Health Information Exchange Organization (HIEO) Assignment

Overview/Scenario:

The Health Information Exchange Organization (HIEO) was launched several years ago with the goal of helping to lower the state’s staggering healthcare expenses and improve the state’s consistent poor rankings in leading health indicators, including obesity, smoking, diabetes and heart disease. Improving healthcare through the enhanced use of information technology and data exchange is the heart of what we do. We manage one of the country’s largest and most successful health information exchange (HIE) networks, provide advisory services that help healthcare professionals effectively use technology and improve care delivery, and supply health plans and accountable care organizations (ACOs) with valuable data that enhance analytics and population health programs. We’ve been in existence for several years and now have the majority of the state’s hospital providers and have many physicians, reference lab, diagnostic radiology centers, mental health providers and other providers participating in our exchange.  All participating organizations send electronic health information to the exchange including hospital transcribed documents (H&Ps, Discharge Summaries, Operative Reports, etc.), lab results, diagnostic radiology results, and other clinical documentation.

As an independent, nonprofit organization, we are dedicated to serving all of the state’s healthcare stakeholders including physicians, hospitals, behavioral health, emergency medical services, public health, long-term care, laboratories, imaging centers, health plans, communities, and patients. We are self-sustaining and our funding comes from a fee-based subscription model. We were previously the recipient of three grants focused on building capacity for statewide health information exchange, including two grants from the American Recovery & Reinvestment Act (ARRA) HITECH program.

Our Mission is:  Through information exchange, we improve health and healthcare.

Our Vision is:  Patients will be measurably healthier as organizations and individuals that contribute to health and healthcare effectively utilize information provided by the HIEO to continuously improve patient care and population health.

1. Type of organization: State Health Information Exchange
2. Number of patients served, number of admissions etc.:  Over 4.5M patients are represented in our exchange database, representing over 75% of the state’s population.
3. Staff:  The executive team is comprised of our CEO, CIO, and CFO.  We also have marketing and sales staff, administrative and finance staff and technology staff who support our exchange database and create and manage HL7 interfaces between our database and each participating organization’s system. In the past year, with the launch of our Information Governance (IG) program, we have added a Chief Data Officer (CDO) and five Data Integrity Specialists to our team.

IG Program Description:

In partnership with the communities and people we serve, we have expanded our data use policies with the goal of improving the integrity and quality of the data we store on each patient. We created an HIM Steering Committee, chaired by the CDO, to provide oversight to our IG activities and it is comprised of HIM and IT professionals from our member organizations.  This Steering Committee creates a report on a quarterly basis that is presented at the HIEO board’s meeting and a more detailed report presented monthly to the HIEO’s executive team. We have developed policies and procedures to guide our Data Management processes. These policies cover data management oversight, data management responsibilities, types of data management staffing required, staff training requirements, quality assurance processes and reporting, and accountability and authority of the HIEO, the Steering Committee, and the CDO.

We are also a participant in the eHealth Exchange initiative, a group collaborating on and working toward interoperable health information exchange, and DirectTrust, a non-profit, competitively neutral entity created by and for participants in the Direct community, including HISPs, CAs and RAs, doctors, patients, and vendors.

1. Staff:  Currently 6 FTEs; Chief Data Officer is required to be a Registered Health Information Administrator
2. How long in place:  Chief Data Officer for 2 years; Data Integrity Specialists for 2-6 months
3. Culture: The first few years of the HIEO’s existence showed an entrepreneurial culture where each employee was empowered to make decisions to support growing the HIEO. While initially supportive of the growth, after time as it grew, the organization became disorganized as their efforts were too much in silos. We began receiving complaints from our members about not being able to find all of one patient’s information in the database. The executive team pulled together and developed a strategic plan to not only focus on growth but also on developing a culture of teamwork, mutual trust, and quality services.
4. Data System: The HIEO utilizes a centralized model for its data exchange.  It stores the clinical data for each patient and organizes that data in a single record for the patient.  This is accomplished through the databases “backbone”, its Enterprise Master Patient Index (EMPI). Its exchange capability provides the sharing of continuity of care documents (CCD), results, transcribed documents, medication and problem lists and links to diagnostic images.

Prior State Analysis:

1. How was information organized prior to the IG program?

Participating organizations send interface transactions into the HIEO’s database and contain information such as lab results, diagnostic imaging results, etc. These interface transactions had to meet basic record match criteria such as matching on the Assigning Authority from the sending organization and medical record number (or other unique patient identifiers for that organization.) If the transaction did not meet that first level of record match a demographic data match was attempted.  The last name, first name, date of birth and address was used to determine if a record for that patient already existed in the database.  If these four elements matched exactly, the transaction was posted to the existing record.  If it did not meet these four criteria, a new person/patient level record was created in the HIEO database and the transaction information posted to the new record.

Additionally, transactions were evaluated to determine that minimum record and patient identity data fields were populated including assigning authority, medical record number (or corporate medical record number), patient’s last name, first name, date of birth and gender. If these basic minimum requirements did not exist, the transaction failed to post to the HIEO database.

