Well being data alternate (HIE) leaders are going through a tough selection because the winds of the policy-driven market blow towards better and better coordination between well being and social providers. Ought to they stick with the medical knowledge lane, or do they reinvent their HIEs as group data alternate (CIE) networks that additionally incorporate social providers, resembling housing businesses and meals banks and even faculties? 



Over eight years in the past, Martin Love, one of many extra forward-thinking HIE leaders within the nation on the time, addressed this query in rural Humboldt County, California. His HIE, the North Coast Well being Data Community (NCHIN), expanded its mission because the North Coast Well being Enchancment and Data Community (NCHIIN) in 2015, launching cross-sector knowledge alternate providers the next yr. 

What does NCHIIN’s expertise as a supplier of each HIE and CIE providers have to show us? As public well being leaders, what are the alternatives and challenges we must always think about with a group knowledge sharing method?

A Transient Case Examine from Humboldt County



Humboldt County, located close to California’s border with Oregon, is blanketed with redwood forests that march right down to the ocean. With a inhabitants of roughly 136,000 individuals, the county shares key financial and social traits with rural areas throughout the nation, resembling important well being and healthcare challenges that embody excessive poverty and demise charges and first care and behavioral well being supplier shortages.

Love was serving because the CEO of the native impartial follow affiliation (IPA) in 2009 when the HITECH Act as a part of ARRA spotlighted the significance of HIE to hyperlink digital well being data (EHRs), and he based NCHIIN in response to this federal coverage. “The IPA had subtle IT abilities and relationships with many of the practices within the county, and the management noticed the potential medical advantages. We had been in a position to leverage all of that to launch NCHIIN,” mentioned Love. The enlargement of Medicaid in California with the passage of the Reasonably priced Care Act added additional momentum, considerably rising the insured inhabitants within the county and serving to stabilize the funds of supplier organizations.



On the identical time, Love and different leaders resembling their COO on the time, Rosemary Den Ouden (now CEO), knew that healthcare didn’t have a monopoly on well being, and their group wanted to additional come collectively to handle challenges such because the opioid disaster. NCHIIN’s multistakeholder method to governance and trust-building — convening a number of group “tables” for discovery and planning — might be additional expanded. Grants from the Robert Wooden Johnson Basis (RWJF) and others supported vital eager about native wants and cross-sector, data-informed service fashions. In 2015, with all of the indicators they wanted to behave, the group modified its title and organizational identification, providing CIE providers and serving as a convenor for group well being initiatives within the following years. They initiated knowledge sharing between the well being and social sectors, facilitated cross-sector case administration, and applied a multipurpose consent for CIE. 

At this time, NCHIIN’s CIE community companions embody WIC, school-based wellness providers, the native company on ageing, nonprofit clinics, and incapacity providers. They launched a care coordination and referrals platform throughout medical, behavioral, and social well being in 2021, and the community now consists of 15 distinctive applications, with many extra within the onboarding pipeline. NCHIIN’s HIE at present has over 55 interfaces with most main healthcare endpoints within the area and over 300,000 lives in its grasp affected person index, and it averages over two million message transactions month-to-month. NCHIIN continues to construct interoperability between its HIE and CIE networks.

For a decade, this small group has been a testing floor for revolutionary approaches to collaboration throughout sectors, demonstrating management to reply holistically to rising native wants in alignment with nationwide finest practices fairly than being pushed by a compliance mindset for particular state or federal applications. Now CEO Den Ouden seems to be to the longer term with hope and optimism that “via the HIE and now the CIE infrastructure, our group has the instruments wanted to coordinate efficient care throughout the supply methods. Having a device to handle the care coordination is vital when people are serving to people obtain their highest well being and well-being potential.” 

Medicaid Innovation

If Love and Den Ouden learn the tea leaves almost a decade in the past that cross-sector collaboration was an crucial, in the present day the message is being blasted from the rooftops. Worth-based care fashions are pushing healthcare upstream, forcing a reckoning with social drivers of well being and incentivizing collaboration throughout sectors. Medicaid, significantly in states with formidable new waivers and advantages resembling California and New York, is main this transformative cost. This isn’t shocking, given the multifaceted nature of Medicaid member wants and the fragmented methods that serve them: whole-person care approaches promise dramatic enhancements in each expertise and outcomes for Medicaid members.

California’s huge Medicaid overhaul — CalAIM — wants built-in knowledge alternate throughout sectors to achieve success with providers resembling enhanced care administration, group helps, built-in behavioral well being, and inhabitants well being extra broadly. CalAIM has particular knowledge alternate necessities, together with for participation within the state’s new Information Change Framework (DxF), which relies on a imaginative and prescient of integrating healthcare providers, social providers, and public well being via public-private partnerships. In New York, the 1115 Waiver being finalized between the state and CMS creates Social Care Networks (SCNs), new aggregators of social and human providers suppliers, as key pillars within the Medicaid supply system. The state will pilot risk- and value-based contracting with SCNs, and they’re going to want the info infrastructure to help it.

In California, HIEs past NCHIIN are responding to the wants of their clients on this new panorama. In 2022, the HIE San Diego Well being Join grew to become a subsidiary of the area’s Neighborhood Data Change, 211 San Diego/CIE — maybe the main CIE within the nation. They’re now aligning their respective knowledge units and instruments. In Santa Cruz, the longstanding Santa Cruz Well being Data Group (SCHIO) modified its title to the Serving Communities Well being Data Group (SCHIO) and has applied know-how platforms for each cross-sector care administration and referrals alongside its core medical knowledge alternate choices. 

