Beth Israel Deaconess Medical Center (BIDMC): A Standard For Better Health Care

Beth Israel Deaconess Medical Center first began the process of medical records exchange with Social Security in 2008, a time when there was very little precedent. Without that precedent, Beth Israel faced a number of challenges. "From our side, we had to be able to take in a web service like an SSA request," explained Robert Beckley, Interface Architect, "and then pass it along to our clinical system. One difficult part was protecting patient confidentiality. So our solution included a scan of the patient's consent to release information with the medical record."

Things have changed since then, "today we're using the C32 standard [summary documents using HL7 continuity of care document component] to exchange data with a lot of institutions in eastern Massachusetts," said Beckley. With the new system, too, the process of responding to records requests from Social Security has gotten much better. "Say someone came into a Social Security field office and applied for disability. Social Security would ask for our records on that person to help them make a disability determination. We'd go through our paper records, pull the records, copy them, and then overnight them to Social Security. This used to take about six weeks. Now it takes about nine minutes. Social Security enters a request, the system assembles the information, and the document gets to Social Security faster—all because it's done electronically." But it's not just speed that's been good for Beth Israel. "We are saving all the costs we used to spend on that manual process—the staff time and a lot of big piles of overnighted paper," said Beckley. We also are able to keep eight separate, secured copies of every record, something you can't do easily with a physical record. "It's been working reliably since 2008, and we handle about 10-20 requests a day. This project was the first step on what will be a very rich and important part of medical care in the future," Beckley continued.

The use of technology in electronic medical records exchange has helped the two organizations cater to patients better. "Connecting payers, providers and patients enhances quality, safety, and efficiency. The Social Security's MEGAHIT project is a perfect example of using technology to enhance the patient experience while reducing administrative overhead. It was an honor to participate," stated Dr. John Halamka, CIO, Beth Israel Deaconess Medical Center, referring to the partnership with Social Security.

Centra: Good for Patients, Good for PR, Good for Centra

Centra first got involved with Social Security's health IT program when they heard about a call for proposals under the American Recovery and Reinvestment Act (ARRA) initiative. The initiative sounded like a good idea. Centra was having to spend significant amounts of time handling paper to provide medical records to Social Security. Reducing that time would be important for patients and the business. Patients will gain a disability determination faster, which will help with overall patient benefits and care.

The system went live in May 2011 after a process that involved working closely with SSA's team of internal experts. In part because of the different types of data involved, a lot of learning occurred during the implementation. The results? Although paper records haven't been eliminated yet, the numbers have shrunk substantially and continue to shrink. "We've gotten far fewer calls from patients inquiring when their records will be sent since the launch," Ripley said. "For our patients getting coverage more quickly is a huge benefit." Centra has also enjoyed positioning itself with the leaders in electronic records exchange. "As hospitals move more and more to electronic medical records, paper is becoming obsolete," said Ripley.

"It was a great learning experience for everyone on our team," said Terri Ripley, Director of Systems and Programming and ARRA Coordinator for Centra. "SSA was wonderful." She also felt confident working with Social Security's expertise. "SSA was the first to accept a Continuity of Care Document," she said. "They are real leaders in this area."

Group Health Cooperative: Making the SSA Connection

Group Health Cooperative is a member-governed, nonprofit health care system coordinating care and coverage for over 60 years and serving more than 600,000 residents of Washington and North Idaho. As early adopters of HIE technology in Washington state, Group Health is a pioneer and regional leader, demonstrating strategic development, execution, and the value of HIE services and partnerships.

Group Health and its Health Information Exchange team are dedicated to a common mission to improve patient care, streamline disability benefit claim adjudication and improve public health reporting through a trusted and interoperable health information exchange. For Group Health, improving the patient experience is paramount to our success.

Participation in the National eHealth Exchange and the implementation of the SSA connection provided a valuable addition to Group Health’s interoperability tool set. A successful SSA query now results in the standards-based, automated transmission of an expanded continuity-of-care document. The automated query/response process and ability to more quickly obtain medical record information yields faster response times to claims and significant improvement in the patient experience. The process also benefits Group Health by minimizing manual processing by internal staff and reliance on a third-party release of information vendor to respond to SSA requests for medical evidence.

