Health Information Exchange Case Study

Redwood MedNet

January 30, 2014

Katherine K. Kim

Danielle Gordon

San Francisco State University, Health Equity Institute

Lori Hack, Object Health, LLC

Prepared for California Health eQuality

University of California Davis

Institute for Population Health Improvement

http://www.ucdmc.ucdavis.edu/iphi/programs/cheq/

Copyright © 2013 The California Health and Human Services Agency (CHHS). All rights reserved.

This publication/product was made possible by Award Number 90HT0029 from Office of the National

Coordinator for Health Information Technology (ONC), U.S. Department of Health and Human Services.

Its contents are solely the responsibility of the authors and do not necessarily represent the official views

of ONC or the State of California

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Contents

Introduction ............................................................................................................................................ 2

Methods.................................................................................................................................................. 2

Description of Redwood MedNet ............................................................................................................ 2

Redwood MedNet’s Project Goals and Plans............................................................................................ 3

Results .................................................................................................................................................... 5

Participants ......................................................................................................................................... 5

Technology .......................................................................................................................................... 6

Transaction Volume ............................................................................................................................. 7

HIE Expansion Grant ............................................................................................................................ 8

Subproject 1 ERx2G Second Generation Electronic Prescribing......................................................... 9

Subproject 2 Enable Electronic Laboratory Orders and Results Delivery ........................................... 9

Subproject 3. Care Transition Messaging Project ............................................................................ 10

Subproject 4 Immunization Reporting ............................................................................................ 10

Subproject 5. DiSTRIBuTE ............................................................................................................... 10

Subproject 6. ADT (Added Later) .................................................................................................... 10

HIE Infrastructure Grant .................................................................................................................... 11

Subproject 1: Lab Results “Laboratory Onboarding” ....................................................................... 11

Subproject 2: Transition of Care Document “Care Transition Messaging” ...................................... 11

Interface Implementation Grant ........................................................................................................ 11

Lessons Learned .................................................................................................................................... 13

Small Organization Managing Large Projects ...................................................................................... 13

Sustainability ..................................................................................................................................... 13

Lack of Guidance on Consent for Exchange ........................................................................................ 14

EHR and other Priorities .................................................................................................................... 14

Conclusion ............................................................................................................................................. 15

About the Partners ................................................................................................................................ 16

Appendix A: Table of Deliverables in Quarter 6 Expansion Grant Progress Report ................................. 17

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Introduction

California Health eQuality (CHeQ), a program of the Institute for Population Health Improvement at UC Davis, engaged San Francisco State University’s Health Equity Institute to develop a case study on one of its HIE Acceleration awardees, the Redwood MedNet (RWMN). This report summarizes RWMN’s grant goals, the progress made towards those goals, and lessons learned along the way. We hope that this information will be of assistance to other organizations who are seeking to launch or sustain their HIE efforts.

Methods

This case study was conducted by San Francisco State University through a grant from CHeQ. Three team members reviewed documentation provided by CHeQ including grant proposals, progress reports, and presentations. CHeQ also made introductions to the grantee’s staff. The SFSU team conducted in-person interviews with the director and one staff member, as well as a community stakeholder who is both a user of the HIE and a member of the Board of Directors. Interviews were audiotaped and transcribed for analysis. The research was conducted from June to December 2013. The protocol was approved by San Francisco State University Institutional Review Board prior to conducting research.

Description of Redwood MedNet

Redwood MedNet (RWMN) was established as a non-profit organization in 2005 in Ukiah, CA. It is led by a nine member Board of Directors of community health care stakeholders. RWMN aims to enhance the quality of health care for all residents of Mendocino, Lake and Sonoma Counties, facilitate the individual and collective practice of medicine, encourage adoption of Electronic Health Records, interconnect all participants in the local health care community and collaborate with regional, State and Federal health information technology initiatives. They are also currently providing HIE services to some health care delivery organizations in Napa, Marin, Colusa and Humboldt counties.

In 2005 RWMN established its first HIE offering, a clinical messaging service for delivery of laboratory test results. In 2008, RWMN began delivery of electronic clinical data by pushing outpatient laboratory test results from a rural Critical Access Hospital (CAH) into a chronic disease registry at a Federally Qualified Health Center (FQHC).

