SummaryThe Arizona Medical Information Exchange enabled clinicians serving Medicaid beneficiaries to immediately access patient-specific hospital discharge, laboratory test, and medication data from other providers, thereby allowing them to make more fully informed clinical decisions, avoid duplication of tests, ensure safe medication prescribing, and provide greater continuity of care. Survey data and anecdotal feedback suggest that the program enhanced efficiency and safety and reduced the costs associated with unnecessary procedures and laboratory tests. As a result of this success, the program ceased operating as a discrete service and became part of a larger statewide program known as the Health Information Network of Arizona.Suggestive: The evidence consists of post-implementation survey results regarding the efficiency, safety, and cost implications of using the exchange.
Developing OrganizationsArizona Health Care Cost Containment System
The Arizona Medical Information Exchange was developed by the Arizona Health Care Cost Containment System, Arizona’s Medicaid agency, located in Phoenix.
Date First Implemented2008
The Arizona Medical Information Exchange project began in 2007; the system went live in September 2008.
Insurance Status > Medicaid
Problem AddressedInadequate or delayed communication about patient care and the inability to share clinical information among clinicians working in different settings can lead to suboptimal quality, inefficiencies in care provision, and waste. However, many providers, particularly those caring for Medicaid patients, do not have access to technologies that facilitate the sharing of information.
- A major cause of inappropriate care: A landmark 2003 study found that Americans receive appropriate care only approximately 55 percent of the time.1 The failure to provide appropriate care often stems from clinicians not having full information when a decision needs to be made.2
- Lack of technology to facilitate information exchange: A survey of 214 health care opinion leaders revealed that 66 percent believe that accelerating the adoption of information technology would be effective or very effective in improving the quality and safety of health care.2 Experts believe that health information technology can be instrumental in providing evidence of effectiveness through decision support, avoiding duplication and waste, and achieving better coordination of care by ensuring the transfer of appropriate information among providers.3 Yet many providers do not have access to such technology.
- Especially among Medicaid providers: In many states, providers serving Medicaid beneficiaries do not have a quick and easy way to share clinical information about patients; instead, they rely on faxed information, which can be incomplete and often causes care delays.4
Description of the Innovative ActivityArizona clinicians providing services to Medicaid patients used an electronic Web-based health information exchange, called the Arizona Medical Information Exchange (AMIE), to instantly access patient-specific information from other facilities at the point of care. The system allowed clinicians to collect relevant information about a patient before treatment, thus ensuring fully informed, efficient, and safe clinical decisionmaking while preventing duplicative care. The program has been discontinued as a discrete service and made part of a larger statewide program known as the Health Information Network of Arizona (HINAz). (See Planning and Development Process section for more details). Key elements of the original AMIE program included the following:
- Secure provider login: Clinicians trained on how to use the system logged into it with a user name and password. The clinician searched for a particular patient by entering the patient’s name and other identifiers. During the pilot project, 100 clinicians at 70 sites (including hospitals, clinics, and private practices) used the exchange, which included 4.1 million records on 2.26 million unique patients.
- Relationship validation: Only clinicians actively involved in the patient’s treatment could access the record. Clinicians signed a contract guaranteeing that they would access only information needed to treat a patient. Furthermore, an “attestation screen” presented after login required the provider to record his/her relationship with and involvement in the treatment of the patient.
- Immediate access to clinical data from numerous sources: The information exchange accessed clinical (rather than claims or administrative) data from numerous sources, including hospitals, laboratories, and managed care pharmacy administrators. Information was not collected or stored; rather, the exchange connected providers to these sources via a Web-based browser and converted the data into a standardized format so that it could be easily indexed and shared. The provider checked the type(s) of information he/she wanted to receive, and the information appeared on the screen within a second. Three types of data could be accessed:
- Hospital discharge summaries and related documents: Discharge summaries (the clinical notes written by a physician when a patient is discharged) included information such as diagnosis, treatment provided, health status at discharge, and postdischarge expectations and instructions. Consultations, operative notes, cardiac studies, and other reports were also available.
- Laboratory test results: All laboratory test results could be accessed through the exchange.
- Medication history: The medication history included all medications prescribed to the patient. Behavioral health medication histories could also be accessed through the exchange.
- Individualized workflow: Use of AMIE varied depending on an individual clinician’s preferences. For example, in a clinic or private practice, the clinician might access the information before, during, or after a visit, and might either review it online or print it. In the emergency department, the secretary might search the exchange for information about a presenting patient and then print the information for the clinicians providing treatment. Sites that have their own electronic medical record (EMR) could use the information gathered via the exchange to inform automated alerts and clinical decision support tools.
