Health Information Exchange in California: Issue Brief Overview of Network Types and Characteristics AUGUST 2021 This brief is a companion piece to "Health Information their data systems such that employed and contracted provid- for participation by organizations, including regional HIOs, large Exchange in California: Assessment of Regional Market ers across the networks can share information through a single health systems such as Sutter and Dignity Health, and state Activity" produced by Intrepid Ascent with the California enterprise health information organization (enterprise HIO). EHR agencies such as the California Department of Health Care Health Care Foundation. Information contained here is vendors also have created the ability for their own customers to Services (DHCS) and the California Emergency Medical Services informed by interviews, online research, and industry expertise. share data with each other on common patients (e.g., Epic Care Authority (CalEMSA). In this way, CTEN functions as a "network- Everywhere). However, the overwhelming focus of EHR vendors of-networks," enabling HIOs, for instance, to query each other H ow do health care providers access patient information today is on enabling data exchange across organizations and for information on common patients, or, for example, for DHCS from outside their practice, clinic, or hospital to deliver between EHRs via national networks. National networks do not to query Sutter Health. informed care? How do organizations and the commu- store patient records, but they provide a framework of technical nities they serve aggregate and analyze patient information to standards and governance agreements with nonprofit oversight, Specialized clinical data exchange networks. A number of guide population health improvement? How do care teams that which enables participants to query one another for information private companies operate large-scale data exchange networks span organizations and sectors (such as health care and housing) on common patients. These networks are particularly useful for that connect many of the same participating organizations as the use data to collaborate and communicate to provide integrated large provider organizations with significant IT resources to con- EHR-centered exchange and HIOs, but that deliver a specific services that address whole-person needs? figure the data systems to meet their needs. type of data or subset of the full patient record. These net- works tend to embed data - such as electronic prescriptions, This document answers these questions through a high-level HIO-centered clinical data exchange. Health information orga- lab results, and clinical event notifications to providers - into overview of the types of infrastructure used to exchange health- nizations (HIOs) operate in California at local and regional levels, provider workflow and EHR systems when patients present at a related information in California today.1 The methods identified with one operating across multiple regions. While these networks hospital or emergency department, to support efficient clinical put information at the fingertips of clinicians, their organizations, vary greatly in their focus and capabilities, they all exchange decisionmaking at the point of care. and partnering service providers for the care of individuals and clinical data regardless of the EHR systems used. HIOs both aug- populations.2 ment EHR-centered exchange networks to fill critical gaps and Whole-person data exchange networks. With the widespread at times compete directly with them. Some HIOs have focused recognition that social and behavioral factors largely deter- While based on similar technology standards, each type of data on aggregating data, laying the foundation for population-level mine population health outcomes, data-sharing networks have exchange infrastructure described is built and organized to insights. Importantly, these networks convene a diverse set of emerged throughout the state that facilitate the coordination address distinct priorities, has specific strengths and weaknesses, local stakeholders to solve data-sharing problems, fostering trust of services across sectors so patients can be supported holisti- and operates differently in scale and geographic distribution. among them. While the methods for data submission to HIOs are cally. Many of these emerging networks address whole-person Many of these networks overlap, and organizations often partici- largely standardized, methods for accessing HIO data are much needs, combining medical, behavioral health, and social data pate in more than one. While the networks represent a significant more variable. Some HIOs primarily push data into their partici- with electronic tools for collaboration across these settings. They advance in capabilities across the state, without further progress pants' EHR, while another common approach is to make data are generally in an earlier stage of development than the other and alignment, they leave significant gaps that contribute to available via an HIO's web portal. Given the providers' interest to networks described here. These networks include Whole Person fragmented services for most Californians. stay in the EHR workflow, use of HIO portals to access a patient's Care Pilots, a waiver program focused on vulnerable popula- comprehensive community record remains limited. tions and funded by DHCS, and efforts across the state to enable The primary types of health information exchange networks are: referrals between health care providers to community-based and Some HIOs share data with one another through the California government social service providers (e.g., housing, food banks). EHR-centered clinical data