Since then the HIE delivery service has grown. To support its technical solutions, the Board has established policies and procedures for secure data sharing, and has been a leader in implementation strategies for the Country. Through their partnership with Mendocino Informatics, a consulting firm, RWMN has achieved national recognition for its innovation in secure health data delivery to clinical practices.

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RWMN is the recipient of three grants totaling $755,580 from California Health eQuality (one

originating from its predecessor funding agency, Cal eConnect) in order to expand their existing HIE

capabilities:

• HIE Expansion Grant in 2011 for $476,900

• HIE Infrastructure Grant in 2012 for $90,000

• HIE Interface Implementation Grant in 2012 for $188,680 RWMN hoped to utilize the funds to build the necessary infrastructure and create a solid foundation from which they would be able to become self-sustaining though subscriptions. They also participated as a designated service provider in CHeQ’s Rural HIE Incentive Program.

Redwood MedNet’s Project Goals and Plans

In 2011 RWMN received HIE Expansion Grant funds, the first of 3 awards received from CHeQ. The overarching goal of this project called Meaningful Use Expansion 1(“MUX-1”) was to assist rural Northern California providers in achieving the Meaningful Use requirements for Stage 1 and Stage 2. This project proposed to build 73 interfaces for 21 community providers. Their five HIE service expansion subprojects were:

1. Second Generation e-Prescribing (eRx 2G) -- Expand RWMN’s e-Prescribing project to five safety net clinics, and improve medication reconciliation at local acute care facilities.

2. Electronic Labs -- Enable hospital laboratories to receive electronic orders from or deliver electronic test results into certified EHRs at outpatient practices in Humboldt, Mendocino, Sonoma, Marin, Solano, Yuba and Sutter Counties; enable public health laboratories to receive electronic orders and post electronic test results to local hospitals.

3. Care Transition Messaging -- Enable eligible providers building patient centered medical home (PCMH) services to receive care summaries for their patients from local hospitals; enable eligible providers with certified EHRs to push patient care summaries to an electronic patient controlled health record (PCHR); enable providers to use Direct Project secure SMTP messaging for electronic care summary handoff between unaffiliated healthcare Facilities.

4. Immunization Reporting -- Enable eligible providers with certified EHRs to submit immunization reports to the California Immunization Registry (CAIR).

5. DiSTRIBuTE -- Enable hospitals to publish daily syndromic surveillance signals on behalf of their local public health agency to the ISDS DiSTRIBuTE portal (operated under a contract with the CDC).

Table 1 below shows the 21 proposed project participants and the type of data exchange proposed.

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Table 1. Project Participant and Proposed Interfaces for the HIE Expansion Grant, 2011

Participant eRx Labs Msg IZ Synd

Alexander Valley Regional Medical Center X X

Alliance Medical Center X X

Anderson Valley Health Center X X

Andy Coren, MD X

Digestive Health Consultants X X

Healdsburg District Hospital X

Healdsburg Primary Care X X

Jerold Phelps Community Hospital X X

Long Valley Health Center X X

Mendocino Coast Clinics X X X

Mendocino Coast District Hospital X X

Mendocino Family Care X

North Coast Family Health Center X X X

Palm Drive Hospital X

Rideout Memorial Hospital X X

Robert Rushton, MD X X

Santa Rosa Memorial Hospital X X

Solano County Public Health X

Sonoma County Public Health X

Sonoma Valley Community Health Center X X

Sonoma Valley Hospital X

LEGEND: eRx= electronic prescribing; Labs= receipt of electronic lab results; Msg= receipt of clinical summaries; IZ= push immunization records to the California Immunization Registry; Synd= push surveillance data to the California Department of Public Health.

RWMN received a second grant for HIE Infrastructure Expansion (“MUX-2”). The original goal of this funding opportunity was to focus on two priorities defined by the Office of the National Coordinator (ONC):

1. Enable electronic laboratory-test results delivery from two hospitals and one outpatient laboratory operated by the Sutter Health West Bay Region through RWMN to five unaffiliated health care outpatient practices with certified EHRs, representing approximately 300 EPs in Marin, Sonoma and Lake Counties.

