HealthInfoNet is applying the $198,659 grant it recently received from Maine Health Access Foundation to link the statewide HIE it operates with Maine Health Data Organization's all-payer claims database (APCD) to better manage patient populations.

"Once you are finally able to marry up the actual clinical outcome with the amount paid, you can take a look on a disease basis, or a provider basis, at the combined impact of what was done, what the outcomes and what the costs were," said Devore Culver, CEO of HealthInfoNet, an independent, nonprofit focused on improving quality of care and patient safety through the use of health IT.

Current risk modeling relies exclusively on claims data, which only measures the amount of resources consumed, he pointed out. "It doesn't really tell you whether it was a good outcome or a bad outcome. You might have somebody who has a therapy that looks like it costs a little more but has significantly better impact. That's what's hard to measure today," he said.

With the trend of hospitals adopting risk models for reimbursement, Culver said it's "absolutely vital" to be able to look at both the dollars and clinical outcomes in order to manage patient populations.

Under grant requirements, HealthInfoNet is responsible for four deliverables over the course of two years. Within the next six months, the nonprofit will line up events of care, and then demonstrate potential benefits in the area of analytics and work with different stakeholders on standards for accessing and using data. It will be well into 2012, however, before the new dataset can be accessed, Culver said.

Maine primed to be pioneer in use of APCD
Only a handful of states - Colorado, Kansas, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, Oregon, Tennessee Utah and Vermont - have or are in the implementation phase of an all-payer claims database reporting program, according to the National Association of Health Data Organizations. (Voluntary - not state-run or mandated - initiatives have been established in Louisiana, Wisconsin and Washington State to aggregate claims data in order to improve market and purchasing decisions.) Maine was the first, however, to establish such a database. "It's not without its issues, but quite frankly it's proven to be a pretty valuable asset for policy making and for comparison," Culver said. "By us bringing the clinical content alongside that on an episode level, [we] will gain an even larger value proposition."

Within the APCD realm, Maine is also poised to be a leader. Many of the states with APCDs don't have a mature statewide HIE. HealthInfoNet has more than a million lives - out of a state population of 1.3 million - and its HIE infrastructure, which is powered by its technology partner Orion Health, is the only resource that provides a community view of a patient across points and episodes of care, Culver said. "This is the heart of the business," he said, enabling providers who are the suppliers of data to be able to look at their communities in a different way.

"This could be a model for other states," he said. While the ability to move data from one point to another by itself is not sustainable, Culver believes that providing valuable, actionable information is fundamental to the sustainability of HIEs.

Developing the model
HealthInfoNet is in the beginning phase of developing the model, including determining who the consumers of this new initiative are and creating a tiered subscription model with payments based on how the data is distributed and used. For instance, a fixed report structure would warrant a low subscription fee. The obvious first customer is the provider community, Culver said. Participating in the initiative in turn would help providers participate in quality initiatives. "They [the providers] need to greatly increase and enhance their understanding of the true cost of episodes of care and also quite frankly the predictive modeling to get out and identify those at-risk populations so you can intervene early," he said. "At the point of care, you're looking at the patient from a variety of perspectives that gets you perhaps doing better on that visit, and it's being driven by that patient's comparison to goals or populations."

Payers coming to the HIE table
Historically, HIEs have "struggled significantly" with gaining the attention of payers because payers haven't seen the value of moving information from Point A to Point B, Culver said. The new accountable care models, however, are putting pressure on payers and making their roles less clear, which is forcing payers to develop new ways to better serve their members, including contracting with private exchanges, he said.

Payers are approaching private HIEs to try to leverage the data to improve administrative processes and reduce costs. For example, payers spend a lot of time and money requesting copies of records from providers. Medicare Advantage programs must demonstrate twice yearly the quality of their services, which requires requesting and sending such documents as secondary diagnoses and hospital discharge summaries. "HIEs have all of that data already," Culver pointed out. Instead of having hospitals copy records and turn around and pay a service to put it back into electronic format, HIEs can seamlessly provide that service more cost-effectively and more efficiently. "We're evaluating a nice little business opportunity to help support what is now a cost to both sides of the equation," he said.

Community performance versus provider organization performance
HIEs potentially have a bright future if these new reimbursement models are adopted and reach critical mass. But there's a caveat, according to Culver. "As long as the model for reimbursement still retains how the ACO [accountable care organization] model has been anchored - paying on community performance and not on individual provider organization performance - as long as that's the basic tenet, then the HIE by its very definition is the backbone of that structure," he said.

If the movement turns into a "channeling strategy," which would resemble the managed care era, providers will become increasingly incentivized not to share data and, as a result, the community-based exchange would become "somewhat of an endangered species," Culver warned.

Culver believes the community-based model can outperform a closed-panel model, citing the Grand Junction, Colo., community as proof. The community came together and now has the lowest Medicare cost in the country. "It tells us it can be done," he said. "So long as the federal initiative through CMS drives the concept of community-based care, others will follow in terms of reimbursement."

HealthInfoNet and its partners in the Bangor Beacon Community are betting that doing better across the community is the best way to manage the patient, he said. "Our standing [as an HIE] is strengthened simply because they [stakeholders by themselves] only have a partial view of the patient," he said.

It's just another way the statewide HIE is bringing value to all its stakeholders.