Randy Sermons of Carespark helped align the HIE’s policies and local data-sharing agreements with national frameworks.

By Lorraine Fernandes

Rural America evokes visions of rolling fields and mountains lush with vegetation and dotted with small towns, where hardworking families hold firm to their roots and traditions. Beautiful as it is, rural America faces tough problems when it comes to population health, technology use and access to care. This is certainly the case in the central Appalachian region served by CareSpark, a regional health information organization (RHIO).

Formed as a non-profit organization in 2005, CareSpark evolved from a grassroots coalition of healthcare, business and community leaders, deeply committed to improving the health in their region through the collaborative use of health information. CareSpark’s leaders faced challenges typical of a widely dispersed delivery system: fragmented healthcare information drawn from different data sources, spanning multiple states and jurisdictions.

The region has high rates of premature mortality from chronic disease including diabetes, cardiovascular disease, hypertension, lung disease and cancer – more than 10 percent above the national average. And per-capita healthcare costs are $2,400 higher than the national average.

Leaders in CareSpark’s 17-county region realized something had to be done to improve overall community health and to use healthcare resources more efficiently. Through a nine-month community-wide planning process, CareSpark brought together local physicians, hospitals, insurance companies, government representatives, employers, academic leaders and patient advocates to design a secure network that allows public and private healthcare providers to communicate electronically to deliver cost-effective services that improve patient safety and outcomes. Alignment with state and federal governments and evolving standards and policies has been difficult, but as pioneers in HIE, CareSpark stakeholders understood and embraced this dynamic environment.

John Dreyzehner, M.D., director of Virginia’s Cumberland Plateau Health District, is one of the physicians sharing information via Carespark.

The CareSpark collaborative established a foundation of trust and defined core strategies that have enabled CareSpark’s growth and continued success. As a result, CareSpark

• provides patient information and decision support at the point of care;
• empowers patients to make informed decisions and healthy choices;
• compiles and analyzes aggregated data to support population health improvement; and
• aligns financial incentives for patients, providers and purchasers.

The coalition needed to provide a flexible technology approach to enable participating organizations (some with legacy systems difficult and expensive to integrate, others with little technical expertise or resources) to choose the solution that best fit their needs and strategies. To accommodate this, CareSpark embraced the necessity for a standards-based architecture and network infrastructure that supports multiple, proprietary legacy platforms.

The CareSpark team interviewed and evaluated dozens of vendors as the components of the HIE infrastructure were defined and selected. They felt strongly that a “best of breed” approach, along with a formal vendor evaluation process, was the best option. Eight local and 10 national vendors were chosen to provide and support CareSpark’s infrastructure. Implementation took approximately two years, which allowed for alignment with emerging standards for security and interoperability.

A vendor consortium was established to implement critical HIE components of authentication and access to a secure network, interfaces to data sources, ability to identify and match patient records across multiple organizations, ability to view, send and receive files, and audit transactions. The technical infrastructure supports hybrid architecture with only patient demographics, patient consent, summary clinical documents and audit trails being centrally stored. All other data resides in the source clinical systems.

CareSpark’s vendor partners use national best practices and standards or protocols such as HL7 and Integrating Healthcare Enterprise (IHE) to ensure true data interoperability. Technology partners include several local small businesses that supply development and operating support services – a sustainable approach that led to broad community support, affordable services, job creation and economic growth.

A mission-critical requirement for successful HIE is an accurate, reliable and secure method for matching a patient’s records across multiple organizations. This enables responses to requests for information based on the patient’s consent preference. CareSpark enables HIE with careful attention to managing the privacy and security of information. Consumers, technology partners, legal experts and health information professionals guide CareSpark in defining the requirements while addressing diverse community viewpoints. This multi-stakeholder approach and significant consumer education resulted in a high level of patient participation. In the first year of operation, nearly 400,000 patients (half the region’s population) elected to participate, with fewer than 100 patients declining. Brenda Getaz, CareSpark’s privacy officer, played a key role in educating consumers and healthcare providers. She described this process simply to patients and clinicians with examples of how they can access information needed to make the best treatment choices, which includes electronically sharing records among caregivers.

There are numerous ways that CareSpark compiles and aggregates data for health improvement. An immunization registry pilot that includes Virginia and Tennessee demonstrates the ability to index, compile and present data to improve the health status of residents. This reduces duplicate immunizations which add costs and create patient safety issues. Additionally, the efficiency of searching for immunization records has been a major time-saver for schools, pediatricians and other clinicians. One local health department reports they were able to reassign one employee half-time to other responsibilities.

“We are just now reaching the level that all of us envisioned initially,” said John Dreyzehner, M.D., MPH, director of Virginia’s Cumberland Plateau Health District and past chair of the CareSpark board of directors. “Technology is the means to the end goal, which is measurable improvement in both health outcomes and cost of service delivery. We have several other projects ready to install and we’re excited about the potential impact for our region.”

Success is also measured by the increase in electronic medical records (EMRs) and adoption of e-prescribing, which has more than doubled in the past three years. This dramatic increase shows that sharing electronic data and care coordination are vital in addressing chronic diseases. “Our clinicians recognize and invest in electronic systems, and are proactive in their commitment to collaborate and share for the good of their patients,” said Liesa Jenkins, executive director of CareSpark. “Progress has been slow and steady, but it’s growing as resources become available.”

Beyond its commitment to regional health improvement goals, CareSpark supported the definition and adoption of standards through its participation in the 2006 and 2008 Nationwide Health Information Network (NHIN) projects. During 2008 NHIN Trial Implementation, CareSpark demonstrated “Wounded Worrier,” “Consumer Empowerment” and “Medication Management” use cases, showcasing how patient record matching, medication reconciliation and secure exchange with patient consent can be executed to improve individual and population health.

In early 2010, CareSpark was awarded a contract by the Social Security Administration (SSA) to provide electronic medical records (EMRs) to the federal agency. The SSA program is funded through the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of the American Recovery and Reinvestment Act (ARRA).

When this program is launched in the fall of 2010, it is anticipated that the time it takes to transmit authorized data between care providers and the SSA will decrease by 50 percent, decreasing the length of time patients wait for disability determination decisions. Communities and patients will benefit immensely from this, as patients receive disability payments sooner and healthcare providers are paid more timely for services provided.

“Our participation in the NHIN projects helped advance CareSpark’s technical capabilities. But more importantly, our understanding of policy issues and contractual agreements across multiple jurisdictions grew through our work on the Data Use and Reciprocal Services Agreement workgroup for NHIN,” said Randy Sermons, CareSpark’s legal counsel. “We aligned our policies and local data-sharing agreements with national frameworks, and are sharing that approach with state leaders in Tennessee and Virginia to address variations in differing laws and regulations.”

As CareSpark looks ahead, financial sustainability is a key concern. Like other state and regional exchanges, funding from public and private sources is tenuous. While there’s no silver bullet in sight, demonstrating value and helping the community achieve its healthcare goals, with costs and benefits shared fairly across the stakeholders, positions CareSpark for continued viability. Building on the trusted relationships between caregivers and patients, CareSpark has established itself as an anchor for the community and a model for the nation.

Lorraine Fernandes is vice president and healthcare industry ambassador for Initiate, an IBM company.