exchange. A majority of clinical data Trusted Exchange Network (CTEN), which also gives them access With the transition from Whole Person Care to CalAIM (California exchange in California happens through approaches that con- to national networks, and through the Patient-Centered Data Advancing and Innovating Medi-Cal), data sharing across sectors nect health care providers to each other and to other partners Home, an approach that alerts a patient's "home HIO" of clini- will become more critical to meet the rigorous new requirements through their electronic health record (EHR) systems. Large hos- cal events that happen outside the patient's residing area. CTEN for qualifying patients and managing them over time.3 pital and health systems have made significant investments in provides a governance framework with technical requirements Prominent Data Exchange Networks: Characteristics and Key Metrics, by Network Type, continued DATA EXCHANGE SERVICE PRIORITIES REACH (FOOTPRINT IN CALIFORNIA) PRIMARY PARTICIPANTS GOVERNANCE GAPS/CHALLENGES EHR-Centered Clinical Data Exchange Hospital and Health Systems Record of all clinical services Most health and hospital systems in Providers and staff System-driven $ Limitedto members of organization and Integrated health and hospital provided by a health system California have made significant strides within the health contracted providers systems support clinical data to its patients; integration of to integrate their numerous data systems, system; may extend to $ Primarily benefit large provider organi- sharing among affiliated facilities external data as available; centered on their EHR. non-employed provider zations with resources to purchase and and providers via the system's increasingly, analytics network; patients can configure EHR systems predominant in E X AMPLES  EHR and supporting technology tools for population health access some informa- the hospital market (e.g., Epic) management; benefit Kaiser Permanente, Sutter Health, tion through health ("enterprise HIOs"). from participating in the and Contra Costa County Health system patient portals. $ Limited behavioral health (BH) and social EHR vendor and national Care Services use Epic; Common determinants of health (SDOH) data networks below. Spirit and USC (University of Southern California) use Cerner. EHR Vendor Networks Clinical data sharing These networks are prevalent in both Hospital and provider Vendor-driven with $ Limitedto providers using a particular EHR vendor networks allow across a vendor's client inpatient and ambulatory settings across organizations with the user input vendor's EHR platform provider organizations that base creates more access to the state; they have limited reach into same EHR vendor $ Primarily benefit large provider organi- use a vendor's EHR to share complete patient records. nonmedical settings like BH and social zations with resources to purchase and clinical data with other users service organizations. configure EHR systems predominant in of that EHR. the hospital market (e.g., Epic) E X AMPLES  Care Everywhere, the network internal $ Limited BH and SDOH data to the EHR vendor Epic, exchanged 221 million records nationally during one month in late 2020 (includes data shared with other vendors).4 National Networks Query-based exchange of Major health systems, large EHR vendors, Health systems, EHR Combination of $ Notall EHR vendors or provider (eHealth Exchange, Carequality, electronic clinical data community clinics, and physician practices and other vendors, system-driven and organizations participate. and Commonwell) across diverse provider use these networks. government agencies, vendor-driven; $ Data overload and quality issues reduce National networks exchange organizations and networks regional HIOs and nonprofit E X AMPLES  utilization at the point of care. clinical records between similar networks, organizations Carequality and At the national level, Carequality supports $ Without customization, cumbersome provider organizations and practices that use CommonWell support over 150 million documents exchanged workflows inhibit small provider organi- health systems by establishing certain EHRs multiple EHR vendors. per month, Commonwell data represent zations lacking internal IT resources common data-sharing agree- ments and standards. eHealth Exchange supports more than 135 million unique individuals, from using organizations rather and 77% of the nation's state and regional $ Query-based exchange does not "push than EHRs and anchors HIEs exchange data within the eHealth out" data that no one knows to ask for. on the Veterans Health Exchange network. $ Robust governance at the national level, Administration health systems and other major but limited ability to respond to state health systems. and local priorities California Health Care Foundation www.chcf.org 2 Prominent Data Exchange Networks: Characteristics and Key Metrics, by Network Type, continued DATA EXCHANGE SERVICE PRIORITIES REACH (FOOTPRINT IN CALIFORNIA) PRIMARY PARTICIPANTS GOVERNANCE GAPS/CHALLENGES HIO-Centered Clinical Data Exchange Health Information Robust clinical record for $ 15HIOs in California with participants Hospital and provider Typically, $ Variable participation and service levels Organizations (HIOs) individuals in network in at least 39 of the 58 counties organizations, county participant-driven $ Large areas of the state with no Typically regional nonprofit service area; lab results $ Morethan 20 million messages health services organiza- significant HIO networks, supported by unaffili- delivery and hospital exchanged per month on patient tions (especially primary $ Limited BH and SDOH data ated health care organizations event notifications; encounters 