Research

Arizona seizes initiative with 'Health-e Connection' project

Arizona's health information technology (HIT) industry and health-care delivery system are on the brink of radical transformation as Arizona Health-e Connection prepares to publish its proposal offering a "road map" for development and implementation of a statewide, unified HIT network. "What the road map does is clearly position us front and center to take a leadership position — to become sort of a model for other states," said panel moderator Ajay Vinze, director of the W. P. Carey School's Center for the Advancement of Business through Information Technology (CABIT).

2006-04-06

Arizona's health information technology (HIT) industry, and the manner in which health care is delivered, are on the brink of radical transformation as a state-facilitated steering committee for the Arizona Health-e Connection prepares to publish its recommended road map for development and implementation of a statewide, unified HIT network.

"Health Information Technology: A Focus on Arizona Innovations" was the topic of a panel discussion held recently at the W. P. Carey School's Transforming American Healthcare National Symposium in Phoenix. The panelists, all of whom have close associations with the AZ Health-eConnection initiative, focused their comments, predictions and evaluations for HIT on the leadership position being taken by the state.

"What the road map does is clearly position us front and center to take a leadership position — to become sort of a model for other states," said panel moderator Ajay Vinze, director of the W. P. Carey School's Center for the Advancement of Business through Information Technology (CABIT).

Cartography for e-health systems

The road map had its origins in President George W. Bush's January 2004 State of the Union address, where he declared that, "by computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care." The president created the Office of the National Coordinator for Health Information Technology (ONCHIT) in April 2004. In a press conference held at the Cleveland Clinic in January 2005, President Bush repeated the challenge made a year earlier: for the nation's hospitals and physicians to convert to paperless systems within the decade.

Arizona Gov. Janet Napolitano responded to the challenge in August 2005 when she signed Executive Order 2005-25, which authorized creation of the 42-member Arizona Health-eConnection Road Map Steering Committee. "This road map will get us ahead of the curve in the HIT process," Vinze said, adding that it will be submitted to the governor's office the first week in April. The steering committee created five task groups involving hundreds of participants.

Discussions ensued within these groups to resolve the myriad of clinical, technical, financial, legal and governance issues that could hinder successful deployment of Arizona's Health-e Connection. The road map, compiled from the exhaustive list of task group recommendations, rests atop "The Four Pillars of HIT": e-health, tele-health, electronic health records, and, in tandem with the handling of those records, privacy and security.

Creating consumer comfort

Kristen B. Rosati serves as chair for the steering committee's privacy and security task group. A partner and attorney with the law firm of Coppersmith Gordon Schermer Owens & Nelson, PLC in Phoenix, Rosati specializes in law pertaining to the Health Insurance Portability and Accountability Act (HIPAA), health information privacy and security, electronic health records, clinical research and consent issues.

In an era when identity theft seemingly runs rampant and stories of the mishandling of paper medical records abound, public trust in a secure HIT system is critical. Public trust that all federal and state laws are strictly followed as they pertain to governing medical records, insurance, state licensure requirements for professionals and facilities — is essential to the success of the Health-eConnection mission.

To allay public concern, the task group identified four specific privacy and security challenges and possible solutions to those issues:

• Challenge: How will the system address consumer control over personal health information?

Possible solutions: Provide consumers with an 'opt in/out' enrollment choices, or automatic enrollment in exchange for rigorous confidentiality and security protection.

• Challenge: How will the system handle sensitive health information (including mental health, communicable disease, genetic testing, and substance abuse treatment) that is usually afforded stricter protection from disclosure?

Possible solutions: Incorporate a safeguard that 'flags' sensitive information for authorized access only; exclude the information with the greatest restrictions on use; include the information, but restrict use of all information to comply with the most restrictive laws.

• Challenge: How will the system handle health information for minors?

Possible solutions:Incorporate a safeguard that 'flags' this information; exclude minors' health information from the system if it relates to health care for which the minor has the right to consent.

• Challenge: Who will have access to the information in the e-health exchange and for what purpose?

Possible participants:Health care providers; health insurance companies and employer group health plans; state public health authorities, and researchers. The efforts of Rosati's task group to ensure the security and privacy of personal health care records, gaining the trust of all potential e-health data exchange system participants, is predicated on the state's ability to create an infrastructure where all participants (health-care providers, health plan administrators, and the patients themselves) communicate seamlessly with one another.

"Many providers are moving towards electronic health records individually," said Rosati, "but they really can't talk to each other right now, and that's a huge problem when you get patients going from hospital to hospital, or from their physician's office to the hospital."

"Right now," she added, "in terms of communications between providers, they do it in their own way," which usually means faxing a paper medical record. "It's slow," she said. "It's cumbersome, with lots of labor costs involved. What we'd like to do is establish a good way for providers and plans, and eventually patients, to talk to each other to create the infrastructure."

The VA Hospital paperless project

"Our goal about 10 years ago was to literally create a paperless electronic record, using state-of-the-art information technology," said steering committee member John Fears, local advisory panel chairman for the Veterans Administration Medical Center.

