Besides the Health Connector, Massachusetts created a virtual gateway enrollment for all its subsidized programs, and now 98 percent of that enrollment is done online. It also replaced its MMIS and started work on the state-level HIE. “These are major projects across four different agencies with three different CIOs, and the policies are not really established across all those boundaries,” DeBor said. “So there are tensions and questions about how coordinated the efforts are.”

Some states may take a wait-and-see approach to insurance exchanges or just allow the federal government to build something for them. “Some states just won’t have the intestinal fortitude to take this on, because they haven’t made progress on health IT, or they don’t have the people, knowledge or resources,” Keane’s Danis said, predicting that states with outdated eligibility systems will not be jumping into it. But there’s a short list of states that, regardless of which party is in power, have already made progress and will pursue their own exchanges.

Public Health Reporting

One priority of federal officials in shifting from paper to electronic health records is to improve public health reporting. Public health officials are working toward electronic reporting of immunization and lab data, as well as improved syndromic surveillance — and the pace of change is frenetic. “We can definitely feel the impact of the federal push and the acceleration in change that is happening,” said Jim Daniel, CIO of the Massachusetts Department of Public Health. “I expect as much change in the next year as we’ve had in the last several years combined.”

The Massachusetts health IT strategic plan says: “Information will be easily, securely and reliably available to better understand public health needs and trends, to support public health interventions and programs, and be available to support research and emergency response efforts.”  Working toward making that vision a reality is among Daniel’s responsibilities. He said the fact that the federal government made electronic public health reporting part of the eligibility requirements for providers to be “meaningful users” of health IT should have a big impact.

“Hospitals have had the infrastructure in place for years, but it has been difficult to convince them to participate,” Daniel said. “They have so many reporting requirements that unless it is a requirement, it’s difficult to get them to do it. Among other things, getting them to report electronically will save us from huge data entry chores.”

With paper-based systems, the reporting on foodborne illnesses just wasn’t fast enough, resulting in secondary outbreaks, Daniel said. Now that data can flow seamlessly into the state’s disease management system, the response time can be much quicker. Daniel also expects to see great improvement in electronic lab reporting. Before the meaningful use incentives, about 50 percent of hospitals in Massachusetts were submitting lab data electronically. “I think by the end of 2011, almost everyone will be on board,” he said.

Daniel co-chairs the Clinical Quality and Public Health Ad Hoc Workgroup of the state’s HIE organization. “We have created a huge spreadsheet of all the conditions for which data is reportable and [are] deciding how to prioritize which data would be useful to get directly from the HIE, such as health-care associated infections, reporting for cancer registries or hospital birth data,” he explained. “Potentially all of that could flow through the HIE.”

There are some instances where being slower to automate may prove beneficial, however. For instance, although Massachusetts is seen as a model for other states on electronic lab reporting, it’s actually one of the last to create an immunization registry. “That may be to our benefit from an HIE standpoint,” Daniel said, “because now we can make sure it fits perfectly technologically instead of having to retrofit it.”

Federal Funds (and Pressure)

The federal government has made a major commitment to digital health records — putting lots of dollars and other resources behind the effort while trying to allow states some flexibility in how systems are designed. Nevertheless, states are finding the pace taxing, and some complain that they are being pushed to the margins of what’s possible in a four-year time frame, said Robert Wah, vice president and chief medical officer of CSC’s North American public-sector group.

“The money has suddenly put attention on this issue that wasn’t there before,” he added. “So in states where it has taken a back seat, they are playing catch-up.”

Many state governments are facing a double whammy of sharp revenue declines and the prospect of turnover in the governor’s mansion, which means many CIOs and state health IT coordinators also will be leaving. There may be some states where health IT-related issues haven’t hit home yet, said Lynn Dierker, senior program director for the nonprofit National Academy for State Health Policy. But the pace of change at the federal level should signal to incoming state officials that they must optimize the systems behind the health services they offer. “Federal agencies are really walking the talk,” she said. “They are pushing a common platform for HIE, Medicaid and health reform agendas. They are signaling how the state IT infrastructure pieces can be used to leverage each other, and they are providing the funding to pull it off.”

No matter what they think politically about health-care reform, new governors and CIOs will have to look objectively at how statewide health systems can be made more efficient. “It begs the issue of redefining the business case of what’s inside and outside state government and what kind of shared services you can create,” Dierker said. “For people sitting inthe state CIO seat, the possibility for leadership on these issues is immense.”

David Raths  |  contributing writer