Whereas participants in the Centers for Medicare & Medicaid Services (CMS) Electronic Health Record (EHR) Incentive Programs will face the challenge of population health in future phases of meaningful use, Indian Health Services (IHS) has always known population health as the core of the agency’s mission. “The fact that meaningful use came along with many clinical quality measures was not a new thing for us,” notes Howard Hays, MD, MSPH, who serves as the acting CIO for the IHS Office of Information Technology.
The division of the Department of Health and Human Services (HHS) has looked to health information technology (IT) solutions to provide quality medical care to members of federally-recognized American Indian and Alaskan Native tribes in 45 hospitals and more than 600 ambulatory facilities nationwide. As early as 1984, IHS introduced its Resource and Patient Management System (RPMS), a derivation of Veterans Affairs VistaA system. As Hays notes, “the two have pretty much grown up together over the past almost 30 years and evolved in their separate environments to adapt to the requirements of those settings.”
Between 2004 and 2005, IHS began rolling out its latest extension of RPMS, its EHR. Like its patient management system, the EHR is based on a VA system, specifically its Computerized Patient Record System (CPRS). Not only is the IHS EHR running in more three hundred facilities across the country, it’s also doing so in a meaningful way. “RPMS is the only government sponsored EHR that is certified for meaningful use at this point in time. The Indian Health Service, Tribal and Urban Health programs bill CMS and so are eligible for the CMS meaningful use incentives,” Hays explains.
And its use isn’t limited to the tribes. “RPMS is in use in non-Indian country settings as well. For example, the Community Health Network of West Virginia is running RPMS in 45 clinics in West Virginia, mostly the FQHC types. There’s also been implementation of RPMS in Hawaii, and Guam, and points west out there as well,” adds Hays.
Exchanging health information
Just as state and federal organizations are developing systems for health information exchange (HIE), so too is the IHS. Last week, General Dynamics announced its role as an HIE contractor for the agency as part of a five-year, $20.6 million award to enable information exchange among IHS facilities and between these facilities in the emerging Nationwide Health Information Network (NwHIN or NHIN) through its open source platform, Health Information Exchange Open Source (HIEOS).
The challenge of exchanging information among IHS facilities isn’t so straightforward, being that it’s compounded the fact that each tribe installs the RPMS system as a standalone system while some have opted to use commercial EHR systems rather than the RPMS. In sense, the IHS experience is a microcosm of the national conversation about what needs to happen in order that different systems can connect to a central network:
Each installation of RPMS at a federal or tribal site is a system unto itself, as are the commercial EHR that some tribal programs use. We do not attempt to link them together. However, the various programs do submit data on the services they provide and on health status indicators so that the agency as a whole can meet its reporting requirement to Congress on our mission. These data are received by our National Data Warehouse, which provides the specifications for data submission. If a tribe has a commercial solution, they will work with their vendor to provide the necessary data extracts for our national reporting purposes.
Because of the local nature of the RPMS installs — a vast majority are client-server systems to deal with bandwidth needs — the capacity to exchange patient information has lagged behind other health IT advancements.
Model management of the patient population?
For IHS, HIE is crucial to meeting the needs of unique patient population. While Hays hesitates to classify the agency’s tribespeople as distinct from the rest of the American population, the former’s needs do bring to light the flexibility required of EHR, HIE, and health IT systems to accommodate them:
There are definite disparities in health status among Indian patients, as there are with many other safety net communities. That said, it is not a homogeneous population; there are 566* federally recognized tribes across the country, and they each have both cultural and geographic characteristics that can influence access to care and the types of services that are needed.
Editor’s note: The original posted indicated the number of federally-recognized tribes as 565.
Furthermore, that IHS shares patients with other agencies such as the VA and that its patients generally move from ambulatory care to community hospitals, the mobility of health information would more effectively coordinate a patient’s care no matter the point-of-care. “Having the ability to electronically share information with those community hospitals through the exchange will be beneficial as well,” says Hays.
Although meaningful use measures for population health are many years away for most eligible professionals and hospitals, the success of IHS is already and will continue to be measured by its ability to provide meaningful healthcare to its patients. The disparate patient population and the need to be interoperable make the efforts of IHS a valuable experiment for decision-makers and health IT innovators to observe and learn from.
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