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Policy Innovation Profile

Statewide Health Information Exchange Generates High Levels of Participation and Many Reports of Improved Quality and Efficiency


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Snapshot

Summary

The Delaware Health Information Network is the country's first operational statewide health information exchange. Facilitated by State legislation and overseen by a board and committee structure, the Delaware Health Information Network seeks to support health care quality, safety, and efficiency for patients who receive care from Delaware providers. The Delaware Health Information Network gives clinicians immediate access (via a Web portal or electronic medical record interface) to patient-specific laboratory and pathology results; radiology reports; transcribed reports; and hospital admission, discharge, and transfer data from other providers, thereby allowing them to make more informed clinical decisions, avoid duplication of tests, ensure safe medication prescribing, and provide greater continuity of care. The Delaware Health Information Network also helps member hospitals and laboratories fulfill all public health reporting requirements by transmitting data directly to a statewide health registry. The exchange has attracted the participation of the vast majority (97 percent) of Delaware providers, tracks nearly 88 percent of Delaware's population, delivers more than 10 million clinical results and reports to participating providers annually, and has generated high levels of clinician satisfaction and anecdotal reports from both clinicians and patients/families of improved quality and efficiency.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion of Delaware providers participating in DHIN, the number and proportion of Delaware residents tracked by DHIN, the number of annual clinical transactions delivered by DHIN, and clinician and patient/family reports on their satisfaction with DHIN and its impact on the quality and efficiency of care.
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Developing Organizations

Delaware Health Information Network (DHIN)
The development of the Delaware Health Information Network was a collaborative effort undertaken by many public and private organizations and stakeholders throughout Delaware.end do

Date First Implemented

2007
May 1

Problem Addressed

Inadequate or delayed communication about patient care and the inability to share clinical information among clinicians working in different settings can lead to suboptimal quality, care inefficiencies, and waste. However, many providers do not have access to technologies that facilitate information sharing.
  • 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: In a survey, two-thirds of health care opinion leaders reported believing that accelerating the adoption of information technology would be effective or effective in improving the quality and safety of health care.2 Experts believe that health information technology can be instrumental in providing decision support, avoiding duplication and waste, and achieving better coordination of care by ensuring the transfer of appropriate information among providers.3 A health information exchange (HIE)—an organization or system that enables the electronic sharing of health-related information—can facilitate data sharing among providers and thus improve care quality and efficiency, yet many providers do not have access to such technology.

What They Did

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Description of the Innovative Activity

