SummaryThe Nation’s largest health information exchange (with more than 90 facilities linked through a secure, robust network), the Indiana Health Information Exchange provides health plans and Medicare-chartered accountable care organizations with daily alerts on members of their attributed populations (e.g., health plan members, individuals assigned to the Medicare accountable care organizations) who have visited an emergency department or were admitted to the hospital in the past 24 hours. Based on near real-time data, these notices (known as admission, discharge, transfer alerts) allow the receiving organization to act on the information in a timely manner. In a pilot test, the program helped a managed health plan improve quality and lower costs by significantly reducing nonurgent emergency department visits, replacing them with lower cost primary care visits.Moderate: The evidence consists of pre- and post-implementation comparisons of nonurgent ED visits and primary care visits, along with an estimate of the cost savings generated by the movement of nonurgent patients from the ED to primary care.
Developing OrganizationsIndiana Health Information Exchange; Regenstrief Institute, Inc.
Date First Implemented2009
Pilot testing with a large managed health plan began in 2009; testing with accountable care organizations began in 2012.
Problem AddressedOrganizations responsible for managing the health of a population often lack access to timely information on when and where patients receive care, including emergency department (ED) visits and inpatient admissions. Without such information, these organizations cannot take proactive steps to address potential problem areas, such as visiting the ED for nonurgent conditions, using non-network facilities for care that can be provided in network, or being readmitted to the hospital. Health information exchanges (HIEs) have the potential to offer such information, but few organizations have access to HIE-generated data.
- Lack of timely information: Most health plans, accountable care organizations (ACOs), employers, and other organizations that assume the financial risk for managing a population must rely on claims data to identify when and where patients receive expensive care, such as ED visits and inpatient admissions. Claims data, however, are typically not available until 60 to 90 days after the episode occurs.
- Inability to identify and address problem areas: The lack of timely information makes it difficult for organizations to proactively identify and address problem areas, such as at-risk patients being readmitted to the hospital within 30 days of an initial discharge, patients being admitted to out-of-network hospitals for care that can be provided in network, and patients visiting the ED for conditions that can be treated in lower-cost settings (e.g., primary care). For example, each year an estimated 56 percent of ED visits are for nonurgent conditions that could have been treated in a lower-cost ambulatory setting (e.g., primary care); treatment in the ED instead of these alternative settings costs public and private payers an estimated $38 billion a year.1,2
- Unrealized potential of HIE-generated data: HIEs have the potential to merge near real-time information on a single patient from multiple settings, thus allowing an entity responsible for that patient's health to know about any episode soon after it occurs. Yet few organizations have access to such information.
Description of the Innovative ActivityThe Indiana Health Information Exchange (IHIE, an acronym pronounced “eye-high”) provides health plans and Medicare-chartered ACOs with daily alerts on members of their attributed populations (e.g., health plan members, individuals assigned to the Medicare ACO) who have visited an ED or were admitted to the hospital in the past 24 hours. Based on near real-time data, these ADT notices allow the receiving organization to act on the information in a timely manner. Key program elements are outlined below:
- Near real-time collection of data: During each day, IHIE engages in the near real-time collection of admission, discharge, transfer (ADT) messages from hospitals throughout Indiana. These messages document whenever a patient visits an ED or is admitted to or discharged from a hospital (including transfers to other facilities). Relying on the commonly used Health Level 7 (HL7) standards for transferring and communicating health information, these messages store key information about the event, including the patient’s name, his or her basic demographic information, the name of the facility, the patient’s chief complaint, and a preliminary diagnosis code (if a diagnosis is made).
- Matching to identify ADTs for patients in attributable populations: As part of their contract with IHIE, partnering health plans and ACOs provide a list of all individuals within their attributed populations, including their names and basic demographic information (e.g., age, sex, address). Each night, a software application combines the information in the ADT messages with other information in IHIE’s master patient index and record locator service to determine which ADT messages are for individuals within these attributed populations. For each one identified, the system creates an ADT alert stored within IHIE’s clinical data repository (a large database that stores detailed information on patients).
- Transmission to appropriate entity: Each night around 2 a.m., IHIE conducts a sweep of the repository to collect all ADT alerts for members of attributed populations processed in the last 24 hours. The system creates and transmits to the relevant organization a simple-to-interpret text file that provides various pieces of information about the event, each separated by a comma to facilitate integration into the receiving organization’s information technology (IT) systems. Each alert contains the patient’s name, chief complaint, hospital visited, attending physician, and preliminary diagnoses.
