The Arizona Medical Information Exchange (AMIE) is a Web-based health information exchange that allows participating practitioners to view hospital discharge and other clinical reports, lab test results, and medication data for many of their patients. AMIE was developed by Arizona's Medicaid agency (the Arizona Health Care Cost Containment System, or AHCCS), went live in September 2008, and is slowly growing in capabilities and utilization. Focused primarily on the Phoenix region, AMIE is the only operational HIE in the state, and will play a key role as it works to build interoperability with other developing exchanges in the region.
Arizona recently submitted a proposal for federal stimulus funds (under the State Health Information Exchange Cooperative Agreement Program) to support a cooperative effort among AMIE, another HIE developing in the southern region in the state, and several smaller HIE efforts under way. The goal is to make these HIEs interoperable, essentially building a statewide system in which the whole will be greater than the sum of its parts. A new state HIT coordinator will oversee this collaborative effort.
AMIE's Development and Evolution
The short-term objective of AMIE is to make patient health information readily available to health care providers at the point of service when care is provided. The long-term goal, according to Tony Rodgers, director of AHCCCS, is to "transform the health care delivery system."
Though Arizona's Medicaid agency developed AMIE and other payers are not yet participating, the information accessible through the HIE is not limited to the Medicaid population or Medicaid data. In fact, AMIE is now moving out of the Medicaid agency and will be operated by a private, nonprofit entity governed by the data partners (major hospitals, health systems, lab systems, and others).
As of early October 2009, AMIE contains about 6.5 million records for more than 2.5 million individuals (about 40 percent of the state's total population). The information is not collected and maintained at a central repository, but rather remains at its source and can be viewed via AMIE's Web-based application. It offers access to information from AMIE's "data partners": hospital discharge summaries and other documents from seven major hospitals and health systems; laboratory test results from one of two major lab systems in the state (the second lab is coming on board); and medication histories supplied by a subcontractor (Managed Care Pharmacy Consultants) that aggregates pharmacy claims data received from the AHCCCS-contracted health plans and from the state-funded behavioral health providers serving a large portion of low-income residents in the state (Figure 3). Planners hope that the addition of the latter source in early 2009 will lead to fewer interactions between drugs prescribed for behavioral health reasons and those prescribed for physical health care.
Figure 3. Types of Records Accessible Through AMIE |
Cardiac Study/Reports |
Consultations |
Discharge Summaries |
Emergency Reports |
Medical Histories and Physicals |
Lab Reports |
Medication Histories |
Operative Reports |
Procedure Notes |
Study Reports |
Source: Arizona Medical Information Exchange, http://www.azamie.gov/about/Default.aspx, accessed 10/1/09.
About 150 medical practice personnel, representing about 400 physicians, are currently using AMIE. Participating practices must sign a contract stating that they will access the information only for treatment purposes and will not share it with employers or insurance companies. This helps ensure privacy and means that patients do not need to sign additional consent forms. AMIE is rolling out a centralized mechanism that allows patients to opt out of sharing information on AMIE, but the default is for information to be included (this and other privacy and consumer control issues remain a source of debate in many other states.)
A 2007 federal Medicaid Transformation Grant provided $11.7 million for HIE development and implementation through the end of 2009. AHCCCS created an internal development and business operations team that built and now operates AMIE, without outside vendors or service contractors. A staff of about 15 members train and support users, perform audits, maintain and develop the software and systems, and develop policy. According to Perry Yastrov, project director, about half the costs have involved addressing legal and policy issues, and the remainder covered background analysis, focus groups, technology development, and maintenance.
An evaluation by the University of Arizona of the initial three-month testing phase (October–December 2008) found that most of the users believed that AMIE improved efficiency (saved time, made the medication reconciliation process more efficient), safety (reduced medication errors and interactions), and health care quality (based on immediate access to complete and reliable medical histories); users also thought it reduced costs and duplication of health care services. Administrators would like to do a quantitative study to assess the system's effectiveness, costs, and other outcomes when AMIE reaches a larger user base.
Challenges, Lessons, and Next Steps
AMIE's experience suggests that an HIE should not be limited to the Medicaid population, and should include as much patient information as possible. Physicians using AMIE report that they and their staffs are more likely to use the tool if they can do so for all of their patients, not just a subset. In response, AMIE is not restricted to Medicaid data or patients, and AHCCCS is transferring AMIE to a new, nonprofit entity governed by AMIE's data partners. AHCCCS will have a seat on the Board of Directors; other roles for the state have not yet been defined.
Despite significant growth of accessible data, utilization of AMIE is still quite limited. Only about 30 to 40 patient records are being viewed each day, and AHCCCS is "eager to bring AMIE to a larger scale," according to Yastrov. Only with widespread adoption will the system's potential benefits in terms of patient safety, quality, and efficiency be realized. But it has been challenging to educate stakeholders—physicians, hospitals, insurers, and consumers—and bring them on board. AHCCCS has not done any formal marketing, other than approaching partners for sharing data. But Yastrov says that they are being approached more as providers learn about AMIE from those who are already participating. Further, the ARRA incentives for hospitals and physicians to achieve "meaningful use" of technology that includes interoperability with other entities has encouraged hospitals and physicians to work with AMIE. And he expects more aggressive promotion efforts once AMIE is run by the nonprofit organization.
The key lesson to other states is to "create a coalition of hospital and insurance executives early in the process, educate them, address their fears about data management and 'big brother,' and get their commitment to make the HIE happen," according to Yastrov. "The technical issues are relatively easy."
Another serious challenge is financial. Under major budget pressures related to the current recession, many of Arizona's public programs are being cut, and AMIE officials can no longer expect the state to help fund AMIE's operations when Medicaid grant funding runs out at the end of the year. The federal stimulus funds are expected to help sustain AMIE temporarily.
Yastrov stresses, however, that while federal grants are extremely important, they are not a long-term solution. Perhaps the greatest challenge for AMIE—and for other states developing HIEs during difficult fiscal times—is to create a sustainable business model. This involves identifying revenue sources to cover development, operations, upgrades, and expansions, to address legal and policy issues, conduct audits, and other work. For example, AMIE authorities are examining options for charging providers user fees, such as subscription rates, or per-use fees. But first they must convince those providers of the HIE's value—how it could enhance efficiencies at their practice and improve patient care.
Another plan is to partner with facilities that own and operate EHRs, to be able to convert AMIE from a Web-based "viewing" application to an interoperable system in which physicians, clinics, hospitals, and other providers can more easily communicate and integrate information. To facilitate this movement, AHCCCS has established a Purchasing and Assistance Collaborative for Electronic Health Records. An Early Adoption program offers medical practices discounts to EHR software, hardware, and a subscription for interfaces with other systems as well as training, maintenance, and support services.
Meanwhile, Arizona is continuing to educate stakeholders, partner with organizations, and add patient information to AMIE, including data from a government-funded children's rehabilitation program, a major children's hospital, and a second laboratory company that includes about half of the medical laboratories in the state. It would like to bring private insurers on board as well. Support from private payers—providing claims data, encouraging participation from contracted providers, and paying some operating costs—would likely help any HIE be successful, and private payers would benefit from efficiencies achieved through HIEs as well.
Lessons drawn from AMIE's accomplishments and challenges will inform the emerging cooperative effort to build HIE interoperability statewide.
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