Regional health information exchange projects involving insurers, hospitals and clinics typically require years of consensus building and planning to get off the ground.
But Louisiana found a sure-fire way to speed up the process.
"Just have a major hurricane, and it drops a lot of barriers," said Dr. Roxane Townsend, deputy secretary of the Louisiana Department of Health and Hospitals in Baton Rouge, La.
With its prototype, called the Louisiana Health Information Exchange, the state and eight local health-care providers have accomplished in nine months what in other instances would have taken two to five years, Townsend said.
"The challenges were easier to overcome because we had a bunch of shared pain," she said. "We had all been in the same boat -- almost literally."
Townsend witnessed firsthand the disruption to the medical community when Hurricane Katrina hit the Gulf Coast. At the Superdome, she saw people carrying their medications in Wal-Mart bags.
"When you opened them up, it was all wet and the labels were peeled off," she remembered. "The medicines themselves were just a white slurry. And that's all the information you had. It's an unacceptable place to be."
When the city flooded, providers lost tons of paper records. Even many doctors who had electronic medical records lost access because their servers drowned.
"So we learned that records have to be easily transportable and have redundancy in a remote area," Townsend said.
Serving as a positive counterexample to the chaos at the Superdome was the Louisiana Immunization Network for Kids Statewide (LINKS). Pediatricians use this Web-based, state-run program to enter data on children's immunizations, and LINKS lets enrolled users search for patients and view their vaccination record. In the months following the storm, the records were accessed in all 50 states, as children moved to new locations with their families.
"We estimate this saved re-immunization costs of $6.3 million," Townsend said.
Change of Pace
Louisiana juggled multiple health IT efforts prior to Katrina, including a public health information network. In early 2005, the state applied to the federal government to be one of four regions to build a prototype for a National Health Information Network.
When Katrina hit, Dr. David Brailer, who was then national coordinator for Health IT in the U.S. Department of Health and Human Services, contacted Dr. Fred Cerise, secretary of the Louisiana Department of Health and Hospitals, and asked if the state would be interested in a separate proposal specifically in response to Katrina.
In September 2005, Louisiana received a one-year, $3.7 million grant to create a prototype of a health information exchange. The exchange group consists of eight hospitals and health providers in New Orleans and Baton Rouge, including Blue Cross and Blue Shield of Louisiana, and the state Medicaid program.
Regional efforts are under way to examine the possibilities of expanding the Louisiana experiment across the entire Gulf Coast region.
The exchange uses Oracle's Healthcare Transaction Base. All providers submit data into the system in either XML or a format called 837, which is an electronic file format that supports medical bill data. The provider information shows results such as lab tests and X-rays.
"Some have more than others, depending on how much is done electronically," Townsend explained. "We drew up a list and said, 'This is what we'd love to have, but send us what you've got.'"
Each area -- Baton Rouge and New Orleans -- has its own master patient index located on its own regional server. In addition, a record locator service lets users query the system about where to find additional patient information.
Louisiana tested the exchange with emergency room (ER) physicians treating patients new to their hospital, and clinic physicians treating patients who recently went to an emergency room. Townsend believes the latter case is where the exchange may prove most valuable.
"ER docs are used to working in the dark all the time and do a good job," she said. "But primary care docs could really use the information that someone went to an ER recently and had an X-ray or a lab test done. That is really beneficial, so you don't duplicate tests."
One participant in the prototype is Ochsner Health System, a group of 700 physicians with offices in New Orleans and Baton Rouge. Ochsner uses electronic medical records, and its network survived the flood, said Dr. Lynn Witherspoon, vice president of information systems. Nevertheless, the storm drove home the urgency of the problem, he said. "We know full well the value of health information exchange," he said. "We're all passionate about getting it up and running on a routine basis."
Although Witherspoon considers the prototype a success, some technical issues remain. Uploading the data to the exchange is straightforward, but the patient identifier doesn't work well yet, he said.
There is no unique national identifier, and Social Security numbers can't be used for security reasons. He said if a patient was seen at Ochsner, at Louisiana State University Hospital and by a clinic in Baton Rouge, the master patient index is challenged to pull all those pieces of data on Mr. or Mrs. Jones into one clear picture.
It's a big issue, and Witherspoon said a solution does not seem to be forthcoming on a national level.
Other challenges include getting more physician groups to use electronic records and involving more organizations in the exchange. "The fact that we chose to do it with a small number of organizations so we could rapidly show proof of concept means we now have to reach out to other providers and insurers," Witherspoon said.
A big piece of phase two will be to make the exchange more inclusive, so all providers will have some sense of ownership. The grant period ended in September 2006, and the goal now is to take it from the prototype to the pilot phase, and deploy it in emergency rooms and doctors' offices. To do that, the state will have to secure additional funding.
Townsend admits that the state has put the cart before the horse.
"We have a working prototype, but all of the things you usually work out beforehand, the policies and procedures, we haven't worked through yet. That's why we're not ready yet to take this live."
Still to be resolved are the tough issues of governance. Who owns the exchange? Who makes decisions? What are appropriate levels of privacy and security?
Yet Townsend said she and her colleagues feel a sense of accomplishment about what they've done in the wake of Katrina.
"We're trying to answer the question, 'Can you make a difference in people's health care with shared electronic records?'"