Setting the pace: A case study of how the Indiana Health Information Exchange works

Before connecting with the Indiana Health Information Exchange, physicians at Cardiac Care Associates in Crown Point, Ind., received lab and test results in a way familiar to many practices.

The doctor would send the patient for the test, then wait. And wait. The doctor would call the lab, leave several messages, get placed on hold, and maybe get an answer within a few days. Add in a lost fax or a report placed in the wrong file and it all added up to one big frustration.

When Cheryl Agent, practice administrator, was told the five-physician cardiac care practice could get lab results in real time, and in an organized, uniform fashion, it definitely got her attention. The kicker? The electronic system was free.

"It has cut down the time waiting for results tremendously and has streamlined everything we do," she said.

Now Agent can log into the system, open her in-box and pull all relevant reports for the day. She also logs in throughout the day, pulling new results as they are completed and entered in real time.

Developing a system that is free to doctors and delivers real value was the main objective of the Indiana Health Information Exchange when it developed its Docs4Docs clinical messaging system, the organization's flagship product that was jointly developed with the Regenstrief Institute, an informatics and health care research organization affiliated with the Indiana University School of Medicine.

Many regional health information organizations have failed in recent years, making President Bush's goal of having a National Health Information Exchange by 2014 seem further out of reach. But Indiana's exchange has been referred to by many as the model to emulate.

Since IHIE started in 2004, more than 30 million messages (currently more than 1.4 million per month) have been sent through Docs4Docs. The network has also expanded from the six founding hospitals to more than 40 hospitals and more than 10,000 physicians across the state to cover more than 30% of Indiana's population.

Some factors have contributed to IHIE's success: its limited focus; value proposition and affordability; success breeding success; and its forward-looking approach.

Limited focus

Marc Overhage, MD, president and CEO of IHIE, knew from experience the frustration of trying to get test results. If IHIE could create a way to streamline that process, there would be instant value.

He said too many others have made the mistake of trying to "boil the ocean." It's a phrase he has used many times to underscore the importance of keeping the focus on specific tasks instead of trying to solve all of health care's problems.

Drilling down even further, Dr. Overhage said although several types of data could be exchanged, the organization decided to first focus on data such as lab and tests results that were already on a common electronic platform. Those also happened to be the data doctors relied on the most for patient care.

By narrowing the focus, he said, the organization was able to fine-tune the exchange process, making it as secure and efficient as they could, before starting to "fill in the holes" with other data.

Dr. Overhage said it was also important for the organization to start locally to grow the system in a way that made sense to those involved and addressed specific problems.

Collaboration among all stakeholders, which in the beginning included Regenstrief, six Indianapolis-area hospitals, and a large group of researchers and investors, made it possible to focus on the needs of that core community.

Even though IHIE has since grown beyond the Indianapolis area, and includes much of the state, it's still considered a regional health information exchange. Dr. Overhage thinks it should remain regional, as a way to capture the unique dynamics of the market it serves.

Many have referred to IHIE's business model as one of the few sustainable HIE approaches in existence. Dr. Overhage says it's sustainable because it's collaborative. And the key to a national HIE, he said, is to build multiple regional networks that meet the needs of their specific markets, then provide connectivity among them all. The result -- a network of networks.

The idea is similar to the Internet, said Dr. Overhage. There is no business model for the Internet, but people choose individual providers to gain access. The same will be true for a national HIE -- people will choose RHIOs based on certain criteria, which in many cases will be proximity and the sharing of the same patient population.

Value proposition

Physicians who don't want to join the network can get test results from the exchange via fax. Very few choose that option, said Debbie Banik, clinical messaging program director for IHIE, because joining offers a practice little to no risk and a high return.

Because historically hospitals and labs paid to get results delivered to doctors, IHIE organizers knew they couldn't ask doctors to start paying.

So hospitals are still footing the bill, but their savings are substantial. Pricing is based on a sliding scale determined by volume, but averages less than 20 cents per transaction.

Mary Ranta, director of information services at St. Margaret Mercy Healthcare Centers in Dyer, which recently joined IHIE to extend its reach to Northwest Indiana, doesn't discount the benefits on the hospital side. But she added, "The benefits as we see them [are] more geared toward physician offices and practice managers having access to information and having information delivered in a timely fashion to the right place on a secured system."

Ranta, whose background is in nursing, oversees IT for the two-campus hospital system in Northwest Indiana and its 20 off-site offices.

"I know how challenging it is when reports come to the office and they all are different. One benefit I see is standardized reports," Ranta said.

And even though the system is built on technology, individual practices don't need to make a large technology investment to participate. Todd Rowland, MD, a physical medicine and rehabilitation doctor who founded HealthLink, an RHIO that serves the Bloomington, Ind., area, knows from his experience that building an exchange that relies on practices implementing EMRs would be a hard sell.

Dr. Rowland and others in the Bloomington medical community set out in 2004 to build an RHIO by outfitting area practices with a "one-size-fits-all" interconnected EMR system. But he quickly found physicians wanted to adopt EMRs on their own time, and they weren't in a hurry.

Dr. Rowland decided to connect with an exchange that didn't rely on EMR use. He ended up with HealthBridge, an exchange in Cincinnati that is also considered one of the country's strongest. HealthBridge acted as an adviser to IHIE when it was developing its system, and much of IHIE's business model reflects that of HealthBridge.

Adding to the value of IHIE's system is the free support that comes with membership. At the practice level, technical expertise is not needed since IHIE staff does all the setup and training. The exchange also provides a technical help line and fields all calls regarding missing lab reports.

Success brings success

When St. Margaret Mercy began connecting to IHIE, much of its homework had already been done, said Becky Randazzo, clinical system analyst for the hospital system.

Randazzo said the Sisters of St. Francis hospital system in Indianapolis, which helped launch the exchange, "shook out any technical issues, and we followed in their footsteps since they had a good technical plan in place."

Since IHIE's launch, there has been a pattern of one hospital joining and the others in the community following suit. The success of those who have already joined have created something of a competitive environment, Ranta said.

"When doctors see value in the system, they will be more apt to send patients here [to St. Margaret Mercy] for tests," Ranta said.

Patient satisfaction also is higher when doctors get test results quicker, said Debra Halton, director of health information management at St. Anthony Medical Center in Crown Point.

Looking to the future

Since its inception, IHIE and Regenstrief Institute have been exploring ways to expand and maximize the value of their network. So it makes sense that the Indiana exchange was one of nine regional health information organizations to receive part of a $22.5 million grant from the U.S. Dept. of Health and Human Services to demonstrate a National Health Information Network.

The relationship IHIE has with neighboring HealthBridge is one example of the collaborative environment IHIE is creating in order to advance health information exchanges.

The two organizations are expected to announce later this year interconnectivity that will allow the exchange of data between members of both organizations.

The Indiana exchange is also in talks with colleagues in Chicago to experiment with data exchange among health facilities and public health agencies there and in neighboring Northwest Indiana, according to Dr. Overhage.

The current step is figuring out what data carry the most value to users in that region, then figuring out a way to exchange information in a secure way.

While growth has come relatively quickly for IHIE, it has also been very deliberate. Even though its initial purpose was to exchange data that were already electronic, it has successfully experimented with capturing nonelectronic data in other ways. But don't expect it to start marketing that feature until it has mastered the technique in a way that would work for everyone. "We haven't found the secret sauce yet," Dr. Overhage said.

"At the end of the day, we are a nonprofit organization, as are others, and so I don't think it's as much about competition as it is about making sure patients get good care and making sure information flows seamlessly," he said.

"It's the right thing to do."