Commonwealth of Kentucky

Commonwealth of Kentucky Sets Out to Create a Statewide e-Health System

Many patients' medical records are stored by multiple healthcare providers in different locations, which means that doctors frequently lack access to current, complete information. With the help of Microsoft® technology, the many health-related government agencies in the Commonwealth of Kentucky are creating a statewide e-Health network that will provide caregivers secure access to more complete medical information and reduce healthcare costs and administrative inefficiencies.

Situation

Patients’ medical information frequently exists in many medical records kept by multiple caregivers in different systems and locations—and is often unavailable at the point of care. When doctors have no access to critical patient information, such as allergies, current treatments or medications, and prior diagnoses, this can lead to medical errors, administrative inefficiencies, and soaring medical costs.

The Commonwealth of Kentucky believes that there is a better way. A leader in healthcare technology innovation, it supports the concept of e-Health, which is the use of information technology (IT) to improve the delivery of healthcare. Its focus on e-Health comes from Governor Ernie Fletcher, who is a physician and a legislator. Fletcher’s background helps him understand the challenges that both public and private healthcare systems face in managing increasing patient loads, complex reporting requirements, and stringent privacy provisions with obsolete processes and technologies.

My administration is focused on improving the quality and lowering the cost of healthcare in Kentucky. One of the most important steps … is establishing a statewide e-Health network. Ernie Fletcher Governor, Commonwealth of Kentucky

“My administration is focused on improving the quality and lowering the cost of healthcare in Kentucky. One of the most important steps in accomplishing these goals is establishing a statewide e-Health network,” says Governor Fletcher. He believed that such a network could provide faster and more accurate information-sharing to reduce mistakes, inefficiencies, and administrative costs, but he faced many challenges in implementing it. Not only were there dozens of state agencies and stakeholders who would have to coordinate their efforts, but also the state’s healthcare information infrastructure had several common problems:

• Systems, information bases, and program funding were siloed in various agencies and organizations in different formats—there was no central information repository that all authorized personnel could access.
• Healthcare objectives were based on quality patient outcomes, while payments were based on procedures and volume.
• It was made up of complex systems with multiple, uncoordinated data collection requirements, and there was no way to transfer information easily among them.

One of the agencies involved in creating an e-Health network was the Kentucky Cabinet for Health and Family Services (CHFS). CHFS manages a multitude of health information for the Commonwealth, such as patient data related to Medicaid, Public Health (including data stored in state labs, local health departments, and so on), Mental Health (including data from state-run facilities), and Vital Statistics (including birth and death records). 

CHFS realized that in order to improve healthcare services, it needed to be able to share information inside—and outside—its organization if it was to support centralized access to patients’ medical information. After all, the Commonwealth’s 4.2 million citizens could choose from 128 health departments/clinics and 2,000 private physician practices. CHFS envisioned a radical new two-part solution as its contribution to the e-Health network. One part of the solution would be called Medicaid Management Information System (MMIS), and it would require:

• A cabinetwide architecture based on shared IT services, with a standardized approach to data exchange, including data formats and vocabulary.
• Adequate security to safeguard patient confidentiality.
• A common user interface for all health information access (including Medicaid), designed to accommodate the way users and healthcare organizations actually work.
• A patient-centric health record framework, known as the master patient index, that would begin at birth and could be continuously updated as health events occurred.
• Ability for authorized healthcare professionals to share health data among themselves, with patient permission.
• A system life-cycle approach to technology development that would emphasize long-term partnerships with key technology vendors.

The other part of the solution would be called Kentucky e-Health Interchange System (KHIS). To provide a complete solution that encompassed all healthcare information stored across the various systems and agencies, KHIS support the exchange of the data in MMIS both inside and outside CHFS, and would connect MMIS to the statewide e-Health network. Lorna S. Jones, CIO, Cabinet for Health and Family Services, says, “As Kentucky’s statewide e-Health network is developed, it is important that health-related data from state government–sponsored programs be included. This is necessary to assure that health data collected for individuals who have been provided care by the cabinet’s programs are utilized to provide complete health records for individuals. The cabinet must build their portion of the system components in order to participate in a comprehensive, statewide e-Health network.”