2. Enable bi-directional exchange of care summaries (supporting patient discharges, referrals, and health home) between St Joseph Health Sonoma (SJH-S) and safety net primary care providers in Sonoma County to facilitate transitions of care (ToC).

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Finally, RWMN received a third Interface Implementation Grant to develop 23 interface deliverables at 16 covered entities participating in the HIE services provisioned by Redwood MedNet (“MUX-3”).

Results

Participants

RWMN has expanded its operations in rural communities to serve additional providers and offer new product lines. In total, 30 provider organizations were involved in testing or production use of the RWMN HIE in the scope of these three grant funded projects. The participants involved were:

• Andy Coren, MD

• Alexander Valley Healthcare

• Alliance Medical Center

• Anderson Valley Health Center

• Andy Coren, MD

• Digestive Health Consultants

• Healdsburg District Hospital

• Healdsburg Primary Care

• J. Nevin Smith, MD

• Jerold Phelps Community Hospital

• Kent Matsuda, MD

• Long Valley Health Center

• Lucerne Community Clinic

• Mendocino Coast Clinics

• Mendocino Coast District Hospital

• Mendocino Family Care

• North Coast Family Health Center

• North Valley Family Physicians

• Palm Drive Hospital

• Prima Medical Group

• Redwood Coast Medical Services

• Rideout Memorial Hospital

• Robert Rushton, MD

• Santa Rosa Imaging

• Santa Rosa Memorial Hospital

• Sonoma Family Community Health Center

• Sonoma Family Practice

• Sonoma Valley Community Health Center

• Sonoma Valley Hospital

• South Health Clinics of Santa Clara

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RWMN acknowledges that their work and deliverables has often shifted during the course of these grant cycles; as priorities shift for their clients. Due to the number of participants, departments impacted by the interfaces within the provider facilities, the work under these grants has been quite challenging.

Technology

RWMN’s current technology supports point-to-point bi-directional data sharing among providers in the community. See Figures 1 and 2. Each provider has its own interface engine stored at its own site that allows the provider to securely transmit or receive data from external providers in the network. RWMN uses open source technology from Mirth that meets federal and state standards.

Figure 1. Point to Point Architecture

(http://www.redwoodmednet.org/news/present/20100722_rmn_oscon.pdf)

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Figure 2. Data Flow Schematic

Transaction Volume

RWMN reports 28,000 clinical messages delivered during October 2013, up from 12,900 in October 2012. These include final lab results and immunization reports send to CAIR. Figure 3 below shows the tremendous growth in transaction volume since 2009.

Figure 3. Transaction Volume of lab results and immunization reports

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Detailed results from each of the subprojects within the three grants follows.

HIE Expansion Grant

RWMN worked to integrate their established participants into new services and acquire new participants through the additional offerings. Many of the stated goals of the grant were to provide for the technical capability of providers to exchange data and test that capability. There is no clear, comprehensive record of the total data exchange produced through these awards. RWMN was successful in implementation and testing of interfaces for the exchange of data and has increased substantially the volume of lab results and immunization messages. More challenging, for a variety of reasons, was the ongoing participation of partners and their continued use of technology. There were numerous shifts in the use cases and deliverables identified in the original grant proposals. A general summary of the status of the subprojects is in Table 2.

Table 2. HIE Expansion Grant Subprojects Summary Findings

Subproject Name Modification (date and reason) Final Disposition

1. eRx 2G Expand the electronic prescribing and medical reconciliation capabilities

Abandoned due to insufficient need

2. Electronic Labs Enable hospital labs to receive electronic orders and deliver test results, includes Public Health Hospitals

Public Health Hospitals did not participate but 5 hospitals and over 200 providers were reported with more than 33k transactions

3. Care Transition Messaging

Eligible Providers receive care summaries and send to patient health care record (PHR)

Enable DIRECT messaging between unaffiliated providers

This project was substituted with the implementation of HIE Gateways to facilitate the ability of providers to share data within the HIE.

Radiology reporting was added to this project.

4. Iz Reporting Enable submission of immunization date to CAIR using a flat file.

This project was completed for two providers

5. DiSTRIBuTE Enable hospitals to send syndromic surveillance data to CDC portal

This project was not completed and substituted for the HIE Gateway.