The Delaware Health Information Network (DHIN) is the country's first operational statewide HIE. Participants include health plans, hospitals, physician practices, laboratories, radiology groups, Federally Qualified Health Centers, skilled nursing facilities, assisted living facilities, home health agencies, hospices, pharmacies, and the state's Division of Public Health. Facilitated by State legislation and overseen by a board and committee structure, DHIN seeks to support health care quality, safety, and efficiency for patients who receive care from Delaware providers. DHIN gives clinicians immediate access [via a Web portal or electronic medical record (EMR) interface] to patient-specific laboratory and pathology results; radiology reports; transcribed reports; and hospital admission, discharge, and transfer data from other providers, thereby allowing them to make more informed clinical decisions, avoid duplication of tests, ensure safe medication prescribing, and provide greater continuity of care. DHIN also helps member hospitals and laboratories fulfill all public health reporting requirements by transmitting data directly to a statewide health registry. Key program elements include the following:
  • Enabling legislation: In 1997, the Delaware General Assembly passed legislation (House Bill 276) creating DHIN as a public instrumentality of the state. The legislation specified that DHIN be operated as a public–private partnership under the auspices of the Delaware Health Care Commission, part of Delaware’s Department of Health and Social Services. In July 2010, the Delaware General Assembly passed Senate Bill 231, which removed DHIN from the Delaware Health Care Commission's purview and legislated its establishment as a public–private, not-for-profit corporation.
  • Memorandum of understanding: DHIN and participants that will be sending data to the exchange sign a Memorandum of Understanding that defines each party’s responsibilities and expectations. For its part, DHIN agrees to manage and oversee project planning, development, implementation, and participant coordination. For their part, data senders agree to provide a project manager to develop and manage the DHIN interface, test and validate new functionalities, meet financial obligations related to transaction fees, and maintain other requirements related to participation in the network.
  • Governance structure featuring board and committees: DHIN's governance structure includes a board that serves as an oversight body and a set of committees that evaluate and provide input on specific issues, as follows:
    • Board: Per the 2010 legislation, the DHIN board includes 19 public and private representatives, including the Director of the Office of Management and Budget, the Chief Information Officer of the Department of Technology and Information, the Secretary of the Department of Health and Social Services, and the Controller General (or their designees), as well as the following governor-appointed members: 6 members, with at least 1 representing consumers and at least 3 with health care industry expertise; 3 members representing hospitals or health systems; 3 members representing physicians; 1 member representing employers; and 2 members representing insurers.
    • Committee structure: Committees provide a mechanism for the board to receive feedback and input from various stakeholder groups. Committees include an executive committee, a clinical advisory group, a consumer advisory committee, a health information management committee, a finance committee, a continuum of care workgroup, a project management committee, and a laboratory standardization workgroup.
  • Transmission of clinical information: DHIN transmits five types of clinical information: laboratory results; radiology reports; transcribed reports; pathology results; and hospital admission, discharge, and transfer data. DHIN can also provide data on medication history to hospitals and physicians paying a subscription fee, but to date no providers have signed up for this feature.
  • Multiple options for access to information: To ensure that use of DHIN can fit seamlessly into clinical practice workflow, providers can quickly access clinical information in three different ways.
    • Web-based access: Using a user name and password, providers can access a Web-based feature called the Clinical Inbox to view patient reports they have previously ordered or to query data stored in a community health record (e.g., to research a first-time patient’s laboratory test history).
    • Interface with EMRs: DHIN automatically transmits reports to a participating practice's EMR system if that system interfaces with DHIN.
    • Printed reports: In paper-based practices, providers can set the Clinical Inbox to automatically print reports in a standardized format.
  • Public health reporting: DHIN also helps member hospitals and laboratories fulfill all public health reporting requirements (such as those related to syndrome surveillance and electronic reporting of laboratory data and immunization administration) by transmitting data directly to the statewide health registry.

Context of the Innovation

In the mid-1990s, leaders of a number of public and private organizations began recognizing the need to share health data electronically, with several of them initiating plans to build systems for doing so. Representatives of these organizations quickly realized that creating one statewide initiative would be more effective and efficient than having multiple programs. Consequently, they created a public–private workgroup charged with drafting bylaws in preparation for the formation of a statewide HIE system. However, in 1996, the Delaware Public Integrity Commission issued a report concluding that State officials could be in violation of the Delaware Code of Conduct if they sat on a private organization's board of directors. As a result, workgroup members decided that legislation was needed to create an HIE system as a public–private partnership.

Did It Work?

