In Arkansas, building an HIE from scratch
Ray Scott was pretty much ready to retire when Arkansas Governor Mike Beebe asked to him to work as a consultant in the state’s health IT office. With Arkansas lagging in electronic health record use and also ranking as one of the poorest, sickest and most obesity-plagued states, Beebe, a Democrat, was trying to improve and modernize the state’s health system, and wanted Scott to help craft an application for the ONC’s HITECH Act grant to build a statewide health information exchange.
“He said, ‘We only need you for 90 days,’” recalled Scott, a veteran Arkansas politico and bureaucrat who’s worked for seven governors, including Bill Clinton and Mike Huckabee, and most recently was head of the state’s health agency. “I tried to convince him that I wasn’t the guy.”
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Scott then became Arkansas health IT coordinator in 2010, and has led the construction of Arkansas’ statewide HIE, the State Health Alliance for Records Exchange or SHARE. SHARE, its infrastructure and policy, has basically been built from scratch. A few community health systems, hospitals and Blue Cross Blue Shield Arkansas had internal HIEs, but there wasn’t much regional exchange, and at one large hospital, Scott said, more than half of the patients have been coming from outside its network. In a state where a lot of areas still lack broadband Internet, small practices are just starting to use, or consider using, digital health records.
“I knew we were way behind in terms of how health information is used, compared to how IT is used in finance,” Scott said.
SHARE has been built as a public utility, a model that in other states, like Kansas, has been controversial and not panned out as intended. Although the details about data ownership and financing haven’t been worked out, leaving some stakeholders, like the Arkansas Hospital Association, with lingering concerns, SHARE seems to have mostly broad support.
“He’s gone out of his way to be inclusive of all parties,” Paul Cunningham, vice president of Arkansas Hospital Association, said of Scott.
Experience with public policy — where politics, business and science intersect — is probably why Scott was chosen for the job. He recalls Governor Beebe saying to him: ‘’I need you to do this because you know the players and this ain’t your first rodeo.”
“We weren’t trying to build a new large bureaucracy that would control and run everything,” Scott said. “I tried to disarm any notion that folks had of ‘Here goes Ray building an empire.’”
The public utility model evolved out of stakeholder talks, Scott said. He focused on what functions the HIE would have and how to build it, rather than the more controversial question of who owns the data, who’d be running the HIE and how it would be financed.
“If we started there,” Scott said, “we would never get anywhere.”
Those are central questions, of course, and they haven’t been answered yet. Now doing direct messaging with 2,000 providers (and about as many signing up currently) and with query functionality set to go live in a year, SHARE, its IT built by the vendor OptumInsight, is operating on the original $8 million ONC grant and set to start financing itself with provider fees in the future, their nature still to be decided.
Those issues aside, the progress with SHARE is palpable, said Joe Thompson, the state’s surgeon general and director of Arkansas Center for Healthcare Improvement.
“I think we’re in a transition period, we’ve got to find the balance between how do we keep the IT nimble enough and secure,” Thompson said. “We’re really trying to transform the whole system,” referring to Arkansas plan to shift private and public healthcare away from a fee-for-service system to a pay-for-quality model, as recently noted in The New York Times Opinionator blog.
Both Thompson and Cunningham, from the Arkansas Hospital Association, note that there is always the option to turn SHARE into a private nonprofit or create private HIEs.
“Whichever route you take, there’s going to be a cost for it,” Cunningham said.
[Q&A: Taking a radiology practice from no IT to HIE -- with ROI.]
And whichever route SHARE ultimately takes, the ONC is pretty impressed.
“One state that seems to truly have embodied the goals of the State Health Information Exchange (SHIE) Cooperative Agreement program is Arkansas,” ONC spokesperson Peter Ashkenaz said. “They look towards the overall bigger picture of the quality and efficiency of health care, and are always seeking ways to increase meaningful exchange, including collaboration with other programs such as payment reform initiatives.”
And Scott, who is also a noted nature photographer and is retiring at the end of the year, has much praise for the ONC and federal government: “I think the wisdom by those visionaries who wrote the HITECH Act is that you’re not going to transform the healthcare system in this country if you don’t build a comprehensive communications network.”