HIStalk Practice Interviews Jeff Loughlin, Executive Director, New Hampshire Health Information Organization

Jeff Loughlin is executive director of the New Hampshire Health Information Organization, project director for the Massachusetts eHealth Collaborative, and part of the Medical Command Team with the Massachusetts Army National Guard.

Tell me about yourself and the organization.
I have the privilege of serving as executive director for the New Hampshire Health Information Organization, or NHHIO as we call ourselves. We are the state-designated entity for New Hampshire for electronic exchange, created back in 2011 by state legislation. We are currently a nonprofit charitable trust organization helping providers implement and adopt health information technology across the state. I’ve been there since just after it was formed in 2011. I also work for a parent company called the Massachusetts eHealth Collaborative, which is a small nonprofit consulting company focusing on health IT. We were the organization that created the Regional Extension Center of New Hampshire.

In the course of those duties, as we started to look across the spectrum of needs in New Hampshire around health IT overall, it seemed to make sense to bring these organizations together. As the REC of New Hampshire grant comes to a close, all of the staff members of the REC program become staff members of NHHIO. Collectively, we all work as a partnership. The staff members all now work for NHHIO, and we’ll maintain the legacy of the REC program under that umbrella. We’re essentially moving into that next range of health IT.

You recently surpassed NHHIO’s goal of helping a thousand physicians achieve Meaningful Use with certified EHRs. What challenges did your team face in getting physicians to that point?
The first challenge we had was simply finding a thousand providers. New Hampshire is a very small state. We came to the table under the third round of funding for the REC program. At that time, every other state had been implemented with the exception of a small portion of Florida. There was a gap, I believe, in California. New Hampshire was the only single state that did not have a REC program. When we first came to the state, we struggled, because in New Hampshire a lot of small practices are struggling to stay open. They’re either being bought out or merging with larger organizations. New Hampshire’s become a very hospital-centric state overall. Trying to find a thousand providers that qualified under the REC program was challenging. We worked with all the different organizations around the state to bring folks to the table.

Out of the roughly $7 million that we had, almost two-thirds of it went back to the state. We used a sub-recipient model where the REC team would serve as expert resources. We created a website with a lot of valuable tools and worked a lot with the public health department. We actually paid organizations to make the implementation of MU a priority in their organization, and we would simply provide the education as they needed it. I think where the struggle came is that when you do rely on organizations to do their own internal work, they get overtaken by a variety of priorities. That has certainly exponentially increased over the last several years with the onslaught of ACA work around pay-for-performance contracts. There’s a lot of variance in the metrics they’re trying to meet for the different payers and incentive programs they’re involved with. Sometimes there’s an overlap with MU and sometimes there isn’t. Even things like the patient-centered medical home, which is a hugely valuable program … the metrics for patients in that program are just slightly different from those for MU. They can focus on the overlap, but it’s those outlying measures that then become challenging to meet in some cases. I think that’s really been our biggest hurdle – just making the attainment of MU a priority for these organizations.

Another piece that’s loomed large in our conversations with providers has been the overall value of the MU program. When we came to the state, New Hampshire had a very high level of health IT usage. I think we were in the top 5 percent of e-prescribing. There’s been a large number of “Most Wired” hospitals awarded here over the last couple of years. There’s just a huge amount of technology here. In general, organizations get the value of technology in improving efficiencies and economies of scale, but whether or not the actual attainment of MU provided quality/benefit to the patient has yet to be seen.

What part of the process were you pleasantly surprised by?
The REC program overall was great. The motivation behind it, the goals of MU, made sense. How applicable they were at the ground level remains to be seen, but we found really wide-open doors at ONC. They were very receptive to our comments and suggestions. They are constantly looking for feedback on how to change the program. At the highest level, that was very present.

At the ground level, the relationships that our staff built with the providers, and in some cases even patients, helped us to really get a feel for the actual implications of using technology right in the exam room. That has made a huge difference and helped us to really understand the challenges moving forward, both from the patient side in terms of safety, confidentiality, security, and the intrusion of having technology in the exam room, as well as the pain points that the providers go through using it on a daily basis. From a NHHIO perspective, it’s really forced us to ask, ‘How do you now take that huge wealth of information that’s stored locally, and put it into good use in your community in more practical and efficient ways?’