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Results

DHIN has attracted the participation of the vast majority (97 percent) of Delaware providers, tracks nearly 88 percent of Delaware's population, delivers more than 10 million clinical results and reports to participating providers each year, and has generated high levels of clinician satisfaction and anecdotal reports from clinicians and patients/families of improved quality and efficiency.
  • Broad participation: As of December 2012, 97 percent of providers in Delaware who order diagnostic and laboratory tests participate in and use DHIN. Other participants include all Delaware hospitals, skilled nursing facilities, and Federally Qualified Health Centers; 99 percent of laboratories; 75 percent of radiology groups (representing 95 percent by patient volume); and 72 percent of assisted living facilities. DHIN health plan members provide coverage to 43 percent of Delaware residents. Four home health agencies, three hospices, five pharmacies, and the state's Division of Public Health also participate in DHIN. (Providers who have primarily administrative roles, such as those in public health and who work for insurance companies, are not included in the denominator for provider participation.)
  • Many patients tracked: As of June 2012 (latest data available), DHIN included information on 1.4 million unique patients, including 787,000 Delaware residents (nearly 88 percent of the state's population).
  • Millions of transactions each year: DHIN delivers more than 10 million clinical results and reports annually. Approximately one-half are sent to practices that use DHIN as their only source of the types of information included in the exchange.
  • Highly satisfied clinicians: A 2012 survey found high levels of satisfaction among Delaware clinicians and practice managers using DHIN, including overall satisfaction with the system (rated 8 on a scale of 1 to 10), customer service (9), and willingness to recommend DHIN to colleagues (9.2).
  • Anecdotal reports of better, more efficient care: Program developers have heard many positive reports from clinicians, patients, and families regarding the positive impact of DHIN on the quality and efficiency of care, including improvements in communication and care coordination; several representative quotes are provided below. DHIN's impact on the burden of chronic disease in Delaware will be assessed in the coming years.
    • “We recently had a patient who was referred to our office for [prenatal] counseling and a level II ultrasound due to a family history of a congenital anomaly. In her appointment, the patient stated that her OB/GYN office called her that morning and stated that her AFP [alpha-fetoprotein] tetra screen, a screening test for Down syndrome, came back indicating that her pregnancy was an increased risk for Down syndrome. Her OB/GYN had not faxed over these records to our office prior to her appointment. With the DHIN, we were able to access her risks, answer all of her questions, and offer her the appropriate followup testing.”—Genetic counselor
    • “I believe the benefits of the DHIN are most evident in the field of emergency medicine. [Our] emergency departments are receiving sites for patients from the entire state and surrounding region. Many patients are incapacitated and unable to provide vital medical information. Where in the past emergency physicians were working blindly without this information, DHIN gives us real-time access to critical data that will save lives.”—Attending emergency physician
    • “At [our] emergency room, we cared for a patient who was complaining of abdominal pain as a result of a condition named diverticulitis. According to the patient, this condition had been diagnosed by ‘cat scan’ at another Delaware facility just a few days prior. We used the DHIN to obtain the results of the test. We found that in fact the patient had the test more than once at different facilities and the results were negative for diverticulitis. We also learned that the patient had multiple emergency room visits for the same complaint all over the state of Delaware. Thanks to the DHIN we were able to avoid unnecessary testing and prevent further exposure to radiation and risk of complications for this patient.”—Emergency department physician

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion of Delaware providers participating in DHIN, the number and proportion of Delaware residents tracked by DHIN, the number of annual clinical transactions delivered by DHIN, and clinician and patient/family reports on their satisfaction with DHIN and its impact on the quality and efficiency of care.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Passing initial legislation: As noted earlier, the Delaware General Assembly passed legislation in 1997 that created DHIN as a public–private partnership for exchanging health information and electronic data.
  • Identifying stakeholders: The DHIN workgroup engaged a wide variety of stakeholders including physicians, hospitals, health plans, ancillary services, State government, business, and consumers/advocacy groups. These representatives provided input on data elements and functionality that should be included in the exchange.
  • Creating governance structure: Workgroup representatives created the aforementioned governance structure, including the overall board and committee structure.
  • Forming technical advisory panel: In November 2004, DHIN formed a technical advisory panel that met monthly until January 2006. This panel outlined the functional and technical requirements for the system, selected vendors to implement and operate it, and oversaw system design and implementation.
  • Conducting survey: In 2005, the technical advisory panel surveyed hospitals, primary care physicians and specialists, laboratories, radiology groups, consumers, and government agencies about the type of information that DHIN should include. Survey findings informed the development of the functional and technical requirements.
  • Developing privacy policy: DHIN developed a privacy policy that outlines patients’ rights regarding the use and disclosure of their personal health information and that ensures an appropriate level of data security.
  • Phasing implementation: DHIN implemented the system in stages, beginning with four providers and three data senders in May 2007, and then expanding the number of users and data elements over time.
  • Recruiting and training participating providers: Members of the DHIN provider relations team attended professional society meetings and visited clinic sites to solicit new members. Team members continue to visit participating practices on a regular basis (usually quarterly) to provide ongoing relationship management, assistance, and training.
  • Creating independent public instrumentality: In July 2010, the Delaware General Assembly passed Senate Bill 231, which removed DHIN from the Delaware Health Care Commission's control and established it as an independent public instrumentality of the state that would function as a public–private, not-for-profit corporation.
  • Enhancing services and functionality: DHIN continues to develop new services and functions to better serve members and the community. For example, a daily event notification system is being created that will notify health plans and primary care providers whenever an individual visits an emergency department. In addition, private practices and pharmacies are beginning to use DHIN to send immunization data to the statewide public health registry.