- Recipient response to data: Health plans and ACOs use this information in a variety of ways to improve quality and reduce costs, including proactively reaching out to patients to educate them about the merits of visiting an in-network (rather than out-of-network) provider or seeing a primary care provider (rather than using the ED) for nonurgent conditions. Some organizations use the alerts to notify care managers about at-risk patients who may need inhospital or postdischarge support to reduce the risk of readmission. Examples include the following:
- Managed health plan use of alerts: During a 6-month pilot test from 2009 to 2010, a 320,000-member managed health plan received daily alerts about visits by members to any of 9 EDs in Central Indiana. The plan analyzed the alerts to identify members who likely could have been seen in the primary care setting rather than the ED. These individuals received an automated call to inform them about the plan’s 24-hour nurse line and encouraged them to use it in the future to determine the need for an ED visit. The call also reminded them to contact their regular provider with any questions they may have about the recent ED visit or the need for followup care. Those who repeatedly used the ED for nonemergent care were assigned a case manager who offered more personalized support. After the pilot program ended, this initiative expanded to include all of the more than 90 hospitals covered by IHIE and to include alerts related to inpatient admissions as well as ED visits.
- ACO use of alerts: Since late 2012, an ACO working with IHIE has been integrating information from the alert files into the organization’s care management system. Consequently, whenever an overnight alert is generated for a member of the ACO’s attributed population, information on the event (an ED visit or inpatient admission) is available the next morning when the care manager assigned to that person logs into the system. The information is prioritized according to the severity of the event (i.e., the care manager can quickly tell if the event involves a non-network facility or if it relates to an ED visit or an ED visit combined with an inpatient admission). The care manager uses this information to prioritize his or her work for the day, in many cases proactively reaching out to the individual or a family member to offer inhospital or postdischarge support. Support might include education about the availability of in-network (rather than non-network) hospitals for care; assistance in scheduling and accessing followup care; or education about appropriate self-management, including tips for adhering to the prescribed medication, diet, and physical activity regimens.
Context of the InnovationIHIE is the Nation’s largest HIE, providing a secure, robust network that connects the vast majority of the state’s 126 hospitals. (IHIE has contracts in place with 94 hospitals, although not all of them have “gone live” yet.) The network also includes long-term care facilities, rehabilitation centers, community health clinics, and other providers. Collectively, these organizations serve a geographic area with roughly 6,000,000 residents and more than 25,000 physicians.
IHIE began as a way to commercialize technology developed by the Regenstrief Institute, a nonprofit organization affiliated with the Indiana University School of Medicine that has been a pioneer in medical informatics research since its founding in the 1960s. Regenstrief created the first HIE system in partnership with a local Indianapolis hospital in the 1990s and has been expanding its work in this area ever since. Over time, it became apparent that a separate organization was needed to run this system. Consequently, in 2004, IHIE formed as a collaboration of stakeholders, including five Central Indiana hospitals and other technology and economic development leaders in and around Indianapolis.
The impetus for the ADT alert program occurred when the leaders of a large managed health plan in Central Indiana approached Regenstrief about the possibility of building an application that could provide alerts whenever a member visited an ED. The plan had a problem with members going to high-cost EDs for nonurgent problems that could be handled more effectively and efficiently in other, lower-cost settings.
ResultsIn a pilot test, the alert program helped a managed health plan improve quality and lower costs by significantly reducing nonurgent ED visits, replacing them with lower cost primary care visits. Information on the program’s impact with this plan since the pilot test ended and on its impact with ACOs is not yet available.
Moderate: The evidence consists of pre- and post-implementation comparisons of nonurgent ED visits and primary care visits, along with an estimate of the cost savings generated by the movement of nonurgent patients from the ED to primary care.
- Shifting nonurgent visits from ED to primary care: During the 6-month trial with 9 Central Indiana hospitals, the 320,000-member managed health plan reduced nonurgent ED visits among members served by these hospitals by 53 percent, while simultaneously increasing primary care office visits by 68 percent.
- Significant cost savings: The shift from ED to primary care visits that occurred during the pilot test saved the health plan an estimated $2 to $4 million over the 6-month period. As noted earlier, the program has now expanded to cover the vast majority of plan members (not just those served by the 9 hospitals in Central Indiana); consequently, the savings generated for the plan has likely increased.
- Additional evaluation to come: Program leaders expect to have more information on the program’s impact in late 2013 or 2014, including additional results from the managed health plan and initial results from participating ACOs.
Planning and Development ProcessKey steps included the following:
- Creating ED alert application: After leaders of the managed health plan made their request, IHIE programmers worked with Regenstrief over a period of several months to create an application specific to a managed care organization. The resulting product extracted the relevant information from the IHIE central repository to create daily alert messages for health plan members who visit the ED.
- Pilot testing and subsequent expansion with managed health plan: During 2009 to 2010, IHIE and the managed health plan pilot tested the ED application with nine hospitals in Central Indiana. As noted, since the test ended, the program with this health plan has expanded to include all hospitals that work with IHIE and to incorporate inpatient admissions as well.
- Iterative testing with ACOs: In the spring of 2012, IHIE began discussing use of the program with several Centers for Medicare & Medicaid Services (CMS) Pioneer ACOs in the Indianapolis area. IHIE got the attention of ACO leaders by sharing data showing significant “leakage” to non-network facilities among members of their attributed populations. Over a period of several months, IHIE worked with one ACO to develop and get hospital feedback on an expanded application that covered ED visits and inpatient admissions. After several iterations of testing and revisions, the finalized application was pilot tested with this ACO in late 2012, and then with several other area ACOs in early 2013.
