issue brief MISSISSIPPI HEALTH INFORMATION NETWORK (MS-HIN) Moving From Development to Sustainability PUBLISHED OCTOBER 2018 The shortfalls of documenting health care services in paper medical records MISSISSIPPI LEGISLATION were realized broadly after Hurricane Katrina hit the gulf coast in 2005. §41-119-1 ff Mississippi has since enacted policies to promote electronic health information The Health Information Technology Act authorizes exchange (HIE). In 2010, the Mississippi Health Information Network (MS- MS-HIN, provides its governance structure, HIN) was authorized by law as the state entity to coordinate a statewide HIE. sets the legal parameters for statewide health information exchange, and is up for MS-HIN is up for reauthorization by state policymakers in 2019. This issue reauthorization in 2019. brief outlines MS-HIN’s progress and summarizes policy developments to inform the continued growth of the Network and the policy debates. HEALTH INFORMATION NETWORK MS-HIN facilitates the secure exchange of electronic clinical information within (HIN) its network that enables provider access to patient health records at any location. Entity that provides the administrative structure Participating providers can be informed in real-time if a patient is admitted into and manages the technology to facilitate health an emergency department or other health care setting. Participants may also information exchange among unaffiliated organizations. obtain other details not available in an electronic health record (EHR) such as prescriptions filled or lab results. MS-HIN allows the exchange of information with HEALTH INFORMATION EXCHANGE other participating providers, supports interoperability (see sidebar), meets public (HIE) health objectives (including immunization reports) and provides summaries of care Process of sharing health information electronically. to help providers manage patient care. INTEROPERABILITY Figure 1 illustrates the growth of hospital participation in MS-HIN over time. Ability of two or more systems or components to Hospitals participating in the Network represent nearly two-thirds (61%) of all exchange information and to use the information licensed acute hospital beds in the state. In addition to hospitals, over 800 clinics that has been exchanged. and other types of health organizations participate in MS-HIN. FIGURE 1. HOSPITALS PARTICIPATING IN MS-HIN, 2014 & 2018 2014 2018 2018 HOW DOES HIE SUPPORT PATIENT CARE? •Serves as an unbiased community data trustee for health information •Connects health care systems, private HIEs, and independent providers •Fills gaps in patient health information for more comprehensive patient records •Provides real-time access to patient information for better clinical coordination and decisions •Improves the quality, safety, efficiency, and reliability of care Source: MS-HIN. (2014 & 2018). 1 of 4 Center for Mississippi Health Policy � Brief: Mississippi Health Information Network (MS-HIN)—Moving From Development to Sustainabilty � OCTOBER 2018 MS-HIN Operations MS-HIN BOARD OF DIRECTORS MS-HIN is an independent organization that serves a diverse set of stakeholders. •Delta Health Alliance •Health Insurance Carrier in MS (with IT It is governed by an 11-member board of directors who represent public and knowledge, Governor appoints) private health organizations (see sidebar). Administrative support for network •Hospital in MS (with IT knowledge, Board operations is provided by the State Department of Health. Currently, MS-HIN of Health appoints) •Information & Quality Healthcare participants electronically exchange laboratory, pharmacy, hospital, and clinical •MS Board of Information Technology health information regardless of location. The available data are limited to those Services (ITS) possessed by other providers participating in the network. The value of enrolling in •MS Department of Mental Health (Board of Mental Health appoints) MS-HIN is heightened as more providers participate and add their data. To date, •MS Division of Medicaid most of the participating providers are hospitals and large health systems. Plans •MS Primary Health Care Association are in place to add reference laboratories, pharmacies, third party payors, and •MS State Department of Health (Board of Health appoints) other providers and organizations that are depicted in Figure 2. •MS State Medical Association (a licensed FIGURE 2. VISION FOR FULL STAKEHOLDER PARTICIPATION IN MS-HIN physician) •University of MS Medical Center MS Hospital Association MS Department of Health MS Division of Medicaid Community HIE Other HIE Initiatives MS-HIN DESIGNATION Department of Defense / Military Physician Networks §41-119-3 “The Mississippi Health Information Network is Surgical Centers Mental / Behavioral Health a public-private partnership for the benefit of all of the citizens of this state.” Hospitals & Clinics Long Term Care Physician Practices Independent Physicians SECURITY & PRIVACY Health Systems Private Health Insurance Carriers MS-HIN provides secure health information exchange consistent with state and federal Clinic Groups Accountable Care Organizations (ACOs) privacy and security laws. Reference Labs / Imaging Centers Critical Access Hospitals Federally Qualified Health Centers (FQHCs) Source: MS-HIN. (2018). While participation grew over the past decade, MS-HIN has not reached the critical mass necessary to be