Resources Used and Skills Needed

  • Staffing: DHIN employs 16 full-time staff: an executive director, her executive assistant, a chief financial officer, a director of operations and government affairs, a chief information officer who leads a five-member technical team, and a director of provider relations and business development who oversees a five-member provider relations team.
  • Costs: Data on total upfront development costs are unavailable (see the Funding section for some details); DHIN’s annual operating budget totals approximately $5 million.
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Funding Sources

Agency for Healthcare Research and Quality; U.S. Department of Health and Human Services; Christiana Care Health System; Bayhealth Medical Center; Beebe Medical Center; Highmark Blue Cross Blue Shield Delaware; Labcorp Inc.; State of Delaware; National Health Information Network; Doctor's Pathology Services; Quest Laboratories; Alfred I. duPont Hospital for Children; Nanticoke Memorial Hospital; St. Francis Hospital; TriState Imaging Group; Papastavros Medical Imaging
Organizations that helped to fund the development and implementation of DHIN include the following:
  • Three of Delaware's hospitals (Christiana Care Health System, Bayhealth Medical Center, and Beebe Medical Center), which contributed funds for program development.
  • A State of Delaware bond bill allowed the state to match private funding up to $9 million over 5 years (2007 to 2011).
  • Blue Cross Blue Shield of Delaware (now Highmark Blue Cross Blue Shield Delaware), which provided a one-time donation of $250,000.
  • LabCorp provided ongoing financial funding as a data sender.
  • AHRQ awarded a 5-year, $4.7 million implementation contract in 2005 that allowed DHIN to serve as an HIE demonstration project.
  • Quest Laboratories, Doctor's Pathology Services, the National Health Information Network, and the HIE Cooperative Agreement Program (a program of the U.S. Department of Health and Human Services), which have all provided funding to support DHIN’s development and implementation.

Organizations that support the ongoing operation of DHIN include the following:

  • Data senders (hospitals, laboratories, and imaging centers), which pay volume-based transaction fees (i.e., a fee for every clinical result/report sent to DHIN) according to a tiered fee system reflecting whether the recipients (physicians) are also DHIN members and whether they have agreed to accept DHIN as the sole source of their clinical results/reports. These fees are lower than what data senders would pay to send the information via mail or fax.
  • Health plans (including Highmark Blue Cross Blue Shield Delaware, Medicaid, and the State Employee Benefits Commission’s contracted health plans), which pay a $0.78 per-member-per-month (PMPM) fee to DHIN. One-half of the Medicaid PMPM fee is paid by the state’s Division of Medicaid and Medical Assistance, and one-half is paid by the U.S. Centers for Medicare & Medicaid Services.
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Tools and Other Resources

An HIE toolkit developed by the eHealth Initiative is available at: http://www.innovations.ahrq.gov/content.aspx?id=3277.

More information about HIE is available at the Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services: http://www.healthit.gov/providers-professionals
/health-information-exchange?utm_source=google&utm_medium=cpc&utm_campaign=technology
.

