and also covered 65% of year 1 maintenance fees, up to the
total Program budget of $1MM. CHeQ included Service Providers who could provide a range of
services, from those easiest to adopt such as Direct (secure e-mail), to Directed Exchange via HL7
messaging, to full query-exchange with longitudinal patient records, to fit the needs of the varied
profiles of communities adopting HIE.
RATIONAL FOR SOLUTION
CHeQ recognized the wide range of provider-readiness to adopt HIE, and flexibly crafted solutions to
meet those providers where they stood. While some providers were (and are) in need of replacing their
dependence on a fax machine, others had formed up to 7 county consortia to create an HIO suited to
their needs for that region. By widely raising awareness of the Rural Incentive Program through
outreach channels such as CalHIPSO and its LECs, the California State Rural Health Association, the
California Hospital Association, the California Primary Care Association, the California Association of
Rural Health Clinics, consultants, HIE Service Providers and the CHeQ e-mailing list, CHeQ reached
those communities most able to come together to form consortia to make this decision and adopt HIE
within the timeframe allotted.
The extensive technical development and standards for policy, legal agreements and protocols CHeQ
worked on in parallel ensured excellent, credible, stable, lasting choices for providers to choose among
with confidence to adopt HIE.
OUTCOME
CHeQ enabled the addition of 16 new counties implement HIE, as well as increasing density in at least
7 other counties with partial use of HIE already, creating richer exchange for a greater percent of the
population. More than 1,500 physicians came on board for the first time, some via three new HIOS:
SacValley MedShare (7 counties), Central Valley HIE (4 counties) and Connect Healthcare (2 new
counties), some by connecting to currently existing HIOs (San Luis Obisbo joining OCPRHIO), and
others linking to Redwood Mednet for HL7 secure transport to and from local labs, hospitals, clinics and
provider offices.
California Health eQuality Project Summary
HIE Rural Incentive Program
January 2014
The majority of rural and frontier California now has local and regional HIE options to choose among
and become operational in time for the 2014 deadline for MU2.
BENEFIT
Rural California now has several different strong models for operational HIE, both helping improve care
coordination for those communities, as well as providing examples for the remainder of rural/frontier
California to adopt HIE sustainably within a trusted community framework. An added benefit was the
insight gathered about the need for a California State Direct HISP, for those smaller, more disparate
communities as a first step on the path to full HIE. CHeQ was able to craft one more program to create
California Direct, awarding its operation to Axesson, to help providers without a ready community to
launch HIE simply, via secure HIPAA-compliant e-mail, inexpensively, and with ease.