6.ADT This project was added after approval of the original grant and reported as a deliverable of patient demographic data delivery from one hospital to RWMN.

Mendocino Coast District Hospital successfully completed ADT delivery as a predecessor for CCD delivery.

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Of 30 deliverables recorded in the most recent progress report available (Quarter 6 of grant period, dated November 30, 2012) for the HIE Expansion Grant two were completed, 16 were cancelled, and 12 were changed. 15 new deliverables were listed as replacing the cancelled or changed deliverables. Since there was no progress report listing the final disposition of these replacement deliverables, it is unknown whether they were accomplished. See Appendix A for table of deliverables.

Subproject 1 ERx2G Second Generation Electronic Prescribing

The eRx 2G project proposed to expand the electronic prescribing and medical reconciliation capabilities between providers as defined as a core and menu set requirement for CMS Meaningful Use Incentive program.1 This proposal was made as a result of discussions with the regional stakeholders and their desire to achieve meaningful use in 2011 and 2012. Because the Meaningful Use program was not clearly defined at the time of the discussions, this project was to ensure the ability to meet the MU requirements without consideration of the capabilities of the certified Electronic Health records subscribed to by the stakeholders. During 2011, as each clinic adopted an EHR, they migrated away from the eRx service hosted by RWMN. The project provided a learning experience for how the HL7 data elements work in eRx, but there was no business reason for an HIE service to be offering eRx to eligible providers who were adopting certified EHR technology. With regard to medication reconciliation the pure quantity of real-time longitudinal data necessary for an HIE service to be relevant to a MedRec enquiry exceeds electronic medication history data streams that are currently available. It was subsequently determined that there is no current business case to support the cost of acquiring and maintaining real time eRx data streams. No further action was required on this interface.

Subproject 2 Enable Electronic Laboratory Orders and Results Delivery

The Electronic Labs project was designed to enable hospital laboratories to receive electronic orders from or deliver electronic test results into certified EHRs at outpatient practices in Humboldt, Mendocino, Sonoma, Marin, Solano, Yuba and Sutter Counties; enable public health laboratories to receive electronic orders and post electronic test results to local hospitals. The development of HL7 interfaces between the laboratories and provider EHRs to allow for the receipt of results as structured data began with stakeholders already working with RWMN. Among current EHR or CDMS vendors, RWMN sees two business models for interoperability: simplex interfaces, in which the EHR or LIS vendor requires the facility to purchase a separate interface license for each data source (e.g., eClinicalWorks, Meditech); and multiplex interfaces, in which the vendor allows multiple clinical data streams to share a single interface. By full implementation of the project, RWMN will operate at least 4 dozen interfaces to certified EHRs.

Documentation of laboratory ordering and delivery results was not available. From interviews, we gathered that testing had occurred but production exchange was not yet occurring. The intended participants for lab data exchange were: St. Joseph Health Sonoma, Meritage Medical Network, Sonoma Valley Hospital, Prima Medical Group, PSC Urology Services, Marin Sonoma IPA (67 providers).

1 RWMN Proposal MU Expansion Part 1, January 31, 2011, pg.1

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Subproject 3. Care Transition Messaging Project

The proposed project included the transmission of clinical care summary records between providers and to the personal health records of patients affiliated with those providers. This process was demonstrated as a capability at various conferences and workshops such as HIMSS in 2012, however there were no providers in the community willing/able to test the workflow of delivery through direct clinical messages. Subsequently, the stakeholders were offered a DIRECT messaging service solution for transition of care messaging and personal health record updates. However, data from DIRECT were not integrated into EHRs. Despite offering free DIRECT mailboxes to multiple partners, no providers availed themselves of this product.

Subproject 4 Immunization Reporting

In 2011, RWMN proposed to enable the submission of Immunization reporting data to the California Immunization Registry (CAIR) through the transformation of electronic data submitted from an ONC Certified EHR into a flat file to CAIR. This format was the only viable format in 2011. In the quarterly reports, RWMN reports successful completion of this project with data currently being transmitted to CAIR for Dr. Andrew Coren and Alliance Medical Center’s primary care provider sites. It is the second most used source of data flow behind lab results for RWMN. However, because this is a requirement of Meaningful Use, the use of the CAIR interface may grow. RWMN developed a specification for a Direct-enabled gateway to bridge the gap between these two incompatible formats in an automated fashion. As of 2013 CAIR is now able to accept real-time HL7 messages but cannot provide data back to submitting providers, obviating the need for the file transformation utility RWMN had created. RWMN has worked to develop HL7 interface capabilities for providers in their region as part of the HIE Expansion Grant. No additional providers are reported as having completed this process with RWMN at this time.