Group Health’s Chief Technical Officer Don Lewis is very pleased with this latest milestone. "Our HIE strategy has been focused on using the best possible information to provide quality care to our members at an affordable price. Connecting with the SSA is a win on both counts—we get more current information and we eliminate a resource-intensive manual process. This was a logical next step for us. "

Guthrie: Real Impact on our Workflows

As a rurally based health system working in two states, Guthrie is always looking for ways in which to better manage and share patient data across a widespread population to ensure our patients have the best outcomes, quickly. Still, the organization was very cautious about the safety and security of this data, and was therefore nervous about sharing it with external parties. Candice Tofts, Director of Medical Records at Guthrie describes how the system approached SSA: "In 2013, we heard about HealtheWay (now the Sequoia Project) enrolling organizations using our electronic health record, Epic, and we were interested in learning more about using this national standard. After investigating more into the Social Security work on DURSA, we were impressed by what we found. We felt that the federal government’s involvement paved the way for secure exchange of records."

Before embarking on the project, Guthrie wanted to ensure that the process was smooth, and did not have a negative impact on our patients. This involved a period of planning and testing to ensure the final product was secure and user friendly. "While we had exchanged records with other institutions who share the Epic product, the partnership with SSA was the first non-Epic entity partnership for Guthrie," explains Brian Shaffer, Guthrie’s Application Coordinator. "The staff at the SSA were knowledgeable and very supportive as we worked through a comprehensive work plan and testing. They have established a thorough audit process which we find very transparent and easy to access."

Since the project officially kicked off in 2014, through September 2015 Guthrie has shared over 3,500 records with SSA. SSA now can instantly access to the files that they need, thereby greatly reducing a lot of labor-intensive work which is required through a paper process. The faster process is also very beneficial for any of Guthrie’s patients who are seeking SSA support. Candice concludes" This project has made a real impact on our workflows, by reducing the need for a great deal of manual paperwork for the large majority of our SSA requests. We appreciate the efficiencies this gives our staff. Almost as important was the way in which SSA worked with our team to make this process smooth. They were very sensitive and responsive to our diligence about patient confidentiality, and the final product reflects this collaborative partnership."

Indiana Health Information Exchange/Regenstrief Institute: Generating Efficiencies in Healthcare

With its beginnings in health information technology in the early 1970s, the Regenstrief Institute has over 40 years of experience pioneering enhancements in this field. The Regenstrief Medical Record System, first developed during this decade, was one of the earliest electronic medical records (EMR) systems. Led by current president and chief executive officer William Tierney, M.D., Regenstrief's partnership in Social Security's health IT initiative aligned two organizations with concurring goals.

"Using health IT to streamline determination of disability helps Regenstrief fulfill its mission of improving the quality, safety, and efficiency of health care services," said Brian Dixon, Ph.D., Research Scientist at Regenstrief. "We are proud to partner with SSA on a project so closely aligned with Regenstrief's vision of a leaner, smarter health system. We immediately recognized the potential value."

Regenstrief was a part of the original architecture team that developed the first version of the Nationwide Health Information Network (NwHIN) Exchange, for which it received an award from the Office of the National Coordinator (ONC). "We saw this as a natural progression to use what we built under ONC, and put it into use," said Dixon. "It was rewarding to demonstrate that what we created is not just a theoretical architecture, but actually something that can apply to the healthcare system in a way that is replicable."

Because Regenstrief has a range of providers and networks participating in the Indiana Network for Patient Care, their health information exchange (HIE) created in 1993, the health IT team did not need to develop a lot of underlying infrastructure and was able to leverage existing HIE data. While the project had its share of technical and coding challenges, Regenstrief is excited to be a part of Social Security's health IT initiative. "As an educator and developer of health IT, we believe this project absolutely supports our core mission and business," said Dixon. "We can learn from it and share the lessons learned."

The Regenstrief Institute is confident that this partnership with SSA will support greater collaboration and future innovation in the field of health information technology. "Hopefully this partnership will allow us to work together with SSA in addressing other challenges and initiatives in healthcare," said Dixon. "The nice part of this process was that it created opportunity for collective learning and operation."

"Everybody wins," said Regenstrief CEO Dr. Tierney. "The process of collecting healthcare information is easier, less time-consuming, and less costly."

