State Strategies to Address Market Barriers and Increase Information Flow Between Health Care Providers
Strategy 1: Create Meaningful Economic Interests That Encourage Exchange of Health Information
One of the main obstacles to exchange of health information between providers is the lack of appropriate and strong economic incentives for exchange. The primary way a state can create economic interest for information exchange is through its larger efforts to change the way health care is paid for, delivered and measured. Governors can use their regulatory and oversight authority through Medicaid, the Children’s Health Insurance Program (CHIP), state employee health benefits, state retiree health programs and health insurance marketplaces to encourage change. Reforms that move away from FFS volume-based payments toward aggregated risk and population health, such as accountable care organizations (ACOs), can create meaningful economic incentives to facilitate information exchange between providers.35
In addition to longer term payment and delivery system reforms, states can pursue shorter term payment and incentive strategies to encourage procurement of interoperable EHR systems and meaningful information exchange. These strategies include:
- Developing and linking Medicaid payments to performance metrics that tie directly to the exchange of health information (for example, the Oregon Health Authority has established “emergency department information exchange” as a quality metric for incentive payments to hospitals.36 Click here for additional information on Oregon’s approach to creating economic interest in exchange);
- Developing and linking Medicaid payments to performance metrics for which information exchange is critical to success, such as reduced number of duplicate tests, lower readmission rates or improved coordination of care for patients who have chronic health conditions;
- Creating financial penalties for information blocking (for example, a one-time fee for engaging in information blocking or penalties tied to Medicaid or other insurer payments such as those imposed for hospital readmissions in Medicare);
- Using federal funding, such as the expansion of 90 percent matching funds in Medicaid, to support the cost of developing interoperable systems for Medicaid providers;37 and
- Providing other financial support to providers or certain categories of providers for expenses related to: purchasing interoperable systems; updating existing systems to be interoperable; establishing EHR connectivity with critical partners (middleware and interface costs); and HIO connectivity.
Considerations for Creating Economic Interest
Shifting to VBP methodologies will take considerable time, and will not be a sufficient strategy on its own if a state is looking to make progress on exchange in the short term. Rather, states should consider such a shift as part of a multipronged approach that has the potential for both short- and long-term success. For instance, many states have included pay-for-performance initiatives in their Medicaid managed care contracts and may see early progress by incorporating performance targets specifically tied to information exchange, or for which exchange of health information is critical to success. For example, if a state requires reduced readmission rates as a performance target tied to payments, providers may be incentivized to participate in an admission, discharge and transfer (ADT) notification system that requires them to send, receive and use data effectively.
Federal investments, such as the 90 percent matching funds in Medicaid, offer a prime opportunity for states to maximize resources. By design, however, these federal investments primarily support infrastructure development and will not sustain ongoing provider costs related to maintenance and operations.
In some instances, states may consider making information blocking illegal and levying fines for such activity. States considering levying financial penalties for information blocking should weigh the time and cost that may be involved in both identifying and enforcing penalties and consider opportunities to leverage existing rules and enforcement mechanisms. For example, Connecticut passed a law that prohibits health care providers and IT vendors from engaging in health information blocking by establishing such action as an unfair trade practice. As a result of the law, information blocking is subject to associated trade rules and regulations.338 Click here for additional information on Connecticut’s approach to prohibiting information blocking.
