Survey Results: States and HIE Initiatives Describe their HITECH Plans and Concerns

By Laura Kolkman, RN, MS, Chair, HIMSS HIE Steering Committee

Great optimism – tempered by very real concern – is the best characterization of how states and health information exchange (HIE) initiatives view passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act.  That was the overarching tone of responses to a survey conducted by Mosaica Partners to identify plans for leveraging stimulus funds to advance HIE.

The survey, conducted in March and early April, was the basis for a presentation at HIMSS 2009 in Chicago.  It involved interviews with more than 40 individuals in 30 states based upon the following three questions:

  • What do you think the impact of the ARRA will be on HIE?
  • What was not included in the bill that you think should have been? 
  • What is your state/organization doing or planning to do to benefit from the ARRA?

What we found was that aggressive timelines, lack of clarity and fears over possible unanticipated consequences dampened – but did not extinguish – enthusiasm over what many predict will bring about the tipping point for EMR adoption and health information exchange.  We also found a surprising variance in activities underway to prepare for accessing and leverage stimulus funds.

Optimism Abounds

The responses to the question on HITECH’s impact on HIE revealed a general sense of optimism.  In the past, funding for HIE has been minimal, with only a few notable exceptions.  Now, however, with the laser-like focus on HIE and health information technology, expectations are high that the HITECH Act will be the catalyst to accelerate efforts.

Because exchange of information links tightly to “meaningful use” and improved quality of care, many survey respondents anticipate a change in expectations regarding HIE.  Specifically, it will transition from a concept struggling for survival to an impetus for better healthcare, as well as economic recovery.

HITECH is also viewed as a tipping point to EMR adoption, which will positively influence the value of HIE.  Many HIE efforts have had difficulty getting off the ground, largely due to the “chicken and egg” effect:  Providers did not support EMRs primarily because of the costs and therefore could not participate in information exchange, while HIEs had difficulty demonstrating value because they lacked a critical mass of provider data; typically found in EMRs.

Incentivizing providers to deploy EMRs and exchange information may finally eliminate that Catch-22.

The survey also found that HITECH is changing many states’ approach to HIE.  The attitude is migrating from little emphasis on establishing HIE roadmaps to the proactive creation of specific plans (and acceleration of existing plans) for HIE implementation.  As one interviewee noted, HITECH provides “20 billion reasons to get [our] attention.”

Grounded in Reality

Despite their optimism, survey participants are also experienced realists when it comes to HIE.  As such, their enthusiasm was tempered by concerns regarding the best use of funds to ensure that each dollar spent goes toward improved quality of care.  We grouped these concerns into six categories:

  • Competition:  Many feared that competition for funding could cause states to work independently rather than cooperatively in developing plans for HIE.
  • Complexity:  Many mentioned the complexity of accomplishing the required tasks in the short timeframes imposed by HITECH.  Specifically, the Act “severely under-appreciates the complexity to deploy EHRs, knit them together, and improve care delivery.”
  • Fragmentation:  The reality is that the healthcare industry is already fragmented.  The concern of many respondents was HITECH’s multiple funding targets (national efforts, states, regions, sub-national organizations, loan programs, privacy and security efforts, etc.) creates a very real potential for the distribution of funds to be fragmented as well.
  • Waste:  Without solid controls, there is a significant potential for HITECH funds to be wasted or invested in a way that does not maximize their impact on HIE.  In other words, we cannot spend stimulus funds simply for the sake of spending money.  Another concern was the potential for an unnecessary and costly bureaucracy to apply for, spend, and report on funds.
  • Confusion: A lack of guidance on the definition of “meaningful use” led to concerns that many providers may choose not to risk an initial investment in EMRs if there was a chance that they would end up ineligible for incentive payments.  Worse, there may be a rush to purchase EMRs without proper due diligence, or from “fly-by-night” vendors that will not deliver promised (and required) functionality.  There was also confusion as to how states or other entities should apply for the funds and when the funds would be available.
  • Workforce Shortage: The existing shortage of trained healthcare informaticists gave rise to concerns that the demand for EMR implementation in the short timeframe allotted by HITECH will place an unprecedented strain on the workforce.  Also in doubt was whether people could be trained quickly enough to support both EMRs and HIE.

As serious as these concerns are, most survey participants recognized that the unforgiving timelines set forth in the HITECH Act do not provide the luxury of simply waiting until they have all the answers.  Instead, many are forging ahead with plans and preparations to leverage the stimulus funds.

Efforts Already Underway

The adage “There are those who make things happen, those who watch things happen and those who wonder what happened” held true when it came to the responses and the readiness preparations for stimulus funds.  Reported activity ranged from statewide coordination, to independent activities, to a real “wait and see” attitude.

The state-affiliated responses ranged from waiting for more information to launching coordinated statewide efforts.  Many states were beginning to draft their HIT strategic plan as a first step in their approach to HITECH funding.  Those with existing HIT strategies reported confidence that they are in a strong position to compete for funds.

Other states believe that the best way to predict the future is to be part of shaping it.  These are the ones reporting active solicitation of input from within the state.  They are proactively defining how they can expand upon the work already done and coordinating their key institutions into building a cohesive plan, with a stated goal “to win as much of the funding as we can.”

All of the non-governmental HIEs surveyed were actively pulling together stakeholders, having discussions and beginning to create an approach on how to leverage funds.  Most were working in coordination with their state governments or, when state leadership was lacking, on their own.

A Few Recommendations

As evidenced by the survey findings, there is no “one right answer” or “single best approach” to leveraging HITECH funds.  However, it is critical that states and HIE initiatives be moving forward now if they hope to take advantage of this unprecedented opportunity.

After analyzing the survey responses, we proposed the following recommendations to help states and HIE initiatives make the best use of stimulus funds to advance their efforts in a meaningful way:

  • Centralize:  Form a team to centralize each state’s planning
  • Build on Your Foundation: States should build their plans and requests upon previously laid foundations such as state HIT strategies, existing HIEs, telemedicine networks, etc.
  • Establish Partnerships: Leveragepublic/private partnerships
  • Collaborate:  Encourage efforts across stakeholder organizations within the state, such as hospitals, universities, public health departments, physicians and consumers
  • Coordinate: Develop plans that take a holistic vs. scattered approach to utilizing the funds
  • Communicate: Use the resources available to share ideas about what can be accomplished, and who is responsible for what
  • Support: Develop specific programs to help physicians understand the role of HIE and HIT; modify and optimize their work processes; and choose the right EMR package
  • Manage: States should develop a solid approach to managing and auditing the allocation and spending of stimulus funds, and develop clear metrics for measuring recipients’ progress
  • Standards: Assure that standards for exchange are enforced when implementing HIT
  • Connect: Connect with other states to compare ideas and activities

Finally, as plans and strategies are developed, keep in mind that the future of healthcare depends upon everyone moving in the right direction.  At the forefront of every discussion about the stimulus funds must be the question: What can we do to magnify the impact of the dollars spent to help move the country toward the goal of better healthcare?  This opportunity is too important not to get right.

Laura Kolkman, RN, MS, is Chair of the HIMSS HIE Steering Committee and President of Mosaica Partners, a nationally recognized HIE consulting firm.