Subproject 5. DiSTRIBuTE

This project proposed to enable the reporting of syndromic surveillance data for the local public health agencies to the CDC sponsored portal. During the course of the project , RWMN reported on discussions and preparations. For example, in the Quarter 7 (early 2013) progress report discussions were held with Sonoma County Public Health. Submission of electronic syndromic surveillance structure data to Biosense II requires a data use agreement signed by the Health Officer for the local public health jurisdiction that is submitting the data to the CDC. RWMN offered to create the signals and submit them to Biosense II for no charge to the local agencies. RWMN proposed this with two local public health jurisdictions of Mendocino County and Sonoma County. However, each county declined to initiate a syndromic surveillance service from RWMN.

Subproject 6. ADT (Added Later)

This project was added based on an additional request from participants. The project was substituted for the Care messaging project. RWMN reported that the ADT feed is in production for Mendocino Coast Hospital.

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HIE Infrastructure Grant

This proposed project would provide funding necessary to expand the current RWMN capabilities to allow for additional providers in the region to send electronic laboratory results and other clinical data among key stakeholders.

Subproject 1: Lab Results “Laboratory Onboarding”

The goal was to enable meaningful use eligible providers (EP) to receive structured laboratory test results in their certified EHRs. Electronic laboratory test results were delivered from two hospitals and one outpatient laboratory operated by the Sutter Health West Bay Region--Sutter Santa Rosa Medical Center, Sutter Lakeside Hospital, and Sutter Shared Laboratory--to five unaffiliated health care outpatient practices with certified EHRs in Marin, Sonoma, and Lake Counties. Sutter backed out of the project. There was no documentation of the reasons for this.

Subproject 2: Transition of Care Document “Care Transition Messaging”

This project was to enable EPs to facilitate transitions of care (ToC) by sending discharge care summaries via RWMN bi-directionally between St Joseph Health Sonoma (SJH-S) and safety net primary care providers in Sonoma County. At the time of this grant, RWMN had existing private contracts with the hospitals which he’d intended to leverage to fulfill the match requirement for this grant. In the time lapse between submitting the proposal to Cal eConnect, and the execution of contract, the business case for the 2 projects changed, and in the end neither one was built.

Interface Implementation Grant

The interface grant proposed to implement 23 of interfaces across 14 community practices. The intention of this grant was to significantly add to the existing exchange capacity, and to support local practices to adopt HIE. The specific interfaces proposed for each exchange partner are listed in the table 3 below.

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Table 3. Exchange Data Type by Practice

Provider ORU Receive labs

CCD ADT VXU IZ

MDM Receive Rad

MFN Provider directory

1. Andy Coren, MD X X

2. Alliance Medical Center X X X X X

3. Alexander Valley Healthcare X X

4. Anderson Valley Health Center X X

5. Healdsburg Hospital X X(send)

6. Healdsburg Primary Care X

7. J. Nevin Smith, MD X

8. Kent Matsuda, MD X

9. Lucerne Community Clinic X

10. Mendocino Coast Clinic X X

11. Mendocino Family Care X

12. North Valley Family Physicians X

13. Prima Medical Group X X

14. Redwood Coast Medical Services X X

15. Santa Rosa Imaging X(send)

16. Sonoma Family Practice X

17. Sonoma Family Community Health Center

X X

18. South Health Clinics of Santa Clara X X

19. Sonoma Valley Hospital X X(send)

Legend: X= interface proposed for indicated practice. ORU= HL7 message type for “Order Result”; CCD= Continuity of Care Document; ADT= HL7 message type for “Admissions, Discharge and Transfers”; VXU= HL7 message type for “Unsolicited Vaccine Report”; MDM= HL7 message type for “Medical Data Report” (eg transcription); MFN= HL7 message type for “Master File Update”.