Strategy 2: Use Legislative, Regulatory and Contracting Authority to Bolster Exchange of Health Information
One way governors, state legislators and policymakers can improve information exchange between health care providers is by using their legislative, regulatory and contracting authority to expressly require providers or IT vendors to participate in information exchange or prohibit information blocking. Legislation for increased participation in exchange of health information could also require that providers fully connect to an HIO, or share certain data feeds; it could also require that IT vendors have certified technologies that meet minimum standards for connectivity. States can also use existing or new contracts with managed care organizations (MCOs), state employee health insurance providers or other organizations to impose requirements indirectly. For example, through its managed care contracts, Iowa has stipulated that in order for MCOs to connect to the statewide alert notification system, they must require that providers in their network send ADT feeds to the statewide system.39
Considerations for Using Legislative, Regulatory and Contracting Authority to Bolster Exchange of Health Information
Primary considerations for states that seek to use legislative, regulatory or contracting authority to bolster exchange of health information relate to how the stakeholder community will react, the dominance of specific vendors (market share) and whether there is political will to pass or implement such a measure. State efforts will face greater challenges if there is limited support within the legislature or if there is significant pushback from IT vendors, providers or other stakeholders. In pursuing legal changes, states should engage stakeholders to establish buy-in and ensure clarity about definitions of and expectations for information sharing, information blocking, connectivity, certification and other concepts around which requirements or prohibitions are being structured. States will also need to think critically about the specific oversight authority they seek to implement and how it can be effectively enforced, including a review of financial resources, staff and technological capacity to carry out the policy in a meaningful way. Similar to making legislative or regulatory change, to amend contracting arrangements, states will need to engage key stakeholders and establish buy-in and agreement for new contract terms.
Strategy 3: Set the Vision and Hold People Accountable
Governors have the unique ability to set a statewide vision for interoperable exchange of health information that clearly articulates to key stakeholders and the public its importance and value. The statewide vision may include a high-level mission or series of goals, or may involve detailed strategic objectives. Establishing information sharing as a priority for the governor will help set expectations and allow the state to hold relevant parties accountable for their role in realizing the vision. The governor can then use her or his bully pulpit to highlight best practices. This strategy also allows the state to place pressure on entities that may be blocking information by making their business practices known to the public. For example, Oregon established a health IT oversight council that is responsible for setting a strategic vision and plan for the state; as part of this effort, the state envisions highlighting state entities that are making notable progress in information exchange.40 Click here for additional information on Oregon’s approach to setting the vision
Considerations for Setting the Vision and Holding People Accountable
In establishing a statewide vision for interoperable exchange of health information, governors and their staff should consider what level of detail to include, who should be responsible for executing the vision from a state perspective and which practices or policies do and do not represent alignment with that vision among key stakeholders. Another primary consideration for states will be how to hold people accountable for alignment with the state vision. States may choose solely to highlight those that are doing an exemplary job aligning with the state vision and working toward interoperable exchange of health information, or they may choose to highlight those that are doing poorly. Stakeholders should be engaged early and often in the development of this strategy.
Strategy 4: Serve as Convener
One of the most important levers governors have is their ability to bring diverse parties together on an issue. By serving as convener, a state can support consensus building among parties that may have differing interests, helping establish common ground and compromise. States can serve as an intermediary or resource for issues or conflicts between specific parties.
Governors and their state leaders benefit from bringing stakeholders to the table to listen to their perspectives and get buy-in on strategies to achieve a solution. The state convener role can also be useful in helping those in the provider community align on specific use cases for information sharing—such as newborn screening or advance directives for end-of-life care—which has proven to be a successful stepping stone toward broader information sharing for some organizations.41 Defined use cases give providers a better understanding of the value of information sharing to their specific business unit from both a process and resource perspective and allow for greater control over the management of information exchange.
States can also work with providers and vendors to build model contracts that prevent information blocking. States can play an important role in helping providers prepare to negotiate with EHR vendors by identifying specific criteria for evaluating contracts and establishing clear requirements for interoperability with other systems. For example, Vermont provided assistance to the statewide health information exchange network, providers and EHR vendors by participating in conference calls and other forums to provide clarity on connectivity standards and state law.42 Click here for additional information on Vermont’s approach to serving as convener.
Considerations for Serving as Convener
States that serve as a convener must clearly define what they aim to achieve in their convener role and consider the most effective manner by which to achieve that goal. The state may serve as an intermediary or may bring like-minded organizations together to coalesce around key priorities and create new partnerships. States may also consider bringing in outside experts to elevate discussions and serve as unbiased intermediaries. Importantly, serving as convener does not require that states direct the dialogue but rather allows a chance for facilitated discussion among parties that may not otherwise have the opportunity or impetus to connect with one another.
Serving as convener can be a relatively low-cost strategy that states can use to achieve important consensus building among key stakeholders. States should be sure, however, to dedicate the staff time needed to develop an effective strategy for engagement and manage the process.