Capital New York
May 7, 2015
New York's Health Information System Nears Critical Mass
By Dan Goldberg
When New York health officials refer to the state’s ambitious new health-information project, they like to say that they are building nothing less than a new public utility.
They say that the new system, which will ultimately cost more than $600 million to build, will effectively be a grid. Instead of power, it will distribute patient information, uploaded to a central hub, to any doctor authorized to view it.
If the investment in the project—officially called the State Health Information Network for New York and known to health care wonks as SHIN-NY, which they pronounce “shiny”—is enormous, so are the challenges it’s meant to address.
The majority of patients and doctors are not sharing health data, and the current system—such as it is—is plagued by problems related to interoperability, privacy and security.
As the state moved to address the problems in recent years by building the new system, critics in the health care field wondered whether the cost was good money after bad, and whether the New York eHealth Collaborative, with which the state contracted to build SHIN-NY, was up to the job in the first place.
But over the last few months, thanks to public pressure from the state’s health department and a confluence of private market forces, the state may be on the cusp of a breakthrough.
If the system works, the effort will make New York an undisputed national leader in health-information technology, allowing access to data that will fundamentally change the way health care policy and high-level caregiver decisions get made.
The SHIN-NY project was first announced in June 2012 as a way to connect the state’s nine Regional Health Information Organizations, or RHIOs.
The exchanges, which have similar missions and were all made possible by a state grant program that began in 2004, were different from each other in many other ways, with varying standards and policies.
Some RHIOs worked better than others. Some barely worked at all. Healtheconnections in Central New York has thousands of users uploading and querying data. New York City’s Interboro system, run by the city Health and Hospitals Corporation, has fewer than 100.
There was no way for RHIOs to communicate with each other, which has been particularly problematic in New York City and Long Island, where four of the nine regional organizations are located, and many patients’ information is split up between those organizations.
The SHIN-NY project was supposed to fix all that—to standardize regulations across the state in order to ensure the regional information hubs had minimum technical capabilities that would allow an internist in Buffalo to communicate with the cardiologist a patient wanted to see at New York Presbyterian. The cardiologist could access the patient’s allergies, medications and clinical diagnostic tests no matter which electronic medical records system the doctor used.
“At a 60,000-foot level, the goal of the SHIN-NY is to produce the pipes [that connect the RHIOs], design the policies … and it’s to overlay a governance structure,” said Amanda Parsons, vice president of community and population health at Montefiore Health System.
To help reach that goal, the state Legislature spent $55 million in 2014, and last month, allocated an additional $45 million to the New York e-Health Collaborative (NYeC), a not-for-profit in charge of system overhaul. That was augmented by more than $30 million in federal money.
But after two years and the commitment of $130 million, the SHIN-NY remains a notional concept. The regional information centers still can’t communicate with one another. The patient portal, which allows patients to see their own records and was supposed to be ready in 2014, does not yet exist.
Only 18 percent of ambulatory physicians and only 11 percent of clinical practices are members of a RHIO, according to NYeC’s own numbers. Only 55 percent of the state’s public health departments are connected. Two out of every three New Yorkers have not consented to share their electronic medical records.
But the money keeps flowing because just about every policymaker believes this is a good idea, and every stakeholder has something to gain from its success. The Cuomo administration, legislators, hospitals, insurers, doctors, health officials, liberals and conservatives all want to see NYeC succeed, and believe it must.
A number of historic developments in the evolution of American health care—along with a number of newly available, finite funding streams—have converged to make the state’s health information overhaul an urgent proposition.
There is, to name one, the more than $6 billion the federal government is giving New York for the Delivery System Reform Incentive Payment (DSRIP) program, which is paying groups of providers to implement projects aimed at better coordinating care.
Many of these groups, known as Performing Provider Systems, or PPSs, exist beyond regional boundaries. Montefiore, for example, has partners in the Bronx, Manhattan and the lower Hudson Valley.
The aim of the federal payments to these groups is to reduce hospital use by 25 percent over five years.
“RHIOs are the tool that should make that easier to accomplish,” said Tom Check, president and C.E.O. of Healthix, a RHIO representing Manhattan, Long Island and Brooklyn.
Check said that because patients move around, the regional organizations must be able to communicate with one another.
“No matter how fully integrated a delivery network can be, a patient is still going to get outside with other providers,” he said.
In addition to the DSRIP payments, there is also the federal government’s “meaningful use” program, and the trend toward greater consolidation among health systems across the state.
The federal government has doled out nearly $30 billion in incentive payments to doctors and hospital systems that adopt and purposefully use “meaningful use” electronic medical records. The program comes in stages but its emphasis is on patients and physicians becoming “actively engaged” with their electronic records.
A further, major impetus for speedy progress on the SHIN-NY initiative is the trend toward ever-larger health systems across New York. Hospitals traditionally based in Manhattan are moving into Brooklyn. North Shore-L.I.J.’s insurance company, CareConnect, touches all five boroughs as well as Westchester, Putnam and Dutchess counties. Montefiore and New York Presbyterian are each partnering with organizations outside the city. The Cuomo administration plans to help rural hospitals upstate shore up their finances so they can be more attractive to larger health systems.