Context of the InnovationThe Arizona Health Care Cost Containment System, Arizona’s Medicaid agency, serves over 1 million Medicaid recipients in the state. Because the agency contracts patient care out to several managed care organizations (which, in turn, contract with many providers), and because behavioral health is a carve-out service administered separately, Medicaid recipients typically receive treatment at many different locations, including clinics, hospitals, and private physician offices. The impetus for the program came from Arizona Medicaid executives, who realized that there was no way for these different locations to share clinical information easily and quickly to ensure appropriate coordination of care, patient safety, and efficiency. With these goals in mind, they sought and won a Medicaid Transformation Grant in 2007 to fund the development of a health information exchange.
ResultsA 3-month proof-of-concept study involving convenience sampling methods and questionnaires, focus groups, and personal interviews found that users of the exchange strongly believed it led to greater efficiency and safety and a reduction in costs associated with unnecessary procedures and laboratory tests. (To read specific anecdotes that demonstrate the benefits of the exchange, see the Story section.)
Suggestive: The evidence consists of post-implementation survey results regarding the efficiency, safety, and cost implications of using the exchange.
- Greater efficiency: Seventy-one percent of the 29 respondents believed that the exchange saved time. Nearly 70 percent said that they “agreed” or “strongly agreed” that the exchange made the medication reconciliation process more efficient.
- Improved safety and quality: Ninety-eight percent of respondents agreed or strongly agreed that the exchange reduces the probability of medication errors. Anecdotal responses suggested significant benefits in terms of avoiding narcotic abuse and drug–drug and drug–food interactions. In addition, clinicians reported being happier with the quality of care they can provide when using the exchange.
- Lower costs: Seventy-one percent of respondents agreed or strongly agreed that obtaining clinical information using the exchange reduces costs and duplication of health care services. For example, some providers noted that the ability to access discharge summaries and information about procedures associated with prior cardiac evaluations (including computed tomography scans and magnetic resonance imaging) reduced unnecessary procedures (and hence saved money). Anecdotal feedback suggested significant savings through reductions in duplicative laboratory testing; estimates from project developers suggest that 4 percent of laboratory tests have historically been duplicative, and that the majority of these tests have been eliminated because of the exchange. According to project developers, the cost savings generated through reductions in duplicative testing alone more than paid for the costs of adopting the system.
Planning and Development ProcessKey elements included the following:
- Focus groups to identify needed data: The agency held focus groups with clinicians around the state to identify the types of clinical information that would be most useful in providing clinical care. The groups identified three categories of data—hospital discharge summaries, laboratory test results, and medication histories.
- Clinicians advisers and surveys: A group of 40 clinicians served as an initial advisory group to the project. (These clinicians also served as the initial users and testers of the exchange.) The agency surveyed these clinicians to understand what features and information were important to them, and how they could use and interact with a health information exchange.
- Provider selection: The 100 providers who participated in the pilot study were selected based on their willingness to commit the time involved to evaluate the exchange and provide feedback regarding its use and expansion.
- User feedback: Program leaders used weekly electronic surveys of users during the pilot project to inform project enhancements and expansion.
- Data partner identification: The agency approached leaders at each hospital, laboratory, and pharmacy benefit company about participating in the exchange. These partners engaged their clinical, legal, and public relations staff to ensure their understanding of the venture.
- Data-sharing agreement: The agency developed data-sharing agreements that allowed for and defined the sharing of clinical data. Developers began with templates created by the Markle Foundation, and then adapted these model agreements to the local context. Each data partner had a unique approach based on their specific data requirements.
- Laboratory data accommodation: The Clinical Laboratory Improvement Amendment is a Federal law that regulates the operations of clinical laboratories. Among other things, the law limits to whom a laboratory may release test results. The law specifies an "authorized person" as an "individual authorized under State law to order tests or receive test results, or both." Therefore, sharing laboratory test results through the exchange required the agency to request a policy interpretation and approval from the Arizona Department of Health Services to allow clinicians who did not order the tests to access the data. This process led to the agencies initially excluding certain tests from the exchange, including those related to behavioral health and some genetic and reproductive health tests. Many of these tests have since been added to the exchange (in February 2009), while others will not be added without additional policy changes.
