1st of 2 parts
By JIM STOMMEN
MDD Contributing Writer
Harold Apple is CEO and president of the Indiana Health Information Exchange, the nation's largest HIE organization. IHIE connects the state's hospitals, physicians, long-term care facilities and other healthcare providers, enabling medical information to follow patients regardless of treatment location to improve care coordination and patient outcomes. Physicians in the IHIE network provide care to more than 10 million patients.
Apple was formerly the majority owner, CEO and president of Vector Technologies, a business process outsourcer, consulting and software development company in the life insurance sector. He also was one of the founders of the Indiana Software Association and the Indiana Information Technology Association.
MDD: What is the genesis of health information exchanges, and are there similarities in each HIE's mission?
Apple: The Indiana Health Information Exchange had its genesis probably a couple of decades ago, and it's a very different form. There's an entity in Indianapolis by the name of the Regenstrief Institute, and the technology that we use was actually invented by Regenstrief. It's primarily a medical informatics organization. They have a couple of other missions, but by far their largest focus is on medical informatics, and they've had a long-term partnership with a public safety hospital in Indianapolis, Wishard Health Services.
Initially the mission was to get health records into an electronic form and over the first decade or so of the Regenstrief Institute's existence, they developed systems primarily for Wishard. Subsequently they started getting some recognition on a little broader basis. About 10 years ago or so, the other hospitals in the city there are primarily four other main healthcare institutions got together with Regenstrief and Wishard and decided to start sharing their records, at least on a local basis as best they could at that point in time. In 2004, the organization was formalized under the name Indiana Health Information Exchange and it was established as a not-for-profit supporting entity, meaning that it was to support those five major hospitals.
At that point in time, when they started sharing records electronically between the institutions, Regenstrief developed some technology that captured the information as it passed through the software from one hospital to another and started building a significant clinical database. That database is now manifested itself into a collection of some 12 million patient records and something on the order of 15 terabytes of data on the history of patients, initially in Indianapolis and the surrounding county area. But under the coordination and management of IHIE, it has really expanded significantly.
It was an unusual situation because the hospitals, while they are significant competitors on a regular basis, decided to join together to improve patient care in the community by sharing these records among themselves. Subsequent research has shown that any given patient probably receives as much as 40% of his or her care outside of the domain of their primary care physician and, depending on his association with whichever hospital he is associated with, would always have the problem of the care being delivered to his patients across multiple entities.
This whole effort started creating a master patient record independent of wherever that patient received his or her care. Early on, our mission primarily was exchanging medical records or delivering lab results and prescriptions and X-rays from the point of origin to the primary care or referring physician, so there would be a more complete record of the medication, the diagnoses, various laboratory tests, and today we transmit a million to a million and a half such transactions a day amongst these entities.
The step up was about three years ago or so, when we started actually analyzing that data with help from Regenstrief analysts, most of whom are either PhDs or MDs, and we started generating quality results of care on these patients. If a doctor chooses to participate in that program, one of the major payers in Indiana offers an incentive for demonstrating over the course of time improvement in a patient's care.
MDD: The Indiana Health Information Exchange is the nation's largest, and seemingly most well-respected, HIE. How did you get there?
Apple: We got where we are with lots of hard work and lots of cooperation from the various stakeholders in the care delivery process, and ultimately the cooperation from payers, especially over the past three or four years. There's a built-in contention between providers and payers, but all have kind of joined together with the hopes of improving the delivery of healthcare in Indiana, and thereby hopefully in reducing the costs. It took us lots of decades to get us in the fix we're in nationally, and it's going to take awhile to get out of it. Many of these activities we're involved with today were the result of a community effort, starting many years ago.
MDD: Could you delve into the statistics behind what you're doing, starting with patients and healthcare organizations served?
Apple: Right now we're in a big push, as a result of the federal Beacon program, to sign more hospitals within the state. Based on our original charter as a nonprofit organization, we're pretty much limited to working within the state at this point in time. We have about 60 of the 120 or so hospitals in the state of Indiana online right now, and have over 90 under contract. We're in a push to get those other 30 hooked into us as soon as possible. It's a complex and labor-intensive process because of the multitude of systems we have to communicate with, so we're focused heavily on trying to clean up that whole process and make it more efficient, more cost-effective. With 90 of 120 hospitals in the state signed up so far, it's a fairly significant roster. We also communicate with 122 of the 123 or 124 hospitals in Indiana for the purposes of providing data to the U.S. Department of Health related to non-communicable disease reporting. That's the result of a program that started several years ago to report to the Center for Disease Control certain disease states that are of interest to them, so for that one specific purpose, we pretty much touch all the hospitals in the state.
MDD: Of the 30 or so hospitals that you've not yet signed up, do they tend to be larger or smaller institutions?
Apple: Smaller ones. And there are other HIES that operate in the state of Indiana. One in South Bend is a small, local entity and services 10 or 12 hospitals in the South Bend area. Then there are two major hospitals in Fort Wayne that are not yet a part of our network whose area is kind of separated from the rest of the state from a population point of view. But we have a program going on with the health information technology group that is under the guidance of state government to communicate with those other HIEs so that we can at least use them as transfer points rather than rebuilding connections with the hospitals that they serve. Eventually, and by that I mean probably within a year, we'll be able to intercommunicate with each of those locales.
MDD: Obviously, reaching such magnitude in terms of whom you're serving doesn't happen overnight. What were the key steps taken along the way?
Apple: The key step is that we focus intensively on governance. The technology is always an issue, but it's really important that people trust how we behave as an organization and that's probably one of the most important competitive advantages that we've installed over the course of our existence. Care is tightly woven into the trust element, so we keep that very, very high on our list.
MDD: Indiana traditionally has been among the lower-ranked states in terms of such health indicators as obesity, smoking, diabetes and heart disease. How has IHIE and its programs impacted those issues?
Apple: Most of that impact is just starting to be realized. If we think of the broad segments of time, most of the first seven or eight years were focused on building the exchange, and that was focused more on the exchange of records between physicians. There wasn't a lot of focus on population health; it was more in the sense of providing immediate care.
What has really happened over the past three or four years is building a program that's more oriented around wellness in terms of generating the quality measures that are coming out of a program called Quality Health First. We're just starting to realize some of the benefits of being able to analyze the data we hold and being more proactive in reporting back to physicians and institutions in terms of how we're doing. For example, to physicians participating in the Quality Health First program we provide alerts for diabetic patients who, for instance, have not picked up their latest insulin prescriptions or alerts on females who have not had their regular mammograms and colorectal cancer exams and those kinds of things.
So the proactivity that is required to help impact these chronic diseases is really a later-stage program for us. Even though it's been a goal for a long time, it's a very complex process to be able to impact that goal. As with the state of healthcare nationally, it took us decades to get us into this fix; now it will it's going to take us awhile to get out of it. It is definitely a high-priority objective for us, but the challenge is that it is one that will have to be realized over a longer period of time, so there's no immediate gratification there.
MDD: When you're trying to save people from themselves, that's not always an easy task.
Apple: Yes, that's certainly the case with behavior change. How do you create population behavior change? One by one is how you do it.
(Next week, in Part 2 of this MDD Interview, Harold Apple discusses how his organization's business model compares with those of other HIEs elsewhere, IHIE's involvement in the federal Beacon Community program, and the importance of paying strong attention to privacy and security measures.)
Published September 27, 2012