Inland Northwest Health Services (INHS): Taking a Long-Standing EHR Program to New Heights

Over fifteen years ago, Inland Northwest Health Services (INHS) based in Spokane, Washington, organized a community-driven effort to adopt electronic medical records. Doctors, hospitals, and community representatives united behind the project, which was intended to improve health care for a fairly unique population. "We serve an area between the Cascade mountains in the middle of Washington State through northern Idaho," said Nancye Lahue, Director of Meditech Department, Complimentary Systems and Government Project for IRM, the technology division of INHS. "There are a lot of rural hospitals. In an emergency situation, someone might present at the rural hospital and then be transferred to Spokane. With an electronic health record (EHR) exchange, patients' records are readily available to providers, regardless of where or when a patient arrives to their hospital facility." Even for non-emergency situations, patients needing advanced or continuing care often travel to Spokane, with a need to provide and coordinate their medical records from "back home." As time went on, the project grew, reaching out to more and more healthcare providers and integrating their EHR systems.

As a way to continue to grow and serve the providers and patients of the region, INHS partnered initially with a systems integrator and Social Security on a new project that would make electronic health records available for disability determination. "Given our history and expertise, there were no surprises on the technology side," Lahue continued, "We worked closely with Social Security and our systems integrator; the key to success was communication." The system went live in August of 2011.

"Our region's high EHR adoption rate has happened over time," says Lahue, reflecting on the exchange initiative's place in INHS history. "It's been a very rewarding journey." According to her, the best part is seeing the EHR process extended to the disability determination process. Records are collected, collated into a single document and sent off for disability determination without the delays and processing time of paper records. "Streamlining the [disability determination] process is a wonderful idea that is benefiting the public." That idea is now becoming reality.

Today, disability determination claims are being processed in a more timely manner allowing patients to get the services they need. Providers of care are seeing a reduction in administrative costs to help sustain their services. "Information being sent electronically reduces the amount of time from weeks and months to days," said Lahue. "This project is supporting quicker disability decision-making and benefiting so many people."

Kaiser Permanente: Helping to Elevate Care

"At Kaiser Permanente, we have a longstanding interest in health information exchange," said Seth Selkow, Director of HIE Engagement. "In 2009, we were involved in the initial pilot of the national initiative that demonstrated a successful electronic interoperability capability. Since then we have been increasing the capability of our platform and HIE team," Selkow continued. "The primary driver is to help elevate care for our members."

"Implementing HIE capabilities with Social Security to facilitate disability benefit decisions for Kaiser Permanente members is really the natural next step in the evolution to communicate and share medical information," said Selkow. "The first thing that emerged was the great partnership that we have with Social Security. The two teams work well together and Social Security was very responsive and provided excellent support throughout the implementation activities."

"The communication is a little different with Social Security exchange, which really exposes that the national standards are flexible and provides an insight into what is possible with these exchanges. A lot of progress has been accomplished in the industry and this partnership is a way to demonstrate that," Selkow continued. "We put these exchanges in place to benefit our members, so that when they show up their information is there, in a format that can be trusted."

"The benefits of this exchange are already realized within Kaiser Permanente. Because this helps alleviate manual processes, staff are able to focus on other initiatives that might benefit the patients as well," said Selkow. "The focus is on our members who are trying to get a benefit decision to collect Social Security at a difficult time in their life," Selkow continued. "We really want to ensure that our members receive the best care and service that they possibly can; the partnership with Social Security contributes significantly to this goal."

Marshfield Clinic: Saving Time, Helping Patients

When Marshfield Clinic in Wisconsin learned about Social Security's health IT program to support the disability determination process, the possibility of becoming a partner immediately appealed to them. Not only did Marshfield Clinic have years of experience with electronic records exchange, company leadership believed that expanding their electronic record exchange capabilities was a major step in improving efficiency and the patient experience. Sharing more and more electronic records with Social Security to support the disability determination process made a lot of sense.

"Standards are fluid right now," said Melissa Owens, Manager of Interoperability Development. "And the process is still pretty new. So we used a third party systems integrator to get started. This allowed us to get off the ground quickly, but also meant we could continue to focus on our core business of getting claims processed for patient care." In August 2011, the data exchange with SSA went live.