This coincides with, and partially results from, the largest health systems moving to payment models whereby providers take on more risk, meaning they act more like insurance companies. A percentage of the premium is kept by the health system regardless of how much it spends caring for the patient.
The state’s goal is to have a majority of its Medicaid dollars in risk-sharing models by the end of the decade. The federal government recently announced its intention to tie 30 percent of fee-for-service Medicare payments to value through alternative payment models by the end of 2016, and tie 50 percent of payments to these models by the end of 2018. Smaller physician practices that want to be part of an Accountable Care Organization also need an interoperable electronic health records system.
In this world, a state-subsidized electronic health records network that links providers anywhere in the state and sends alerts to a health system’s care manager whenever one of its patients interacts with the medical system could prove invaluable.
“Borders are stretching,” said Dennis Whalen, president of the Healthcare Association of New York State, and a board member of NYeC, the nonprofit that’s running the health information overhaul. “If you’re going to go at risk to any significant degree, you need a very large patient population, because you need it to be actuarially sound and you want to be able to spread your costs and handle this like a system. So borders are becoming more porous. [Regional organizations] need to talk to each other.”
With a recent change of leadership within the health department, the state increased its focus on NYeC, and its scrutiny of the group’s progress on SHIN-NY.
Pat Roohan, the health department’s director of quality and patient safety, took over responsibility for project oversight in late 2014, bringing a fresh and sometimes critical view of its progress.
“Our role was to get this going at a different pace,” he said, in a recent interview. “This is a different game we’re playing. We need to move into an operational phase.”
NYeC had taken on a number of technical initiatives for RHIOs but managing that architecture was more complex than NYeC had anticipated, and the collaborative was forced to scale back and refocus on its core mission of ensuring connectivity between the RHIOs.
“My sense was [NYeC] was doing lots of things at once, of which connectivity was only a portion,” said Parsons, from Montefiore.
Or as Roohan put it, “There was certainly scope creep at NYeC.”
The fact that NYeC had needed to go back to Governor Andrew Cuomo and the Legislature in need of another $45 million in the current budget, after having received $55 million the year before, also created pressure for greater accountability. (The state health department tasked NYeC with presenting a sustainability plan for the continued development and operation of the SHIN-NY. The state did not fund the SHIN-NY beyond this year.)
Some former critics of the state’s health information efforts, and of NYeC in particular, say the new accountability makes them feel optimistic that the ambitious information-sharing goals may finally be met.
“Under Pat Roohan’s leadership, [the health department] is exceptionally focused on ensuring that the SHIN-NY is positioned to support the goals of DSRIP and meet its overarching goal of improving patient care in general,” said Susan Waltman, executive vice president and general counsel at the Greater New York Hospital Association.
By July 1, the RHIOs are supposed to have a minimum set of capabilities, known (somewhat anachronistically) as dial tone services. That means they are supposed to allow doctors to look up individual patient records through a secure search engine, exchange direct messages with other doctors, and receive alerts when their patient interacts with another health provider.
RHIO executives differed as to how likely it was that the state would meet that deadline, given how much security testing remains to be done. But there seemed to be a consensus that the regional organizations have the ability to communicate with each other by the end of the year.
“You can always make the argument more should have been done,” Whalen said. “I don’t think money has been wasted. I also worry about unreal expectations given how complex the landscape is. Could it have gone faster? Probably but lots of things are going on.”
The prevailing opinion among the stakeholders interviewed for this article is that there is some critical mass of patients and providers that need to be connected to the new system for it to become indispensable, and that the state is getting close.
Only one-third of the state has granted consent to one or more doctors to share information with RHIOs, but that’s almost twice as many as had consented two years ago, and there has been a 20 percent increase in the last 12 months.
“The conversation is slowly changing from ‘maybe I will, maybe I won’t’ to ‘oh my goodness, this is a requirement of care,’” Parsons said.
In the Bronx, 728 Montefiore doctors are registered to use the Bronx RHIO, and more than half of those are “active” users, meaning they’ve accessed the system in the last quarter. That’s a 100 percent increase in three years.
Rochester’s RHIO has seen a 250 percent growth in patient consent forms in the last two years, leading the state with 1.1 million patient consents.
Weill Cornell Medical College is using a state grant to study the effectiveness of health information exchanges and concluded that use of the system will reduce hospitalizations and save money.
Researchers like Dr. Rainu Kaushal, chair of health care policy and research at Weill Cornell Medical College, are also excited by the possibility of having this data in one place to better understand what makes people sick. Not all diabetics are alike, not all interventions work the same and not all investments pay off, and one way to tease out what works from what doesn’t is to gather large samples of data and look for patterns.
“We have this treasure trove of information on the most diverse population in the country,” Kaushal said. “We couldn’t use it fully because we couldn’t appreciate it.”