What resulted was a conglomeration of software applications operating under a database named VISTA — Veterans Integrated System Technology Architecture. Operating from within the VISTA database are what Fears calls "mission-critical" applications, including Computer Patient Records System (CPRS); the Bar Code Medications Application (BCMA), and the VA imaging system, in which a vast array of viewing formats are available on an as-needed basis.

All aspects of patient care are accessible through the system. "The primary goal of CPRS is to create a fast and easy-to-use product that gives physicians enough information through clinical reminders, results reporting, and expert system feedback to make better decisions regarding orders and treatment," Fears said. Fears explained that the nature of the system provides VA hospitals across the nation with instant access to patient records, although he cautioned that records are currently stored at the patient's host facilities.

"In New Orleans, when Katrina hit, we were asked to take 25 to 30 patients out of that hospital and bring them here," Fears said. "We have what we call the Master Patient Index, a computerized system that automatically notifies the central system when we enroll someone we are actually notified right here that there's another VA [facility] that has records [about these patients] on the system."

The technology within the VA system has branched out to include VISTAWeb, which enables care providers to view medical records outside the VA's system. It does not, however, provide the integrated access to those records that the internal system does. Since its origin 10 years ago, the number of patients in the VA paperless records system has more than doubled, from 30,000 to start. Fears projects the current patient count — 75,000 — soon will top 110,000. The VA is broadening its services to provide veterans with Web-based access to treatment.

"Over the next five to 10 years we fully intend to have enabled the veteran to access his or her record through the Internet," Fears said. Also in the cards is the next generation of VISTA software, which Fear said "will allow seamless data sharing between all parts of the VA to benefit veterans and their families." Another key feature will be its use as a national Health Data Repository, something Fears admits to not being too thrilled about.

To be real honest with you, I'm not so sure that this is the wisest thing — it will be extremely expensive," he said. As Fears expresses reservations about the expense of a centralized patient record, the more cynical observer would suspect that there's a catch to the VA success story. When asked how difficult it was to find the right vendor, Fears replied, "We built our own we are a closed system, and that's why we were able to do this on such a massive scale."

Arizona's e-health system

The VA's VISTA database provides, at best, a working example of what a paperless system can become when properly executed. At worst, it exemplifies a closed system with an anticipated, costly one-site-serves-all data storage configuration. In the long run, is this system an example to emulate, in view of the all-inclusive nature of the Heath-e Connection? W. P. Carey's Vinze and Kimberly Harris-Salamone offer an option for consideration when it comes time to design an inclusive, versus an exclusive system: HIT infrastructure based on Open Source design.

Specifically, there is a rather large movement in the Open Source arena," said Harris-Salamone, a health-care technology consultant for Fox Systems in Scottsdale. "It answers the interoperability question in that the source code is open, and adheres to standards. Anyone can use or modify the software with few restrictions." Vinze agrees.

"Will health care go the Open Source route? If I was guessing — and I am — my sense is: absolutely," Vinze said. "Really, what you're seeing is that Open Source is becoming the way of business, not just a way of software development. And what that does is it changes the way you condition and predicate your business practices the value doesn't come out of the service of the goods, the value comes out of the consolidated whole.

"In any open environment, what you want is a true broker, or an impartial broker, that is technology-agnostic and with no ax to wield," Vinze said. "This is the reason why [CABIT] and academia in general is so important to this process — W. P. Carey School can be a trusted partner who can lend truly independent unbiased expertise to the process."

Argument for a centralized database

William Johnson is director of the W. P. Carey School's Center for Health Information and Research. Over the last six years, he has built the Arizona HealthQuery (AZHQ) system into a 5 million-strong database of health records representing Arizona residents. That number is about to explode exponentially with his announcements of contracts to store the records for IBM, Intel, and the state's Medicare roster.

Johnson points to the AZHQ system as a "bridge to e-Health" in Arizona. Like Vinze, he considers the role of his organization as that of an impartial custodian — "a data Switzerland" is how he refers to the ultra-secure installation. "We don't compete in the health-care system whatever our faults as a university, we're assumed at least to be neutral in our health-care operations."

The system illustrates the technical solution needed by the e-health system for physical security and HIPAA compliance. It serves as a model of cooperation and trust — storage in the system by Johnson's many partners in the government and private business sectors is based almost on a gentleman's agreement. "This is a voluntary system. Any one of our data partners can quit tomorrow. Pick up the phone, call me and say 'take our data out of the system' and I am required to do that," Johnson said.

Harris-Salamone might envision the same trust levels for her blueprint for implementation of Arizona's Health-e Connection. Harris-Salamone's strategy, a multifaceted approach that seeks to coax the reluctant as well as embrace the willing, addresses both the operational and implementation aspects for the system. Clinical priorities for the system include securely managed networks and Web portals; secure messaging between providers; results delivery; patient health summary; clinical decision support, and public health alerts and queries.

To implement technologies, Harris-Salamone advocates partnerships with organizations with HIT adoption programs in place; the setting and adopting of standards; provision of guidance, direction and educations; provision of monetary incentives through local, state and federal grant programs, and a troubleshooting process that pinpoints, then resolves, potential snags in the implementation process.

"You have to protect yourself with policy and procedure and as much technology as possible," she said.

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