Solution

Making the e-Health network a reality was a huge task with many participants. For four years, a group of Kentucky leaders worked to pass legislation to support such a network. In March 2005, this bill,

As Kentucky’s statewide e-health network is developed, it is important that health-related data from state government-sponsored programs be included. Lorna S. Jones CIO, Cabinet for Health and Family Services

known as Senate Bill 2 (SB2), passed. SB2 created the Kentucky e-Health Network Board, to which Governor Fletcher appointed members to oversee the development and implementation of the e-Health network.   

Meanwhile, in response to passage of SB2, CHFS developed a request for proposal (RFP) for Medicaid Modernization to begin building MMIS. In reviewing potential technologies, CHFS chose Microsoft® products to support its solution, 

CHFS and the Kentucky e-Health Network Board Work Together as KHIP to Create a Portal

In 2007, the Kentucky e-Health Network Board approved the Kentucky e-Health Action Plan, a long-term strategy for establishing the statewide e-Health network. (See http://www.ehealth.ky.gov/ for a copy of The Kentucky e-Health Action Plan.) As part of this plan, CHFS and the board together formed the Kentucky Health Information Partnership (KHIP). KHIP developed an Internet portal that would include MMIS, KHIS, and many other stakeholder agencies across the state. The portal had two main parts:

• A clinical site that could deliver electronic patient health summaries (including lab results and X-rays, plus information about patients’ medications and recent hospitalizations) to authorized healthcare providers.
• An administrative site for conducting standard transactions across all health plans, such as claims submissions verifications of eligibility and/or benefits.

CHFS was awarded U.S.$4.9 million from the Centers for Medicare and Medicaid Services through a Medicaid Transformation Grant to begin creating the e-Health portal.

The Master Patient Index Will Be Part of the Portal

KHIP began work on the master patient index, which it wanted to be accessible by both public and private healthcare providers, regardless of what IT system they used or where they were located. The data for the master patient index would come from multiple health information systems and would be used to create a unified view of a patient's entire medical history.

In the same way that technology and Web-based communication have transformed every other sector of our economy, instant access to information … [will] do the same thing for health and healthcare. Ernie Fletcher Governor, Commonwealth of Kentucky

Compiling a master patient index from records stored in myriad legacy health information systems throughout the Commonwealth was a huge task. CHFS officials concluded that a logical starting point would be to initiate patients’ master records at birth, and track patients through their entire medical life cycles. 

To create the master patient index, KHIP would have to:

• Create a common interface to all critical systems, simplifying the user experience and increasing the utilization of Web-based information systems and transactions.
• Facilitate connectivity among all the different data points and information silos across the state. 
• Employ an authentication and authorization model to provide role-based access to information and applications on the portal.

KY-CHILD, A Web-Based Application, Will Capture and Compile Data for the Master Patient Index

Building a common patient record for newborns, while a logical approach, was not without challenges. The most significant challenge was the fact that most healthcare organizations have their own information systems and, hence, their own master patient records. In addition to reconciling multiple master records, there had to be agreement among the agencies involved as to:

• How the master records would be created.
• Who would own them.
• Who would be allowed to use them.

KHIP decided that because it was already required for state agencies to record and manage certain health-related information such as vital statistics, newborn metabolic screening tests and hearing tests, immunizations, and so on, that it should use the state’s records to build the master patient index from. Thus it set out to create the KY-CHILD (KY Certificate of birth, Hearing, Immunization and Lab Data) application.

Figure 1. Kentucky Health Interchange System (KHIS)

Says Jones, “KY-CHILD is a Web-based application that automates the collection of data pertaining to the birth of a newborn. KY-CHILD is an important first step in the state’s plan to facilitate electronic health records and a master record that begins at birth and tracks the health information of that individual through life with an ongoing set of data.” KY-CHILD will also provide the initial data feed for a statewide Immunization Registry.

