In Florida, for example, the statewide health information exchange is rolling out an ENS service in which insurers and primary care physicians are notified of transitions of care. The ENS engine was designed by Baltimore-based Audacious Inquiry, which also designed the ENS for Maryland’s HIE, Chesapeake Regional Information System for our Patients (CRISP), and Delaware’s DHIN.
CRISP CEO David Horrocks says the ENS was not part of the HIE’s original design, but the organization began thinking about how best to leverage admission-discharge-transfer (ADT) notifications in 2011, after encouragement from Farzad Mostashari, M.D., former national coordinator for HIT.
“Farzad recognized that we were ahead of the game with ADTs, and encouraged us to think about what we could do with just those,” Horrocks says. “By the end of 2011 we had ADTs from all 46 Maryland hospitals.
“My colleagues at Audacious Inquiry, who have done our HIE program management, and I kept working on ADT ideas and we came up with the ENS concept. The novelty was going to be getting the patient list up front from the primary care physician, rather than relying on the data collected at the hospital, which is often inaccurate, and using Direct. We went live in August 2012, sending just a few dozen alerts a day. It had grown to several hundred daily alerts by the fall.”
Today, Horrocks says CRISP sends close to 5,000 ENS alerts each day, with around 3 million people in the patient roster. The service is used mostly by PCPs and care coordinators at health plans. The HIE is also adding care coordinators at hospitals, who are watching for emergency department visits for patients who were recently discharged, and is about to activate the ability to receive discharge summaries as part of a transition of care. Patients can opt out of both parts.
Horrocks says the system is rolling out in a slightly different vector than originally envisioned.
“We thought a mobile phone alert would be important and built it in, which is almost funny in retrospect because the doctors don’t want to be interrupted for this,” he says. “The practices who have an infrastructure for care coordination seem to make the best use of it, often getting the alerts in a batch early in the morning and maybe again in the afternoon, rather than one at a time throughout the day.”
Mack Baniameri, CEO of Scottsdale, Ariz.-based Health BI, which launched its own ENS platform in September 2013, says the new CMS CPT codes (99495 and 99496) for transitional care management services are a huge driver of the ENS market.
“ENS becomes very important for the primary care providers, so they can communicate with the patient and get them in,” he says. “On the hospital side, obviously they reduce the readmissions. And the ROI for payers is huge because it reduces inpatient admissions.”
Baniameri says the pricing model for the company’s ENS technology varies depending on the customer. Payers like per-member, per-month pricing, while ambulatory and community providers prefer a SaaS-based per-provider, per-month model. The company’s current customers include several clinics and United Healthcare. Baniameri says the company is in the middle of the RFP process with several HIE’s.
Technologically, Baniameri says an ENS system must be able to receive ADT messages in various formats, including HL7, CCD, and XML, and must include some kind of internal master patient provider index and a filtering engine.
“You also have to have several methods of communication to the providers,” he says, “like fax, secure SMS, portals, and secure e-mail. Everybody is different, so we have to have a variety of mechanisms built in.”
CRISP’s Horrocks says the participants recognize the payback they get from the ENS. The system’s development was funded by a portion of the HIE’s operations budget, which at the time was a combination of fees paid by hospitals and grants.
“We operate it today on fees from hospitals, and fees from payers which are collected through a state assessment,” he says. “We also use some grant money to implement ENS improvements. The value which participants get from ENS is part of the reason we are able to collect fees, so it is important to CRISP’s sustainability.”