Why Cross-Sector Information-Sharing Is Laborious

With current medical HIEs largely staying on the sidelines of cross-sector collaboration and knowledge alternate over the previous a number of years, classes of latest convenors and repair suppliers have emerged. Within the know-how house, referrals platforms that embody or hyperlink to social service directories; care administration instruments oriented towards shared care planning throughout distributed, multisector care groups; and CIEs that facilitate medical/social knowledge sharing and sometimes additionally embody referrals and/or care administration performance. Coverage-makers are actually shaping the market to drive the combination of this new social knowledge ecosystem to help their inhabitants well being priorities, begging the query: why aren’t HIEs and different medical data-sharing networks lining as much as paved the way? 

Three the explanation why that is so arduous stand out, referring to HIE knowledge, providers, and clients. 

1. Consent for knowledge sharing. Most HIEs within the U.S. function with an opt-out consent mannequin for the alternate of well being knowledge ruled by HIPAA, that means that a person’s knowledge is shared except they choose out. This “HIPAA tent” is a protected and comfy place for HIEs and different knowledge alternate networks, and HIEs haven’t proven a willingness to alter their core consent mannequin partly because of the perceived operational burden. As a result of cross-sector collaboration requires venturing out past the HIPAA tent to alternate knowledge with social service, housing, and different suppliers who should not “lined entities” below HIPAA, HIEs stay unable to broadly help many rising use circumstances prioritized by policy-makers. 

2. Companies mannequin. The core service of an HIE or comparable data-sharing community is offering entry to historic medical knowledge (maybe as current as an occasion notification that arrived 5 seconds in the past). Whether or not in an HIE portal or built-in right into a supplier’s EHR, it is a “read-only” person expertise. In distinction, CIEs and associated providers supply “read-and-write entry” to collaboration instruments resembling referrals and care administration platforms throughout organizations and sectors. Some HIEs are getting their toes moist by integrating social knowledge — housing knowledge is often step one — however the market is searching for data-rich collaboration instruments for more and more distributed care groups. This may signify an entire change in service mannequin for many HIEs. 

3. Buyer relations. HIE boards are composed of healthcare leaders. Healthcare CEOs and CIOs, who typically sit on HIE boards, might not prioritize or really feel geared up to steer a corporation into group well being collaboration. Diluting their decision-making authority could also be one other concern, particularly if their organizations are the first customers or funders of HIE providers. Thus, whereas new committees could also be established or people invited into decision-making boards, distributing energy throughout sectors would signify a elementary departure for HIEs that might recenter their organizations.

Whereas there are some HIE-specific parts of those challenges, they signify bigger points for your entire healthcare ecosystem through which HIEs function. 

Cross-Sector Information Sharing Is Potential — and HIEs Can Play a Central Position

What now we have in the present day, then, even in California, is a strong medical data-sharing ecosystem and an rising social knowledge ecosystem, with very particular and restricted factors of connection between them. Nonetheless, HIEs stay significantly well-positioned to observe NCHIIN’s lead and function a key a part of the answer of their communities for the next causes, as will be seen with our trio of knowledge, providers, and buyer relations.

Information. The proof is rising that multipurpose consent enabling well being and group data alternate is possible. Some states resembling New York have an extended custom of acquiring consent for medical data-sharing, which is able to seemingly be prolonged to cross-sector use circumstances within the upcoming Medicaid waiver. In California, a just lately accomplished pilot known as ASCMII (pronounced “ask me”) with HIEs working in three distinct areas of the state discovered that 85 p.c of people agreed to their knowledge being shared throughout sectors, and digital instruments made the method fairly environment friendly. With additional enhancements, the worth of acquiring multipurpose consent might start to outweigh the drawbacks. NCHIIN gathers a multipurpose consent for people served in its care coordination platform in the present day, and knowledge flows from its HIE into this service (e.g., for occasion notifications). 

Companies Mannequin. Coverage-makers more and more wish to see medical and social knowledge ecosystems made interoperable to help cross-sector collaboration. HIEs have an incredible alternative to supply this knowledge integration and the interactive “read-and-write” care coordination platforms that distributed care groups want. Up to now, HIEs stayed within the “read-only” historic knowledge lane as a result of their clients documented inside EHRs and didn’t wish to navigate to a different system. At this time, scalable strategies exist to embed third-party purposes inside EHRs, and lots of social providers suppliers are keen to log in to a shared group useful resource to collaborate. This path offers HIEs the chance to maneuver up the worth chain, as seen with NCHIIN, as medical knowledge alternate turns into more and more commodified. 

Shopper Relations. Neighborhood, regional, and small state-based HIEs minimize their enamel on stakeholder engagement and clear governance. The teachings, infrastructure, and belief developed by HIEs for medical knowledge alternate signify a powerful basis on which to construct partnerships with organizations from different sectors. Whereas many communities produce other boards to accommodate group well being initiatives, the CIE element of cross-sector collaboration is a pure extension for a lot of HIEs. Within the midst of its enlargement to CIE, NCHIIN reconceptualized its consumer as a various group coalition. Different HIEs can observe an identical course of, inspecting and reframing who they serve, after which inviting this coalition into the governance construction to share energy. Doing so will naturally result in a rethinking of the group’s identification and place it to ship distinctive worth.

Conclusion
Establishing vibrant ecosystems for cross-sector collaboration is difficult work that requires arduous choices. By constructing on current strengths, such because the expertise and property of HIEs, brave leaders can generate transformative impression for the communities they serve. 

Mark Elson is CEO of Intrepid Ascent, a consulting agency main group collaboration for well being. Every year Intrepid Ascent builds new connections between greater than 500 companions, supporting coordinated, equitable well being and social providers for hundreds of thousands of individuals. With an interdisciplinary background in anthropology, know-how, and coverage, Mark applies built-in native approaches to international challenges.