No communication was sent to the participating organization regarding failed messages. Additionally, no data integrity assessment was done on transactions received to determine whether data values were populated with default data values and therefore no reporting was provided back to the sending organization on the quality of the data they sent.

Describe data management program:

Following the completion of the HIEO’s new strategic plan, the CDO was hired to implement a new data management program. Initially, she had queries run on the HIEO database to identify the volume of records with the inadequate population of key record matching data fields including the patient’s last name, first name, middle name, date of birth, gender, last four of the SSN, address and telephone number. She analyzed the results of these queries to stratify them by members, date ranges of transactions received and each individual data field.

New policies and procedures were then developed to describe minimum data requirements for patient identity, record matching guidelines, duplicate record validity decision-making, interface requirements related to minimum data and data mapping, interface test plans with scenario use cases and testing scripts, data integrity evaluation and maintenance processes, record correction/merging procedures, reporting of data integrity issues and duplicates to provider members and data integrity reporting. These policies and procedures were presented by the CDO to the executive team. Following the initial approval by the executive team, the CDO presented the program and the policies to the full board and they were approved. The data management program was now official.

Eighteen months ago the CDO began presenting to the executive team monthly reports on member data integrity and quality. A high-level data integrity report was provided a year ago to the HIEO board which showed by members (anonymously) the percent of transactions the HIEO received with blank or default values on key demographic data values.  Additionally, research into new record matching algorithm and data integrity products was completed and a product was selected that can be integrated into the existing HIEO platform. After receiving the data integrity report and the financial proposal for the record matching/data integrity product (“identity management” product), the board approved the acquisition of this new technology. This new product utilizes an advanced record matching algorithm that is error-tolerant of typical data discrepancies across multiple records for the same patient. It also has a workflow tool that allows for efficient review of possible duplicate records, error queues for data integrity issues and the evaluation and reporting of such and to support management reporting needs. It was implemented six months ago.

Additionally, in the past year, the CDO began hiring data integrity staff to monitor the daily error logs and aggregate results from these error logs weekly and provide this data to the CDO. Initially, these specialists were only able to monitor and aggregate results from the error logs. Subsequent to the implementation of the new identity management product the specialists are now reviewing the potential duplicate queue in addition to working the transaction error queues. One specialist was appointed as Data Manager and she is responsible for compiling the reports to each member organization regarding the summary of data integrity issues on a monthly basis. Additionally, she provides a list of the data integrity issues for the applicable member’s records. Another responsibility she has is to summarize the intra-facility duplicates sent to the HIEO by each organization and provide that report monthly to the CDO. She also provides each member with a list of their intra-facility duplicates in order for the member organization to resolve these possible duplicates in their source system.

The CDO designed dashboard reports for presentation to the executive team and the board generated from the identity management product.  These reports will address the HIEO’s strategic initiatives and goals set forth by the executive team, HIM steering committee, and board.

After the implementation of the identity management product, a data analysis of the entire HIEO EMPI database was completed. This analysis identified a 30% cross-organization duplicate rate, intra-organization duplicate rate of 8% and several data integrity issues including 35% of the records having a blank value in the last 4 digits of the SSN, 70% of the records missing a middle name value and 10% having a default value in the date of birth field.  All of these data integrity issues severely compromise the HIEO in successfully matching records for the same patient from different member organizations. The HIEO set a goal of reducing cross-organization duplicate rates to less than 5% which was approved by its board and communicated to its members.

The CDO created a plan to resolve the duplicates, work with member organizations to improve patient identity data capture processes in each organization and begin a monthly reporting process to the members, the executive team and the board. The plan included creating a data dictionary with definitions of key patient identity demographic data elements to be shared with all members, documenting the HIEO’s EMPI data model, working with the HIEO technical team to ensure appropriate data mapping of values in transaction messages sent into the HIEO, contracting with an identity management cleanup company to resolve cross-member duplicates, providing members with their intra-organization duplicates and summary reports.  Summary reports included data integrity statistics and data patterns, member duplicate rates and overall cross-organizations duplicates with the HIEO database created due to incomplete or discrepant data.

Following the initiation of the reporting and post the cleanup, the HIEO was able to reduce the cross-organization duplicate creation rate to less than 10%, and an improvement in data capture of SSN, middle name and date of birth. Intra-organization duplicate rates only dropped to 6%. These results allowed the data integrity team to successfully manage these issues and provided the needed information for the CDO to continue to work with member organizations on data integrity improvements in each organization. The number of complaints filed by member organizations and providers dropped 50% and it is expected they will continue to decrease as subsequent efforts by the HIEO and member organizations continues.

IG Drivers:

The HIEO began to get complaints from participating physicians and other organization members regarding four major issues:

1. Results and other information from the incoming transactions were posting to the wrong patient (overlaid records)
2. Duplicate records existed in the HIEO’s database for the same patient sent from each sending organization.
3. Lack of accountability to “cleanse” source system to assure information is valid.
4. No reporting back to sending organizations regarding the quality of the data they’re submitting or the sending organization’s duplicate records.

As specific examples were researched, a fifth challenge was identified.  This was related to the HIEO’s system having immature tools to identify, resolve duplicate records and pull apart data from an overlaid record.