- Software development: The agency identified open-source software for the project, developed by the Massachusetts–Simplifying Healthcare Among Regional Entities initiative and funded by the U.S. Department of Health and Human Services as part of its first Nationwide Health Information Network pilot project (a project to provide a secure, nationwide, interoperable health information infrastructure). The agency significantly enhanced this software using an internal software development team.
- Training: The agency developed a 2-hour, inperson structured training program, led by agency staff, to introduce users to the technology, describe the available information, present the risks associated with breach, and cultivate an understanding of the limits of the information. The agency has since developed online video tutorials and training for new users.
- Formal evaluation: A formal evaluation was performed as part of the 3-month proof-of-concept study (October-December 2008). The University of Arizona produced the evaluation and evaluation report under a subcontract, with the report filed with the Centers for Medicare and Medicaid Services as a deliverable under the Medicaid Transformation Grant. The program then added two pilot sites. The first, a behavioral health site, included pharmacy claims from Arizona's Regional Behavioral Health Authorities, with behavioral health care providers added as users of the exchange; a formal evaluation report was completed in August 2009. The second pilot, launched in June 2009, involved care providers from the Children's Rehabilitative Services program in Arizona.
- Incorporation into statewide exchange: Based on its success, AMIE has been discontinued as a discrete service and made part of a larger statewide program known as the HINAz. HINAz combined two existing entities—AMIE and the Southern Arizona Health Information Exchange—into a single initiative. This program is currently expanding to practices throughout the state to provide a variety of data, including laboratory values, prescription drug information, and hospital discharge summaries. Eventually it will exchange information across the EMRs of the various providers caring for a single patient. This system is open to a variety of payers, including Medicaid managed care plans, Medicare Advantage plans, and commercial insurers. Its board of directors consists of representatives from a variety of entities, including payers, hospital systems, the Medicaid program, and others.
Resources Used and Skills Needed
- Staffing: The program involved 13.5 full-time staff, half directly involved in technology development and half managing business operations, provider training, auditing, data partner and user relationships, and other administrative functions.
- Costs: The exchange cost $11.7 million to develop and implement. Major cost categories included background analysis, program development (including contracting, legal, and policy issues, which collectively represent roughly half of total costs), and technology development.
Funding SourcesCenters for Medicare and Medicaid Services
The project was funded through a Centers for Medicare and Medicaid Services Medicaid Transformation Grant.
Tools and Other ResourcesThe Markle Foundation has developed programs and tools related to communication and information technologies that are available at: http://www.markle.org.
Getting Started with This Innovation
- Assemble forward-thinking clinician group: Begin by hosting a focus group with clinicians amenable to incorporating technology into their work and who recognize the potential quality and safety benefits of sharing clinical data.
- Use clinical (rather than claims or administrative) data: Medicaid agencies have a significant amount of claims and administrative data, but these data often have little value to clinicians making real-time care decisions.
- Set appropriate expectations: Not all data will be available for all patients immediately, particularly if historical information is not preloaded into the system. Prepare clinicians for the likelihood that the usefulness of the technology will grow over time as information and data elements are added.
- Accommodate clinicians who lack EMRs: Realizing that many Arizona doctors did not have EMR systems, the Arizona Health Care Cost Containment System created a simple Web-based application that clinicians could use to search and locate information on their patients.
- Do not limit data to Medicaid patients: Clinicians will find the system much more helpful if data are available for all patients, not just Medicaid enrollees. In Arizona, clinician focus groups noted that using the exchange for a broader patient base would simplify their work processes.
Sustaining This Innovation
- Expect success to spur interest: As information is shared and benefits realized, clinician enthusiasm and excitement about having information at their fingertips will ensure continued use and interest in expansion to additional sites. For example, different groups of specialists, such as optometry providers, are now interested in using the system.
- Expect clinicians to want more data: Once clinicians become used to data sharing, they will likely want access to additional types of clinical data. Consider how to expand the system over time (both technically and with revised data-sharing agreements) to make it even more useful for clinicians.
Contact the InnovatorMarc Leib, MD, JD
Chief Medical Officer
Office of the Director
Arizona Health Care Cost Containment System
801 E Jefferson Street
Phoenix, AZ 85034
Phone: (602) 417-4466
Fax: (602) 252-6536
Innovator DisclosuresDr. Leib has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesMore information about HINAz is available at: http://www.ehealthnetworkaz.org.
McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45. [PubMed]
4 Interview with Marc Leib, MD, JD; Anita Murcko, MD, FACP; and Perry Yastrov.
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Original publication: August 05, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 28, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.