Marshfield Clinic faced a few challenges along the way. Steve Warren, the Clinic's Director of Health Information Management, pointed out that one major obstacle was reconciling the difference in state and federal law for medical information requirements. However, with the assistance of Social Security, this problem quickly resolved itself. "This initiative is growing," said Warren. "There's a real sense of commitment. That means that it's easier now to break down some of the old barriers and bring about change.

"The results have been impressive. Marshfield Clinic expected benefits from getting rid of the paper involved in the traditional disability determination medical records request process. What they didn't anticipate was the time savings that came from no longer having to scan and fax large amounts of data. Processing time to respond to Social Security's medical records requests dropped from 30 days to a few minutes. "That got people the help they needed much faster," said Annette Pyke, Marshfield Clinic's Manager for Release of Medical Information. Added Owens, "This really put us ahead of the industry. We're also in a great place to interface with the standards as they continue to grow and change."

And best of all? "This is one of the most low-maintenance processes we have," said Warren. "It just runs. We applaud the SSA for all they've done and continue to do—this is an ongoing relationship."

Martin Health: Major Benefit for Our Patients

Martin Health is an Epic facility and was in the process of rolling out our interoperability functionality. “The benefits of allowing SSA to electronically access records for benefit determinations definitely outweighed any concerns about the project. In addition, we talked to another facility that recently began working with SSA and they were very complimentary about the technical advantages, as well as the benefits to our patient population”, said Susan Moore, Clinical Applications Analyst.

“The process of getting set up to exchange records was not as labor intensive as first thought and went very smoothly,” continued Moore. We chose to become an interim partner with eHealth Exchange so we could start with SSA and that was a great advantage. Martin Health did become full eHealth Exchange members shortly after going live with SSA. “I loved the project plan that SSA developed and the great relationship between SSA and Epic”, said Moore.

This partnership with SSA is a major benefit to our patients, reducing the turnaround time for disability determinations. That flows back to us as well financially as patients that do qualify for disability benefits get them sooner, so bills can get paid faster.

MedVirginia: The Right Thing to Do is Right for Many Reasons

As the original pilot partner with the Social Security Administration to automate the exchange of electronic health information over the NwHIN into the disability determination process, MedVirginia recognized that the project was groundbreaking. "This complex project had some very aggressive deadlines," said Michael Matthews, CEO of MedVirginia and a recipient of the 2010 eHealth Advocate of the Year Award. "There was skepticism in the industry, as no one had seen this work done in an actual production environment." Nonetheless, MedVirginia committed itself to the project because it believed that electronic records exchange would make a dramatic difference to patient care. "We were passionate about improving health records for our patients," Matthews continued. "Not only was it the right thing to do, it was a way forward for the company." To make the project happen, MedVirginia went so far as to modify its business processes in order to incorporate health IT with Social Security.

The day-to-day challenges of implementing a large IT project soon were in evidence. A strong partnership from the beginning made things easier. "SSA was very driven and this was very encouraging," said Matthews. "Every time a barrier came up, they got everyone together to break through it, and Social Security's leadership gave this project its highest support and priority. I absolutely felt like every ounce of effort we were putting in was being matched by our partners. This was just an extraordinary project, very intense and rewarding."

"We weren't sure when we were going to see results," admitted Matthews. Yet, in just two and a half years, Matthews estimated the health IT partnership generated more than $6,000,000 in enhanced revenue for MedVirginia partner Bon Secours Richmond Health System, driven by improved insurance coverage that accompanied expedited disability determinations. Patients also realized quicker processing of their disability claims and got the coverage they needed faster than ever before. These effects are expected to grow as more providers join the MedVirginia network. "We are proud to be a leader in the health IT partnership with SSA," says Matthews. "We're eager to see this program continue to expand and develop."

MemorialCare: Significant Savings in Resources, Time, and Money

As early adopters of EHR, MemorialCare Health System’s leadership were intrigued for a long time by the potential for information exchange, envisioned by the Nationwide Health Information Exchange and the Direct Project. “Sympathetic to the aims of these initiatives, the information exchange objectives of the EHR Incentive Meaningful Use program gave us the specific motivation to move forward aggressively with the eHealth Exchange and the SSA Health IT Partner projects,” said Harris R. Stutman, MD, Executive Director Clinical Informatics. “As we respond more and more pro-actively to engage our patients and provide even easier access to secure health information, we expect our ability to do so to be markedly enhanced by projects like the SSA Health IT partner program. Further, the efficiencies of electronic transmission of information required for SSA disability and related determinations will allow us to do that at a significant savings in resources, time and money, ever more important in these times,” added Stutman.