GREEN: COMPLETE, BROWN: IN PROGRESS

Every participating site was able to send or receive laboratory results using the interfaces built under this Grant. In some cases, funds were expended from prior grants in order to facilitate a complete solution for the providers noted in the table above. In addition, three of the sites noted are also transmitting immunization data with the CAIR registry (Dr. Coren, Alliance Medical Center, and School Health Clinics of Santa Clara County).

There has been difficulty progressing from testing to production for radiology reports. In some cases the manner in which the EHR is able to render the written reports makes it less useful when received electronically instead of on paper. For this reason, several providers were unwilling to move from test to production.

Some sites are testing CCD exchange and the Provider Directory (MFN) with none in production.

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Lessons Learned

Small Organization Managing Large Projects

RWMN is an organization with less than five staff, yet the projects proposed in these grants alone involved the building of over 70 interfaces and implementation with over 30 provider organizations.

“I’m constantly juggling to abandon a project that’s two-thirds done and

change to something else. Because the sponsor is gone, the business case is

gone; it doesn’t make any business sense anymore; they decided to adopt a

different EHR... So I’m surfing that issue constantly and trying to envision a Redwood Met Net service that doesn’t fall prey to going out of business like a

lot of HIE’s have done because they had this business model that was entirely

dependent upon one thing happening.”

While remaining flexible to meet the needs of clients is laudable, the wear on staff is difficult and organizational stress is the result. Solutions to this challenge are elusive.

“… we try to do every single thing that he says he can do at whatever expense

that it takes because he hates disappointing them all and he wants to get

everybody you know.”

Sustainability

RWMN does receive some fee payments but relies primarily on grants to cover salaries, capital investments, development, and operating expenses. Following grant cycles means staff are consumed with writing proposals, fulfilling overlapping grant accounting and reporting requirements, and then managing the cash flow until funds are received. While they achieved some of their goals in terms of building out interfaces, they haven’t progressed toward sustainability.

“ What Redwood Med Net wanted out of the ARRA funding cycle was to not get

swamped and bankrupted because of chasing something that we could find the grant money to install, but there would be no recurring revenue to operate.

We wanted to focus on the nuts and bolts of interoperability that affected our

participants at the workflow level. We wanted to help our participants to understand the implications of their software procurement decisions. At the

end of the ARRA investment we wanted to be standing with more interfaces to

more people running more data types and so we’ve accomplished all of that.”

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Lack of Guidance on Consent for Exchange

There remains a challenge to HIE in that guidance on how to handle consent and authorization for

data sharing is lacking. This causes a burden for patients and a challenge to HIOs who are looking

for solutions to promote the flow of data.

“I was sitting in the waiting room the other day with my son and this lady

came into the doctor’s office and she says, “I need to send my records to you

know several doctors.” She gave her four sheets of paper, she sat down and she filled in 4 different releases of information. When she finished she went back up

and got one more and says, “Oh I forgot another doctor I had to send it to.” So

she must have spent 45 minutes to an hour filling out the releases of information. There hasn’t been a lot of guidance I don’t think from the State as

far as electronic you know consent you know and how to do it easily it’s a real

big barrier.”

EHR and other Priorities

Though not unique to RWMN, they faced the difficulty that adopting EHRs poses to a medical practice. Because of the rapid timeframe for HIE deployment required by ARRA funding opportunities, EHR deployment was often occurring simultaneously with HIE testing and implementation. As a result, providers may not have been ready to take advantage of HIE. For example, one practice was unsuccessful in adopting their EHR, eventually abandoning the system, which then impacted RWMN’s ability to accomplish the HIE goals:

“…we were simply involved in one aspect of it (the EHR implementation), we were there to turn on the interface for lab results. And we were the straw that

broke the camel’s back, because that turned out to be the workflow

inconvenience that they were unwilling to accept. But that wasn’t the only problem with that EHR; it was that those three providers were done with their

first attempt at electronic health records.”

In addition, many providers have multiple conflicting priorities that interfere with the ability to implement HIE.