of enough value to some stakeholders. Participation is lacking by important partners, including some entities serving on its governing board. Currently, MS-HIN operates from participation fees and from State General Fund appropriations. MS-HIN fees are set by its board and have not changed since their adoption in 2011. In Fiscal Year (FY) 2018, 61 percent of the Network’s funding was generated by participation fees and the remainder came from State funds, nearly opposite from the ratio of its operational funds in FY 2015 (Figure 3). FIGURE 3. MS-HIN FUNDING BY SOURCE, FY 2015 & FY 2018 MS-HIN NOTIFY SERVICE Supports transitions of care by sending providers real-time notification when patients are admitted, 73% 27% FY 2015 released, or transferred from an emergency department or hospital so that they have timely information to manage their patients’ care. 39% 61% FY 2018 0% 20% 40% 60% 80% 100% State General Fund Appropriation Participation Fees Source: MS-HIN. (2018). HEALTH DATA REPORTING Broader stakeholder participation is crucial to reaching sustainability by participant MS-HIN CAN SUPPORT fees alone. Despite Network growth, ongoing challenges include rising vendor •Cancer Registry costs and limited staff. Raising stakeholder participation will bring more data into •Communicable Disease Surveillance •Hospital Discharge Data the Network and encourage others to participate. As MS-HIN brings increasing •Stroke/STEMI Registry value to its participants, more providers will join the Network and pay participation •Trauma Registry fees. In return, additional resources will sustain and grow the Network. 2 of 4 Center for Mississippi Health Policy � Brief: Mississippi Health Information Network (MS-HIN)—Moving From Development to Sustainabilty � OCTOBER 2018 Evolution of Health Information Networks MS-HIN TIMELINE Mississippi was among states that received federal funding over four years to help accelerate adoption of electronic health records (EHR) after the passage of the 2005 Hurricane 2009 Health Information Technology for Economic and Clinical Health (HITECH) Katrina struck Act. In Mississippi, under the leadership of the Governor’s Health Information the gulf coast. 2007 (HIT) Task Force, stakeholders used these funds to help build the legal and Governor’s 2008 HIT Task Force MSCHIE technical infrastructure that became MS-HIN. States had significant flexibility to formed. established with develop HIEs that reflected their own existing infrastructures and organizational five coastal hospitals and a arrangements, and multiple models were developed. MS-HIN was one of a few Federally Qualified Health Center state models assessed by researchers in 2014 to identify specific factors that 2009 (FQHC); Medicity promote or hinder implementation. Mississippi was noted for its following strengths: Federal grant awarded vendor funds awarded contract. to states. 2010 effective state privacy legislation; Beacon grant incentive program to promote provider enrollment; and 2010 awarded to develop HIE in MS-HIN the MS Delta. requirements to use MS-HIN for certain public health reporting. enacted by state law. 2011 Studies of multiple HINs nationwide have identified some of the major barriers to MS-HIN building a successful exchange: operational and participant fee 2014 structures lack of broad stakeholder engagement and financial participation; MS-HIN adopted. reauthorized funds to continue development until user fees can sustain the network; and data security 2015-Present few incentives for providers and vendors to participate; language MS-HIN network strengthened. expands. competition from other HIE efforts; 2019 absence of national standards; MS-HIN law up for reauthorization. competitive business atmosphere that inhibits data exchange; and inability to integrate HIE into provider workflow. Administrative & Policy Strategies GOVERNANCE MODELS Strategies for alleviating these barriers vary widely state-to-state and differ Some states have completely state-led between administrative and policy initiatives built on a range of governance models governance models, others are structured with varying degrees of privatization, including (see sidebar). Some strategies have spurred HIN evolution more so than others. Mississippi, and a few are solely private entities. As MS-HIN revises its fee structure, it will need to strive to reach the best balance between generating sufficient revenue to sustain the Network and setting the fees at a level that is considered affordable by providers for the value received. SINGLE SIGN-ON MS-HIN is also in the process of adding new data sources (see sidebar) that will Implements one set of log-in credentials (such bring further value to participants. Arkansas has focused on refining integration in as user name and password) to access multiple provider settings, with a goal of being the single point of entry to multiple systems. applications. MS-HIN is in the process of implementing this feature to streamline workflow. To address funding issues, Colorado worked with participants to simultaneously develop a sustainable fee structure and to build trust among participants by conducting stakeholder engagement meetings over several years. DATA SOURCES TO BE ADDED Legislative initiatives can also help support HIEs. Eleven states mandate provider VIA NEW GRANT AWARDS participation. North Carolina enacted legislation requiring hospitals to electronically •Behavioral Health submit select data on services paid by Medicaid to its HIN. Two states mandate •Foster Care System •Prescription Monitoring Program (PMP) Query public health reporting. Sixteen states offer financial incentives. Some subsidize costs of establishing connections to the state network or offer monetary rewards to those who use state HIN services. Indiana provided grants to some rural providers in exchange for HIE participation. Twelve states, including Mississippi, provide liability immunity to the HIE and participants. 