“The process of getting setup was relatively simple,” said Ron Lyse, Manager, HIE & Integrated Systems Architecture. “Since we had already done the connection work with the eHealth Exchange, the actual set up was minimal. The majority of the work validating queries by SSA, and SSA validating the content of the messages we sent back was complete. It was a seamless process for everyone involved on our team. The SSA implementation team was highly knowledgeable, guiding us every step of the way, answering any questions or concerns we may have had. We felt confident in working with the SSA team from the very beginning of the project kick-off through to post implementation. We continue to touch base with them on a quarterly basis and obtain helpful reports that assist us with any trouble shooting.”

Sometime after implementation, we were able to look at the data and see our success rate. “Due to the money saved in decreased labor to collect medical records for adjudication and the money received from the SSA for the electronic transmission, the implementation costs were more than covered in the first six months of operation,” said Lyse. The implementation also highlighted some opportunities to further enhance patient intake workflows that ensure that quality-focused patient data is captured in our EHR.

“The project implementation process was a seamless and positive experience,” said Victoria O’Leary, Senior Business Systems Specialist. “I was impressed by SSA’s post-implementation support, providing us with feedback and statistics on how well we are processing and successfully transmitting claims and queries.”

LCF Research: Leading Health Information Exchange in New Mexico

As one of the original Nationwide Health Information Network (NwHIN) Trial Implementations contract awardees, New Mexico Health Information Collaborative (NMHIC) helped to develop the NwHIN standards, services, and policies. Created by LCF Research, a non-profit entity, NMHIC is the health information exchange (HIE) for the state of New Mexico. Upon discovering that Social Security was looking for health IT partners, NMHIC seized the opportunity. "We saw this opportunity as a natural progression of leveraging our Trial Implementations work to enable us to move into a production NwHIN environment," said Mark Butler, IT Project Manager at LCF Research.

Once awarded the contract, NMHIC verified the Continuity of Care Documents (CCD), making sure that the content and structure conformed to standards. There was also a parallel path of on-boarding to the NwHIN, which included interoperability testing. NMHIC overcame initial CCD content and NwHIN messaging issues and was enthusiastic about the collaborative success. "It was very gratifying when we finally met the major milestones of the contract," said Butler. "A lot of hard work went into developing the technology to exchange health information over the NwHIN, so when we completed a major milestone, everyone shared a great sense of accomplishment."

NMHIC and Social Security's Health IT team shared a positive experience collaborating with one another. "It was great to work with the SSA health IT staff," said Butler. "There were many people that helped us along the way and were very interested in helping us succeed."

From an HIE perspective, NMHIC believes that this partnership with Social Security will be an advantage to New Mexico patients and involved stakeholders. "Expanding the opportunity for our stakeholders to participate in electronically exchanging information in the disability determination process will be beneficial to both patients and healthcare providers," said Butler. "Healthcare providers may be able to reduce the amount of uncompensated care they provide since disability applicants may obtain quicker access to public health benefits."

Oregon Community Health Information Network (OCHIN): Bringing Disability Determination to an At-Risk Community

The Oregon Community Health Information Network (OCHIN) has long focused on providing electronic record support to health care providers, with a special emphasis on "safety net," rural, tribal, and small practices. After more than a decade, they have the infrastructure, the skills, and the capabilities for advanced electronic records exchanges. As a result, OCHIN was eager to partner with Social Security to work on a NwHIN pilot project to provide medical evidence electronically for disability determination; especially given the at-risk and vulnerable populations that OCHIN providers often serve.

"Some of our members were very concerned about the conversion from a paper based process to an electronic process," said Mike Matull, OCHIN's Data Integration and Interface Team Manager. "They were concerned about the release of information process and the shift from long standing paper processes. SSA did a really good job of outlining the project goals, and helping with our outreach and education. Once we actually started to exchange records with the new system, the membership very quickly demanded that the electronic process replace the paper process as quickly as possible."

The system to exchange electronic health records with Social Security went live in May of 2011. "The real advantage is that our population is getting help faster, and that's crucial for a lot of them," Matull said. "We see this eventually expanding to across OCHIN's entire membership. While I can't get into specific numbers, I can tell you that this project is the clearest case of a positive return on investment (ROI) of any IT project I've been involved in."