Given your tenure, you’ve worked with at least three national coordinators. As you’ve seen ONC leaders come and go, how easy has it been to work with the office?
I think it’s more of a different vibe, rather than easier or harder. We were there just as David Blumenthal, MD was leaving. When Farzad Mostashari, MD took over, it sort of changed into a much livelier vibe – a different perspective. He’s a public health provider and was very focused on data collection and things like that, which has obviously lead to his ACO work. Then after that, with Karen DeSalvo, MD we encountered more of a bureaucratic mentality, much more focused on the technology and the standards, which I think was the right timing for that as we were starting to share data. We seem to have had, in my opinion, the right person at the right time. Overall, I think the general support and willingness of ONC to help wherever and whenever they could hasn’t changed at all across the spectrum.

As you helped physicians get to MU, did you notice them gravitating towards certain EHR vendors? What criteria did they base their selection on, or what did you help them look for?
We found that the majority of providers already had an EHR in place. There were very few that were starting out from scratch. Those that were did gravitate to some of the big-name vendors. Certainly at the hospital level we saw the usual suspects. A huge amount of Epic, GE, and some NextGen was there. At the practice level, we saw a couple of Athenahealth and EClinicalWorks implementations. The challenge for us, as I’ve mentioned, was that some of the providers that started with us may have joined larger groups or become affiliates of hospitals, so they wound up implementing the hospital system.

What’s the next goal on NHHIO’s horizon? Is MU no longer a priority now that MACRA is just around the corner?
New Hampshire does not have a centralized repository of data. We focus just on the transport of data alone. Now that we’ve helped physicians put EHRs in place and build up those databases, we’re helping them move it and share it. At a tactical level, the sharing of data becomes important. Because we don’t have centralized data, we’re focusing more on the interoperability between systems, and really helping practices work with their vendors to make that interoperability work.

We’re done with MU at the local level in terms of EHR adoption. Now it’s more about helping them build the workflows for the sharing of data, and helping them answer questions like, ‘How do you incorporate another provider’s data into your chart? What do you select? What do you not select? Who can screen it?’ Those types of things. Those are the conversations we’re having now.

There’s also a lot of focus on behavioral health. We’re working with providers on how to implement the different levels of consent required for information sharing, and looking at opportunities to focus on implementation, getting technology into the hands of other providers, and integrating behavioral health into primary care.

You’ve also mentioned data reporting as being a big need in the state. How do you envision helping your stakeholders move toward advanced payment models over the next year or two?
We’re happy to put systems in place to secure the transport of data between organizations. We’ve got a variety of tools to do that. We’re also now looking at a third-party vendor strategy to help bring in different vendors to support these regions as they start to think about their data needs. Because we don’t have a repository, there may be additional needs to share or collect data that we can’t offer, and so we’re looking at a vendor strategy to help do that. Again, I think one of our roles in the state besides as a technology organization is helping to bring all the organizations together to help guide them in the right direction to make a single selection statewide.

Now that physicians have, for the most part, gotten over the EHR implementation hump, what do you think their biggest challenges are when it comes to healthcare IT?
I think folks still struggle with the selection process. The certification process still seems to lag behind some of the goals as the laws come out. There’s always a lag between when the rule comes out and the vendors catch up. People are leery about what vendor to pick. For example, we have a long-term care organization that’s just now implementing the latest version of their EHR and, come to find out, they’re still not certified to use the Direct platform. They’re having to implement a secondary product on top of that to support the direct exchange of information.

I think the challenge is getting vendors to the table – to get them certified and to universally implement the standards the same way because we still see different vendors, both certified, that can’t talk to each other because of the way they decided to implement different pages of the certification standard. That’s really the biggest one, and it’s so hard. They keep changing the laws rapidly. People wait until the final rule. As soon as the final rule comes up, there’s enough yelling and screaming that someone then changes the rule. It’s a struggle to know exactly what to focus on. It kind of becomes blurred across all the different incentive programs.

Do you have any final thoughts?
I think we’re moving in the right direction. This is a matter of how do we start to congeal the standards and bring together all these varied programs into one narrow tunnel. There’s so many outliers of metrics and measures. That’s what people lose sight of. If we can start to narrow the band of what’s important, we’ll do a lot better.

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Contacts

Jenn,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

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