3 of 4 Center for Mississippi Health Policy � Brief: Mississippi Health Information Network (MS-HIN)—Moving From Development to Sustainabilty � OCTOBER 2018 Summary MS-HIN had a strong start, bolstered by outside funding that enabled the state to launch the effort with a sound structure and growth in initial participation. The Network has established itself as a proof of concept for interoperability. While MS-HIN has experienced increased funding from participation fees, it is not yet self-sustaining from those fees alone. For the Network to realize its potential, more health care providers need to participate. Provider participation is needed not only to supply revenue, but also to expand the volume of medical data available to its participating providers. Lack of seamless integration into provider workflow and incomplete stakeholder participation are barriers to the system reaching its full potential value. These barriers prevent the system from achieving a critical mass of statewide participation and threaten its path to financial sustainability. To reach sustainability, increased participation can be driven through incentives, workflow support, mandates, marketing, or some mixture of these approaches. Multiple states have worked administratively to encourage participation by offering technical assistance, strategically structuring participation fees, and fostering dialogue with providers to build trust. Several states utilized legislative policy to address sustainability barriers. Some states mandated participation while others offered financial incentives such as waiving of certain fees in exchange for network participation. A few states provided grants to areas of need or to entities not otherwise able to afford to join the network. Every state HIN has different requirements and different needs, but state HINs strike a similar chord when implementing administrative and legislative policies to further the goals of creating efficiencies in data exchange and improving patient care. Sources Adler-Milstein, J., Lin, S.C., & Jha, A.K. (2016). The number of health information exchange efforts is declining, leaving the viability of broad clinical data exchange uncertain. Health Affairs. 35(7): 1278- 1285. Center for Mississippi Health Policy. (2018). Semi-structured key informant interviews of MS-HIN stakeholders, select officials in other state HIE offices, and the MS-HIN Board of Directors. Conducted June - September 2018. Dullabh, P., Parashuram, S., Hovey, L., Ubri, P., & Fischer, K. (2016). Evaluation of the state HIE cooperative agreement program final report. NORC at the University of Chicago. http://resource.nlm. nih.gov/101679172. Dullabh, P., Ubri, P., & Hovey, L. (2014). The State HIE program four years later: key findings on grantees’ experiences from a six-state review. NORC at the University of Chicago. https://www.heal- thit.gov/sites/default/files/CaseStudySynthesisGranteeExperienceFinal_121014.pdf. Fridsma, D. (2013). Interoperability vs health information exchange: setting the record straight. Health IT Buzz Blog. Office of the National Coordinator for Health Information Technology. https://www.heal- thit.gov/buzz-blog/meaningful-use/interoperability-health-information-exchange-setting-record-straight/. MS-HIN. (2018). An introduction to the Mississippi Health Information Exchange. Presentation to the Mississippi Primary Health Care Association (MPHCA), May 2018. Mississippi Code of 1972. (2014). Health Information Technology Act. §41-119-1–21. Office of the National Coordinator for Health Information Technology. (2018). A users guide to under- Plaza Building, Suite 700 standing the draft trusted exchange framework. https://www.healthit.gov/sites/default/files/draft-guide. pdf. 120 N. Congress Street Office of the National Coordinator for Health Information Technology. (2017). Connecting public health Jackson, MS 39201 information systems and health information exchange organizations. https://www.healthit.gov/sites/ default/files/FINAL_ONC_PH_HIE_090122017.pdf. Schmit, C.D., Wetter, S.A., & Kash, B.A. (2018). Falling short: how state laws can address health Phone 601.709.2133 information exchange barriers and enablers. Journal of the American Medical Informatics Association. Fax 601.709.2134 25(6): 635-644. Smith, P., Araya-Guerra, R., & Bublitz, C. et al. (2005). Missing clinical information during primary care visits. Journal of the American Medical Association. 293(5): 565-571. www.mshealthpolicy.com Strategic Health Information Exchange Collaborative. (2018). HIE 101. https://strategichie.com/ @mshealthpolicy resources/hie-101/#1519863086641-adb25ac0-rb35. 21st Century Cures Act, H.R. 34, 114th Congress. (2015-2016). 4 of 4 Center for Mississippi Health Policy � Brief: Mississippi Health Information Network (MS-HIN)—Moving From Development to Sustainabilty � OCTOBER 2018