Sentara Healthcare: Better Care for Patients

Since becoming interoperable with the eHealth Exchange (eHEX) and SSA in November 2014, Sentara Healthcare, which uses the Epic EMR software from Epic Systems, has had nothing but positive results. For every patient record Sentara sends to SSA electronically, it can help to reduce disability claims processing time. The manual process for SSA would often take weeks or months for a caseworker to make a determination since they were waiting on medical records to be copied and mailed back. It was exciting to hear about a caseworker at the Disability Determination Services in Richmond, VA who was waiting for medical records through SSA’s traditional process, or “snail mail”. Sentara became interoperable that morning, SSA received medical records via health IT, and the case was decided that day.

Sentara Healthcare’s journey with interoperability and eHEX proved to be longer than expected, challenging, with a number of unforeseen bumps in the road, mostly because Sentara was the first Epic EMR healthcare system to utilize a new eHEX process. Despite these obstacles, we were able to resolve issues and constraints leading to a successful implementation. Prior to being approved on the eHEX, Sentara Healthcare started to explore partnering with SSA to provide better care for patients with disability claims. When someone applies for disability benefits, a caseworker must get a complete health record in order to make an accurate determination. Healthcare organizations can take weeks or months to access patient records, make copies and mail the package. In contrast, accessing clinical data using the eHEX can take only minutes. “In this scenario, everyone wins”, said Tom Wilson, Director, IT, Enterprise Clinical Application Technical Services, Systems Integration, & Interoperability. SSA wins because they receive accurate information faster. Hospitals win because there is less uncompensated care, and no costs associated with making copies, postage and labor. “If our patients get their disability benefits quicker, then it is less likely they will walk into our Emergency Department uninsured. Most importantly, the patients win because they get the help they need sooner than with the manual process”, said Wilson.

Sentara found onboarding with SSA significantly easier than onboarding with the eHEX and the Department of Veterans Affairs, partially because we were already a participant with the eHEX, but also because SSA had already done most of the work. At our kickoff meeting the SSA project manager explained that they had successfully onboarded a number of Epic organizations, so there was efficient reproducibility with the structure; another example of the ease of interoperability with the Epic EMR. Just as expected, the process was organized and smooth. Once approved to go into probationary testing, SSA analyzed the clinical data retrieved from Sentara to ensure it met the C-32 standards. “Two weeks later, we went into production, and right away, we saw the benefits”, Wilson said.

Not only were there no costs to Sentara Healthcare to onboard or participate with SSA, but this was an opportunity to recoup some of the investment costs into the eHEX. A uniform national rate for reimbursement to non-Federal medical providers for their costs in supplying medical records through health IT was set at $15 per transaction. This is a substantial monetary gain considering there about 1,000 records retrieved each month. There will still be scenarios in which SSA must request records manually, for example, if there are multiple records for a patient query or if there is a patient match, but there is no electronic medical record.

Sentara’s match rate has been 85%; “we attribute this success to our Identity Management team who manage and cleans up potential duplicates each day in our Enterprise Master Patient Index,” said Wilson.

Marion Swaim, Sentara’s VP of Health Information and Finance Administration is thrilled with the success of this partnership stating, “The interaction with SSA is seamless, and very efficient. Most importantly it expedites disability processing for our patients, supports our customer service goals, while improving our days in accounts receivable.”

SSM Health: Great Outcome for Our Patients and Staff

At SSM Health we strive to help people by making their medical information easier to review and share. We connected with HealtheWay (The Sequoia Project) in 2014 and we began exchanging records with SSA in early 2015. The set-up and connection testing with SSA was surprisingly easy. Within two months of going live, we had exchanged over 2,500 patient records for disability determination with SSA. It’s been a true ‘win-win’ for everyone. Patient claims are processed more quickly due to the immediate availability, standardized format of the information SSA receives from us, and our team at SSM no longer has to manage paper records.

“This has been a great experience and it really proves the value of electronic information exchange,” said Dr. Richard Vaughn, Chief Medical Information Officer. “This process was simple to implement and has a great outcome for our patients and staff. I’d recommend that every health care organization put connecting with the SSA on the top their HIE project list.”