- Expanding to identify those at risk of readmission: As an expansion of the program, IHIE is developing predictive models to help health plans and ACOs identify those at high risk for readmission. This system will create a score that quantifies an individual’s risk within a certain period of time. Health plans and ACOs will then use this information to proactively support these individuals after discharge, with the goal of reducing the likelihood of readmission. Program leaders believe that interest in this application should be high, because CMS began penalizing hospitals with high readmission rates in October 2013.
- Planning future application to address “leakage” to non-network providers: Program leaders are currently in the planning stages for an application that will help health plans and ACOs understand the characteristics of those seeking care from out-of-network providers. The goal of this “leakage analysis” is to help these organizations address problems that may be leading to high use of non-network providers, such as not having enough specialists or facilities in a certain geographic area or inadequate education about the availability of in-network providers.
Resources Used and Skills Needed
- Staffing: Typically, the development and testing of each application requires 2 full-time individuals working over a 90-day period. To date, the program has not required IHIE to hire incremental staff, as existing employees have incorporated program-related work into their regular activities. Going forward, IHIE may hire additional staff as the ADT alert program expands with existing customers and attracts new ones.
- Costs: Data on the development and operating costs for the program are not available.
Funding SourcesU.S. Department of Health and Human Services
The U.S. Department of Health and Human Services (DHHS) selected the IHIE-led coalition as one of 17 “Beacon Communities” in 2010. Under a 3-year Beacon Community Cooperative Agreement Program that ended in early 2013, DHHS provided $16 million to support the activities of IHIE and its partners to strengthen Indiana's health IT infrastructure and extend its exchange capabilities. A small portion of these funds informed or otherwise supported data analytics and other work related to the ADT alert program.
Like other IHIE programs and services, the ADT alert program is supported through contracts with customers. The organization’s goal is to be self-sustaining through the provision of services that these customers value and are willing to pay for.
Tools and Other ResourcesMore information about IHIE is available at: www.ihie.org.
Those interested in learning more about the ADT alert application should contact the innovator; the application was developed so that it can be used by any organization responsible for managing the health of an attributed patient population, including those outside of Indiana.
Getting Started with This Innovation
- Elicit feedback from potential users: Program leaders should avoid the “build-it-and-they-will-come” approach. Instead, they should meet with potential users to find out how information from multiple data sources could be collected, analyzed, combined, and transmitted in ways that would be useful to them. IHIE leaders had a sense that ADT alerts might be useful, and this sense was later confirmed when IHIE shared data with ACOs about high levels of out-of-network use among members of their attributed populations.
- Consider starting with ADT alerts before (or in lieu of) full-fledged HIE: Among HL7 message types, ADTs are one of the easiest to use, requiring little upfront investment to set up the requisite connections. Consequently, would-be adopters might consider creating an ADT alert program before (or instead of) implementing a full-fledged HIE system. As noted, IHIE will be making an application available that can be used by organizations outside of Indiana, including those not yet part of an HIE system.
- "Sell" hospitals on benefits of collaboration: Successful execution of the program and other HIE initiatives requires the cooperation of multiple hospitals, many of which compete with each other. Convincing them to collaborate requires a series of meetings to discuss the merits of doing so, including the benefits that each individual hospital participant can expect. These benefits may include the ability to avoid Medicare penalties for readmissions and, for those with ACOs or other risk-based contracts, the ability to better manage the health of an attributed population.
- Consider including hospitals in governance: In some cases it may make sense to include the leaders of participating hospitals early as part of the governance structure. For example, a key component of IHIE’s success in becoming a trusted entity among competing hospitals stems from the decision to include the chief executive officers of five Indianapolis-area hospitals as voting members of its board of directors.
Sustaining This Innovation
- Cast a wide net: In addition to health plans and ACOs, other organizations responsible for managing the health of attributed populations might be interested in program services, including public and private employers. As readmission penalties are enforced, independent hospitals and health systems may also become interested in inexpensive applications that focus on preventing readmissions by providing real-time information on those admitted each day.
- Monitor and share data on value created by program: As with any business, the sustainability of the ADT alert initiative and related programs depends on convincing current and potential clients of the value generated by the service. To that end, monitor and share information on reductions in ED and inpatient utilization and any resulting cost savings generated by the program.
Contact the InnovatorCurt Sellke
Vice President, Analytics
Indiana Health Information Exchange
846 N. Senate Avenue, Suite 110
Indianapolis, IN 46202
Innovator DisclosuresMr. Sellke reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.
References/Related ArticlesIndiana Health Information Exchange. ADT alerts for reducing ED admissions: a case study. Indianapolis (IN): Indiana Health Information Exchange. Available at: http://mpcms.blob.core.windows.net/bd985247-f489-435f-a7b4-49df92ec868e/docs/4f798bc8-4c8f-4dce-b145-cab48f3d8787/ihie-adtalerts-casestudy.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
1 Weinick R, Billings J, Thorpe J. Ambulatory care sensitive emergency department visits: a national perspective. Abstr Academy Health Meet. 2003;20:abstract No. 8.
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Original publication: January 29, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.