Staff from the Kentucky CHFS Office of Information Technology (OIT) developed KY-CHILD. OIT developers knew that widespread acceptance of the application depended on their understanding of the birthing hospital workflow processes in order to develop IT solutions to automate them so that KY-CHILD could accommodate additional data collection without negatively affecting the end users’ workflows. Thus, OIT visited the state’s birthing facilities to document their information management practices. OIT also conducted a workflow analysis for each center and built the application model around it.

OIT designed KY-CHILD to accommodate a common client indexing solution. KY-CHILD is an N-tiered, Web-based application built on the Microsoft .NET Framework, an integral component of the Windows Server® 2003 operating system. OIT used Microsoft .NET development tools to create a user interface that would facilitate ease of use, have minimal training requirements, and work well with all healthcare systems in the state.

The application was developed in C# using Microsoft SQL Server™ 2005 as the database. In addition, OIT used Microsoft BizTalk® Server as the middleware to run its integration hub, internally referred to as K-TALK. K-TALK is designed to transmit data across the various health and human service systems. K-TALK mediates and manages information flow among disparate legacy systems and end users. SQL Server Reporting Services is used for Web-based reporting and printing of all necessary forms and certificates by system users. The solution capitalizes on the technology infrastructure and reference architecture outlined in the Microsoft Connected Health Framework, which places the citizen at the center of focus for government services (http://www.microsoft.com/hhs).

A role-based access policy based on the Active Directory® directory service, part of the Windows® and Windows Server operating systems, provides secure access to KY-CHILD. Active Directory can be used to grant role-based access to resources based on a user’s credentials.

Benefits

Currently in use in all Kentucky birthing centers, KY-CHILD is an important first step in the state’s plan to facilitate comprehensive statewide electronic public health records. KY-CHILD is designed to be used by Kentucky birthing facilities to register all new births and parents, and to assign unique identifiers to them. The data will then be used by several different program areas including the State Laboratory Systems, Children with Special Health Care Needs, Vital Statistics, and the Electronic Public Health Record System.  Eventually, information in KY-CHILD will be synchronized using a unique record identifier to cross-reference client records across multiple data systems—creating a comprehensive client view by integration of multiple ID records.

The long-term vision for Kentucky’s e-Health network is one in which anyone who lives in Kentucky, or who uses the Kentucky healthcare system, can benefit from the state’s e-Health model. 

When the statewide e-Health network is fully implemented, authorized clinicians and staff will have instantaneous access to critical medical information through an e-Health portal. As of spring 2007, a federated authentication and access infrastructure is being established that Medicaid patients can use to get access to information online and that providers can use to submit and review claims. 

The plan is for the Kentucky e-Health network to someday support or encourage the following types of electronic transactions or activities:

• Automatic drug-drug interaction and allergy alerts
• Automatic preventive medicine alerts
• Electronic access to the results of laboratory, X-ray, or other diagnostic examinations
• Disease surveillance and reporting
• Educational offerings for healthcare providers
• Health alert system and other applications related to homeland security
• Links to drug formularies and cost information
• Links to evidence-based medical practices
• Links to patient educational materials
• Medical record information transfer to other providers with the patient's consent
• Physician order entry
• Prescription-drug tracking
• Registries for vital statistics, cancer, immunizations, and other public health issues
• Secured electronic consultations between providers and patients
• A single-source insurance credentialing system for healthcare providers
• Health Insurance Portability and Accountability Act (HIPAA) of 1996 transactions, including claims submission, payments, coordination of benefits, and plan enrollment

“Today we stand on the cusp of a new wave of innovation and change that will fundamentally reshape the health sector of our economy, as well as how we think about health and wellness,” says Governor Fletcher. “In the same way that technology and Web-based communication have transformed every other sector of our economy, instant access to information when we need it is going to do the same thing for health and healthcare.”
 
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For more information about Commonwealth of Kentucky products and services, visit the Web site at:
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