Rationale / Objectives
- Electronic Health Record (EHR) adoption among Southeast Minnesota’s community healthcare providers was close to 100%, and a common public health EHR was accessible to its public health departments. However, data interoperability had not yet been fully realized, resulting in data not being leveraged for chronic disease management. With the high prevalence of childhood asthma and diabetes, the Southeast Minnesota Beacon Community (SMBC) wanted to use health information technology and a public health approach to improve quality of life by increasing preventive measures, such as treatment plan compliance, for these patient groups. They also wanted to reduce emergency department visits and hospitalizations for these groups.
Project/Program Description & Major Achievements
- By leveraging peer-to-peer Nationwide Health Information Network (NwHIN) Connect infrastructure installed by an ONC-sponsored initiative, SMBC implemented a peer-to-peer HIE. A Clinical Data Repository (CDR) designed and operated by a third party was created to store each provider’s EHR patient data and clinical feeds in protected partitions. SMBC created a portal for school nurses and parents as part of the HIE. They created, exchanged (including through the portal) and maintained asthma action plans for each child with asthma, increasing pediatric asthma plan coverage from 26% to 75%. SMBC increased immunization availability at schools, and collected vaccination data from several sources in order to generate vaccination reminders. For diabetes management, SMBC created online treatment decision tools for use by patients and providers regarding medication use. They used the Patient-Reported Outcome Quality of Life (PROQOL) tool to pinpoint factors that impacted a diabetic patient’s quality of life and required attention, reducing 30-day readmission rates from 1.2 to 0.4%. The project HIE approach (peer-to-peer) saved participating providers as much as half a million dollars yearly in maintenance costs relative to other HIE models. Public health patient portals, school nurse data sharing services and transition of care were all successfully incorporated into the HIE infrastructure.  
- The project demonstrated that community-wide implementation of a peer-to-peer HIE is practicable and sustainable. Development of the patient portal was a sensitive task, as most providers had existing (tethered) portals that were an important part of building relationships with their patients, yet an HIE portal was needed to act as neutral ground and to allow school nurses to access relevant data. Focus groups prior to development were used to gauge support levels for the project, and revealed that privacy was a common concern. SMBC’s role was to facilitate adoption and integration of the solution by the healthcare system, not to be a fixture in the community. Therefore, its dissolution did not impact the momentum of the activities and processes that it helped put in place. The CDR proved not to be sustainable due to changes within the third party broker. The unusually high penetration of EHRs at the start of the project was an advantage to SMBC that threatens the generalizability of the project’s success.  
People / Organizations Involved
SMBC was part of the Office of the National Coordinator for Health Information Technology (ONC) – funded Beacon Communities project that was initiated in 2009. Over $12 million dollars was awarded to SMBC, Mayo Clinic being the main recipient. Providers who received consent were able to request and send Continuity of Care Documents (CCDs) via the HIE using established data sharing agreements, standards and protocols. The Transitions of Care (TOC) system built on the CCD exchange infrastructure to enable notifications to be sent to case managers in public health, mental health and social services when a patient was admitted to hospital. This was used to coordinate discharge planning with inpatient staff. A peer-to-peer HIE model does not require a central repository. Rather, each authorized provider has access to patient data from other partner providers (granted that there is security and identity certification between them) when there is a service request. Information is therefore collected on demand and held in cache. A CDR was envisioned in parallel with the HIE for research, surveillance and other purposes, since the HIE only captured about 1% of the population in the region. SMBC opted for a third party (the Regenstrief Institute) to supply this solution rather than design one from scratch. Once data connections from each provider to the CDR were in place, clinical data was transmitted in real time or in batches. This resulted in a significant data holding spanning 6 years and covering patients who were seen by providers in the Southeast Minnesota region. Only de-identified CDR data was shared with authorized parties. To facilitate the creation of asthma action plans, SMBC distributed asthma management plan toolkits (educational and training materials, consent forms, guidance etc.) to participating school districts.  
|Number of providers involved in Beacon interventions||2500|||
|Asthma patients with a documented asthma action plan||Increased from 17% to 27%||Age 5 – 40, 2009-2012 |
|Pediatric asthma patients with asthma action plan documented in school record||Increased from 26% to 75%||Age 5 – 12, 2009-2012 |
|Flu vaccinations administered||Increased from 174 to 1450||2009-2012 |
|Identification of clinically meaningful problems using PROQOL||20 – 50%|||
|Hospitalization of diabetic patients||Decreased from around 3% to 1%||For complications |
|30-day readmission rates for diabetic patients||Decreased from 1.2% to 0.4%|||
Implementation costs were 1% of the costs of implementing a hub-and-spoke HIE.