“The things that give me nightmares as far as sustainability is as far as

sustainability of this clinic number one is the ICD-10 that’s coming in next year. Training providers. To see if they’ll be able to deal with that and the insurance

companies’ capacity to be able to deal with that. And the changing role of

reimbursement you know Patient Centered Medical Home. I mean there’s got

to be a shift somewhere in there that is going to be able to compensate providers and the clinics for all this extra work in reporting that they’ve

having to do but at the same time getting reimbursed at the same you know

fee for service you know thing. So that’s going to have to come.”

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Conclusion

RWMN is a seasoned HIO. They are active in promoting HIE in their region, and have pursued many opportunities for funding which have facilitated development of needed infrastructure.

While the goals were laudable, the complexity of the proposed technical projects fell prey to common technology problems. Taking more than 8 months to develop stakeholder interest, negotiate, fund and launch the project then obtain the software and ready the test environment was a significant issue. By the time the software is ready for testing and implementation, the stakeholder has lost interest, lost their job or lost this project priority.

The ability to sustain technology projects from proposal through implementation and to achievement of value requires leadership vision, champions within the organizations involved, excellent ongoing project management and communication skills, and the ability to demonstrate interim progress to keep stakeholders involved.

While RWMN attempts to be ‘”agile and responsive” to the needs of the rural, safety-net community, they were challenged by delivery of promised outcomes for a variety of reasons. The required events for successful launch of health information exchange include establishing a shared priority and resources among a variety of stakeholders ranging from clinicians, financial staff, IT staff, administrative leadership and sub contractors and vendors. These stakeholders must agree and adhere to complex and lengthy timeline crossing departments, budget cycles and staff changes. As a small, under-resourced organization, they may not have vetted the projects adequately with partners, accurately budgeted the resources necessary to accomplish the goals, or had the full complement of skills needed within the team.

The RWMN case study shows that HIE is not for the faint of heart. It takes passion and dedication from the team to stick with these efforts in the face of many challenges. While many of the goals were not accomplished, RWMN did implement a number of interfaces and have also grown substantially their clinical transaction volumes, indicating that HIE has been expanded in the rural communities they serve.

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About the Partners

About California Health eQuality (CHeQ)

California Health eQuality (CHeQ) is a program of the UC Davis Institute for Population Health Improvement that administers statewide health information exchange (HIE) projects for California. Funded by the California Health and Human Services Agency, under the auspices of the Office of the National Coordinator for Health IT State HIE Cooperative Agreement, CHeQ is promoting coordinated and integrated care through health information exchange. Programs including a trusted exchange environment, improved public health capacity for electronic reporting, HIE acceleration funding opportunities, and the monitoring of HIE adoption lay a foundation for improved quality of care for all Californians. Please visit CHeQ at http://www.ucdmc.ucdavis.edu/iphi/programs/cheq/.

About Institute for Population Health Improvement (IPHI) The UC Davis Institute for Population Health Improvement (IPHI) is working to align the many determinants of health to promote and sustain the well-being of both individuals and their communities. Established in 2011, the institute is leading an array of initiatives, from improving health-care quality and health information exchange to advancing surveillance and prevention programs for heart disease and cancer. About Health Equity Institute at San Francisco State University The Health Equity Institute at San Francisco State University (SFSU) seeks to foster innovation and community engagement towards a vision of a truly healthy society. The mission of the Health Equity Institute (HEI) is to create an intellectual environment that encourages diversity of perspectives, challenges conventional approaches, and produces innovative action-oriented research in the biomedical and behavioral sciences in order to improve health, eliminate health disparities, and establish equity in health. SFSU is a public university affiliated with the California State University system. Located in San Francisco, it offers 118 different Bachelor's degrees, 94 Master's degrees, and 5 Doctoral degrees.

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Appendix A: Table of Deliverables in Quarter 6 Expansion Grant

Progress Report

Grant

Quarter Deliverable

Due

Date

Date

Completed

(mo/yr)