Adoption Considerations

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Getting Started with This Innovation

  • Emphasize common mission: Before implementation of this program, Delaware hospitals had a competitive relationship, as do hospitals in most small states and large metropolitan areas. However, as the development process evolved, the leaders of these hospitals began to look beyond the competitive nature of their relationship to focus on the potential positive impact of HIE on quality. They agreed to make all health care data available to all providers to ensure fully informed decisionmaking. Emphasizing this common mission can help organizations that normally compete agree to share clinical data and pool resources for HIE development.
  • Seek funding from those that see potential value: HIE development requires financial support from stakeholders that believe in the potential benefits and return from HIE. With DHIN, Delaware hospitals became the first private-sector source of funding because their leaders believed the exchange would generate value. In contrast, payers did not initially commit financially because the potential return on investment could not be quantified.
  • Create structure to allow stakeholder input: Given the many organizations with an interest in HIE implementation and operation, it is critical to have a mechanism for obtaining input. A workgroup/advisory group structure can help engage stakeholders in a meaningful but manageable way, even if representatives of these stakeholder organizations do not serve on the board.
  • Find out what users actually want: Developers should perform a broad survey or environmental scan to identify the functions that end users will value.
  • Provide a few valuable services well before expanding: Developers should initially concentrate on offering a small number of valuable functions and performing these functions well. The goal should be for all functions to be easy to use and free of problems (to the extent possible) at the "go-live" date. After a successful launch, developers will then be well positioned to add new functions and services. However, if the system is designed or implemented poorly at the start, users (who are busy providers) will become frustrated and lose faith in the system, and might not give it a second chance after the problems have been corrected.

Sustaining This Innovation

  • Establish fees based on value to the fee payer: Although grant funding is needed to support initial development of the system, the HIE will be financially sustainable only if ongoing operations are fully supported by service and transaction fees. These fees should be set based on a detailed analysis of the value and benefits to various stakeholder groups. Providers may well resist paying fees, given that they currently receive clinical information and reports for free. For this reason, DHIN adopted a “post office” model in which the sender of the information (rather than the receiver) pays the transaction fee, even though the receiver clearly derives some value. HIE fees paid by data senders should be set at levels that are less than the fully loaded cost of mailing or faxing reports, thus ensuring that the HIE system generates value for those paying the fees.
  • Expect clinicians to want more data: Once clinicians become accustomed to data sharing, they will likely want access to additional types of clinical information. Consequently, program leaders should consider how to expand the system over time (both technical modifications and changes to data-sharing agreements) to make it even more useful for clinicians.

More Information

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Contact the Innovator

Jan Lee, MD
Executive Director
Delaware Health Information Network
107 Wolf Creek Boulevard, Suite 2
Dover, DE 19901
(302) 678-0220
E-mail: jan.lee@dhin.org

Innovator Disclosures

Dr. Lee reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

References/Related Articles

Delaware Health Information Network. Final impact report. Rockville (MD): U.S. Agency for Healthcare Research and Quality.

Maestro Strategies. AHRQ Evaluation Plan: Health Information Exchange Evaluation: DHIN Benefits Assessment. 2011 July 18.

Lee J. DHIN Management Reports [PowerPoint presentation]. 2013 Jan 22.

Footnotes

1 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]
2 Shea KK, Shih A, Davis K. Health Care Opinion Leaders’ views on the quality and safety of health care in the United States. The Commonwealth Fund. 2008 April. Available at: http://www.commonwealthfund.org/Content/Publications/Data-Briefs/2008/Apr
/Health-Care-Opinion-Leaders-Views-on-Health-Care-Delivery-System-Reform.aspx
.
3 Schoenbaum SC. Testimony—vision of health and health care transformed. The Commonwealth Fund. 2009 April. Available at: http://www.commonwealthfund.org/Content/Publications/Testimonies/2009/Apr
/Testimony-Vision-of-Health-and-Health-Care-Transformed.aspx
.
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Original publication: June 05, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.