States Figuring out Their Role in Health IT after Stimulus

While the Office of the National Coordinator in the Health and Human Services Department will be in charge of making sure networks can talk to each other, it will be the states that build those networks, said John Thomasian, director of the NGA Center for Best Practices. “We believe the act clearly gives states the lead in creating exchanges,” he said. This means the states will lead the way in the areas of privacy and security and of developing a business model for health information exchanges (HIEs), he said.

Though the law offers clear incentives to providers and hospitals, as well as planning and implementation grants, it’s less clear on the specifics of the exchanges that really get information moving, Thomasian said. “What is not quite clear is who builds the exchanges, and with what monies,” he said. He hopes states will be able to use implementation grants for capital costs. He also hopes the $300 million required to be used for regional efforts will represent a floor, not a ceiling.

Thomasian said the law pushes states toward one of two models for HIEs: one in which the states sponsor the exchanges, or a public-private partnership that closely follows the utility model. The e-health alliance released a report outlining the business models states might follow. Most members gravitated toward the public utility with government oversight model.

Defining what types of systems are “health information exchanges” is critical because providers are considered “meaningful EHR users” if they connect to an HIE, said Lammot du Pont, senior manager of Manatt Health Solutions. The law is silent on this question, he said.

Washington, for example, is set to go live with three pilot health record banks in March. The pilots, in Spokane, Cashmere and Bellingham, are targeting 18,000 people and are a consumer-centric version of exchanges, in which the patient controls his records. Richard Onizuka, health policy director for Washington Health Care Authority, said he hopes Washington’s different take on the idea will be eligible for stimulus funds. He also wondered if electronic medical record adoption incentives can be granted as part of a larger program, like Washington’s project to ensure “medical homes”

defined as a lead doctor in charge of overall care and records for patients. An important part of the stimulus bill from his point of view is that it allows patients to get copies of their records in electronic form.

Tony Rodgers, director of the Arizona Health Care Cost Containment System, highlighted his state’s efforts. Arizona found doctors who were interested in electronic systems, then used the state’s purchasing power to allow the doctors to buy systems at a bulk purchase price. He said the state expects to save $284 million in Medicaid costs over three years, for example by reducing emergency room admissions. “We think we took a very conservative view of this,” he said of the estimates.

The states are still struggling with how a consent signed in a doctor’s office relates to the electronic world. “When the patient gives you consent, what are they consenting for? That’s what the lawyers ask us,” Rodgers said. Right now doctors can sign on to the system and say they have permission to see a certain patient’s records, but there’s not yet the ability for a patient to give permission ahead of time, he said. This is an issue because doctors should see the patient information before they see the patient, not call to other offices for the data after the patient arrives, he said.

Competing health systems must also be persuaded to share information, Onizuka said. His state found that for many private entities, “data for them is value.” They must change to understand that what is done with data should be the value, he said.