Disposition

6Q Install HIE gateway at 3 (three) RWMN participants 12/1/16

1 § Southern Humboldt Community Healthcare District

OSWPlug @ SHCHD Dec-16 COMPLETED

2 § Solano County Public Health M-1000 @ SOLANO CHANGED

6Q Push lab orders from 2 (two) RWMN participants 12/1/16

3 § Healdsburg Primary Care --> Healdsburg District Hospital CHANGED

4 § Mendocino Coast Clinics --> Quest Diagnostics CANCELLED

6Q Push lab results to 7 (seven) RWMN participants 12/1/16

5 § St. Joseph's Hospital --> Anderson Valley Health Center CANCELLED

6 § SHWBR --> Lucerne Community Clinic CANCELLED

7 § Palm Drive Hospital --> Santa Rosa Endocrinology Dec-16 COMPLETED

6Q Push radiology reports to 1 (one) RWMN participant 12/1/16

8 § Healdsburg District Hospital -->Healdsburg Primary Care CANCELLED

6Q Push medication history from 1 (one) RWMN

participant 12/1/16

9 § Alliance Medical Center --> RWMN CANCELLED

6Q Push visit summaries from 2 (two) RWMN participants 12/1/16

10 § Mendocino Coast District Hospital --> Mendocino Coast

Clinic CHANGED

11 § Santa Rosa Memorial Hospital SJH-S > AMC CANCELLED

6Q Push IZ reports to CAIR from 1 (one) RWMN

participant 12/1/16

12 § Mendocino Coast Clinics --> California Immunization

Registry CHANGED

7Q Install HIE gateway at 3 (three) RWMN participants 12/1/16

13 § Sonoma County Public Health V-1000 @ SONOMA CHANGED

7Q Push lab orders from 1 (one) RWMN participant 3/1/17

14 § Mendocino Coast Clinics --> SDRL CANCELLED

7Q Push lab results to 7 (seven) RWMN participants 3/1/17

15 § PINC --> Andy Coren, MD CANCELLED

16 § Mendocino Family Care CANCELLED

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17 § Healdsburg District Hospital -->Richard Andolsen, MD CHANGED

18 § SJH-S --> Northern California Medical Associates CHANGED

19 § SJH-S > Marin Sonoma IPA (remane MMN) CHANGED

20 § SJH-S > Prima Medical Group CHANGED

21 § SJH-S --> Pacific Specialty Care CHANGED

7Q Push radiology narrative to 1 one) RWMN participant 3/1/17

22 § Healdsburg District Hospital -->Alliance Medical Center CHANGED

7Q Push visit summaries from 3 (three) RWMN participants

3/1/17

23 § Long Valley Health Center --> PDI CANCELLED

24 § Southern Humboldt Community Healthcare District to

where? CANCELLED

25 § Robert Rushton, MD to where? CANCELLED

7Q Push ELR messages to CalREDIE from 3 (three) RWMN

participants 3/1/17

26 § Healdsburg District Hosptial CANCELLED

27 § Mendocino Coast District Hospital CANCELLED

28 § Sonoma Valley Hospital CANCELLED

7Q Push syndromic surveillance from 2 (two) RWMN participants

3/1/17

29 § Healdsburg District Hosptial CHANGED

30 § Mendocino Coast District Hospital CANCELLED

7Q Replacement deliverables for cancelled tasks 3/1/17

R1 § Install HIE Gateway M-1000 @ SOLANO CHANGED

R2 § Install HIE Gateway OSWPlug @ AVH ADDED

R3 § Install HIE Gateway OSWPlug @ MFC ADDED

R4 § Install HIE Gateway SFTP @ RWMN ADDED

R5 § Install HIE Gateway OSWPlug @ PATHS ADDED

R6 § Install HIE Gateway OSWPlug @ RRMD ADDED

R7 § Push Lab Orders Healdsburg Primary Care-->

Healdsburg District Hospital CHANGED

R8 § Push Rad Report Healdsburg District Hospital --> Alliance Medical Center

CHANGED

R9 § Push Rad Report SRI --> Alliance Medical Center ADDED

R10 § Push Visit Summaries Mendocino Coast District Hospital -

-> Mendocino Coast Clinic CHANGED

R11 § Push IZ Reports to CAIR Mendocino Coast Clinic >

California Immunization Registry CHANGED

19 | P a g e

R12 § Push Syndromic Surveillance Healdsburg District

Hospital CHANGED

R13 § Push ADT Messages RAMD > RWMN ADDED

R14 § Push ADT Messages Healdsburg District Hospital-->

RWMN ADDED

R15 § Push ADT Messages Mendocino Coast District Hospital--> RWMN

ADDED

7Q FINAL PROJECT REPORT 5/1/17