5 care and BH), payers, growing analytics other stakeholders $ Questions about financial sustainability capabilities for population E X AMPLES  - large providers leverage EHRs for health management $ Most HIOs focus on building density data-sharing; EHR vendors bundle in their home geographies. national network fees into base costs, $ One HIO, Manifest MedEx, has a making it difficult for HIOs to compete presence in multiple regions with 120 on price. hospitals, 700 ambulatory sites, and eight health plans participating across the state and emphasizes integrating clinical and claims data. California Trusted Exchange Exchange of electronic clini- 16 participating organizations in California, HIOs, health systems, User-driven and $ Not all clinical data in participants' Network (CTEN) cal documents; primary data most of which are HIOs, with the addition and California managed by underlying systems can be exchanged A governance framework with network for the California of several major health systems and state state agencies CAHIE, a public/ and technical methods of exchange technical requirements creating EMS (emergency medical agencies, including EMS and DHCS6 (EMS and DHCS) private partnership are limited, but network is more able a network connecting HIOs, services) data system PULSE supported by the to respond to California-specific needs E X AMPLES  health systems, and others, (Patient Unified Look-up state of California than national networks. System for Emergencies) HIOs in San Diego and Santa Cruz including state agencies $ Limitednumber of participating can query each other for information specific to California CTEN also provides a ramp organizations on common patients. for member HIOs to onboard to the national networks, specifically eHealth Exchange, effectively and economically. Patient-Centered Data Home Enables a patient's "home" 45 HIOs nationwide, with five HIOs in Regional and state Participant-driven $ Minority of California HIOs participate. Network-of-networks approach HIO to be notified when the California participating in the western HIOs nationally and managed $ Governance managed by a national connecting HIOs patient receives care outside US regional network7 through nonprofit. of their HIO's service area. a national HIO E X AMPLES  $ Only nonprofit HIOs can participate. association, the Data sharing between HIOs in Strategic Health San Diego, Santa Cruz, and Information northern Central Valley with Exchange HIOs in Texas and Utah. Collaborative Health Information Exchange in California: Overview of Network Types and Characteristics www.chcf.org 3 Prominent Data Exchange Networks: Characteristics and Key Metrics, by Network Type, continued DATA EXCHANGE SERVICE PRIORITIES REACH (FOOTPRINT IN CALIFORNIA) PRIMARY PARTICIPANTS GOVERNANCE GAPS/CHALLENGES Specialized Clinical Data Exchange Networks Clinical Event Notifications Notifications sent to provid- Collective Medical Technologies (CMT) Hospital and provider Mix of vendor-driven $ Inherentlylimited in scope because Event notification services used ers and/or embedded in supports about 50% of California hospitals organizations, payers and participant- shared data are just a portion of the full to coordinate patient care, most the EHR when their patients with an ED (178 of 340 hospitals) and 744 driven patient record commonly via ADT (admission, receive services in other skilled nursing facilities.8 $ Whilescope is narrow, data provided discharge, transfer) messages organizations; patient infor- by these networks are designed to be E X AMPLES  mation beyond the ADT especially actionable. shared depending on the CMT embeds alerts in a provider's EHR; specific service alerts summarize actionable information $ Emerging but limited connections about the patient, such as drug-seeking between clinical, behavioral, and social behavior, security threats, existing diagnos- service organizations tic and lab results, and care team contact information. PatientPing is also present with a small California footprint. HIOs like Manifest MedEx offer event notifications, as does DirectTrust, a secure messaging capability required for EHR certification, that allows providers to push event notifications out of the EHR. Other Specialized Sharing of specific types Critical infrastructure in specific areas such Hospital and provider Vendor-driven $ Inherentlylimited in scope because they Data Exchange of data and health care as e-prescribing and lab results delivery organizations; ancillary generally involve a single data type Networks for exchange transactions, such as providers (pharmacies, $ Many primarily deliver one-way sharing E X AMPLES  of specific types of e-prescriptions or labs) for specific use cases. clinical data. diagnostic lab results Surescripts, the leading e-prescribing network, counts 95% of US providers $ During the COVID-19 pandemic, public as members of its network.9 health and "pop-up" testing labs that Quest Diagnostics and LabCorp dominate have varying technical ability present the clinical reference laboratory market and challenges to data sharing. are the primary source of lab result data. $ Whilescope is narrow, data provided by these networks are designed to be especially actionable. California Health Care Foundation www.chcf.org 4 Prominent Data Exchange Networks: Characteristics and Key Metrics, by Network Type, continued DATA EXCHANGE SERVICE PRIORITIES REACH (FOOTPRINT IN CALIFORNIA) PRIMARY PARTICIPANTS GOVERNANCE GAPS/CHALLENGES Whole-Person Data Exchange Networks10 Whole Person Care Clinical data sharing $ 26 individual pilots in California Driven by county health Government-driven, small compared to EHR- and $ Relatively (WPC) Pilots11 within California counties, $ Approximately200,000 enrolled departments, with at the state and HIO-based exchanges Medi-Cal delivery system combined with tools WPC enrollees, as of June 202012 local participation from county levels $ Variable levels of integration and integration pilots focused on for collaboration hospital and provider coordination across service sectors, $ CalAIM to scale up WPC approaches high-risk populations; most across organizations organizations, social depending on the county or pilot managed by county health and sectors, including E X AMPLES  services providers, other $ CalAIMwill shift control of the WPC departments. BH and SDOH data Alameda County, which lacked an HIO, stakeholders program to managed care plans to scale, developed a robust data exchange system which has both opportunities and risks. combining clinical, BH, and SDOH data with collaboration tools; has emerged as a viable Community Information Exchange (see note 11). Social Services Referrals Referral and coordina- Rapidly emerging capability across the Hospital and provider Mix of participant- $ These networks are gaining a significant Networks tion tools that leverage state, partly driven by major health organizations, county driven and footprint only now. These initiatives focus on data "electronic phone books" systems and payers, and sometimes and public health vendor-driven $ Implementation is complex and there are sharing to enable social service of service providers related to county-based WPC initiatives. services, social services, significant organizational growing pains. coordination through referrals payers, other local E X AMPLES  $ Interoperabilitywith EHRs, HIOs, IT between health care organiza- stakeholders In Los Angeles, L.A. Care has partnered platforms used by social service provid- tions and non-health care social with Aunt Bertha for access to a social ers, and among competing referral service organizations. service referral platform for use by platforms, is lacking. contracted provider organizations. $ Useof multiple platforms in a region Other prominent vendors include One may place an undue burden on social Degree, NowPow, and Unite Us. service providers expected to use multi- ple platforms to manage patients. Health Information Exchange in California: Overview of Network Types and Characteristics www.chcf.org 5 About the Author Endnotes Mark Elson, PhD, the principal of Intrepid Ascent, 1.Health information exchange infrastructure has two primary 10.Such a network is sometimes referred to as a components, technical and governance, both of which are "Community Information Exchange" (CIE). Whole Person and members of his team developed this snap- examined in this report. Data Exchange Networks was selected as a heading instead shot. Intrepid Ascent supports communities in the for the following reasons. First, DHCS refers to "Whole 2.As such, this overview does not address claims data and exchange and use of data to improve health. payment systems, state-level disease registries, public health Person Care Approaches" as an organizing concept for the CalAIM program, and the networks described here surveillance databases, or quality reporting. The full report, support this approach. Second, being a relatively new term, Health Information Exchange in California: Assessment of About the Foundation Regional Market Activity, provides examples of how these CIE means different things to different people - usually either corresponding to social referrals or to comprehensive The California Health Care Foundation is dedicated parallel ecosystems at times do inform decisionmaking at the exchange and use of medical, behavioral, and social data to advancing meaningful, measurable improvements point of care (e.g., the state CURES database, public health within a community. With the latter of these two definitions, labs with COVID-19 test results, and claims data integrated in the way the health care delivery system provides into clinical services). CIE remains more of a goal than a reality in California today. care to the people of California, particularly those 11.Health Homes represented another Medi-Cal delivery 3.Another Medi-Cal program, Health Homes for Patients with with low incomes and those whose needs are not Complex Needs, provides an additional foundation for system integration pilot run through the managed Medicaid plans. This program did not emphasize cross-sector data well served by the status quo. We work to ensure CalAIM through investments made by Medicaid managed sharing. As a result, the development of data exchange that people have access to the care they need, when care plans, although these investments did not result in infrastructure was limited in this program. infrastructure for data sharing across sectors to the extent they need it, at a price they can afford. seen with Whole Person Care. 12.For more information about Whole Person Care, please visit the "Whole Person Care Pilots" page on the 4.Kat Jercich, "Epic's Care Everywhere Interoperability CHCF informs policymakers and industry leaders, Platform Shows Big Jump in Data Exchange," Healthcare IT DHCS website. invests in ideas and innovations, and connects with News, December 14, 2020. changemakers to create a more responsive, patient- 5."HIE in California," California Assn. of Health Information centered health care system. Exchanges, n.d. 6."CTEN," California Assn. of Health Information Exchanges, n.d. 7."Patient Centered Data Home," Strategic Health Information Exchange Collaborative, n.d. 8.Information provided by CMT. 9.Kate Rusciano, "Why It Matters: Prescribers Can Now Access Accurate Medication History Data for Virtually Every American," Surescripts, May 31, 2019. California Health Care Foundation www.chcf.org 6