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Health Information Exchange in California:
Assessment of Regional Market Activity
AUGUST 2021
AUTHORS
Mark Elson, Jill Yegian, Alex Horowitz, and Sokkim LimContents
About the Authors 3 Introduction
Mark Elson, PhD, is principal, Alex Horowitz
4 Key Findings
is principal technology strategist, and Sokkim
Lim, PharmD, is senior clinical consultant 8 Los Angeles County
at Intrepid Ascent, a consulting firm that
Overview
guides clients through the adoption and use
Hospitals and Health Systems
of technology to improve health outcomes.
Jill Yegian, PhD, is principal at Yegian Health Ambulatory Care
Insights, and provides consulting services Regional HIOs
aimed at improving the health care system on Whole-Person Data Exchange Networks
behalf of patients, providers, and payers.
14 Fresno Region
Acknowledgments Overview
The authors thank the interviewees, review- Hospitals and Health Systems
ers, and other contributors who shared their Ambulatory Care
time and expertise related to data exchange
Regional HIOs
in California at the statewide and regional
levels. They also wish to acknowledge the Whole-Person Data Exchange Networks
dedication and creativity of their colleagues 18 Sacramento Region
in the field, who show up to work every day
Overview
behind the scenes so that providers and their
partners have the information they need to Hospitals and Health Systems
make a positive impact in peoples’ lives. Ambulatory Care
Regional HIOs
About the Foundation Whole-Person Data Exchange Networks
The California Health Care Foundation is
dedicated to advancing meaningful, measur- 21 Humboldt County
able improvements in the way the health care Overview
delivery system provides care to the people of Hospitals and Health Systems
California, particularly those with low incomes
Ambulatory Care
and those whose needs are not well served
Regional HIOs
by the status quo. We work to ensure that
people have access to the care they need, Whole-Person Data Exchange Networks
when they need it, at a price they can afford.
25 Conclusion
CHCF informs policymakers and industry 26 Endnotes
leaders, invests in ideas and innovations,
and connects with changemakers to create
a more responsive, patient-centered health
care system.
DESIGN BY DANA KAY HERRICKIntroduction
A resurgence of demand for health information $ Specialized clinical data exchange networks
exchange (HIE) is underway in California. The COVID- enable the exchange of specific slices of high-value
19 pandemic has exposed fissures in our health data data among customers. Clinical event notifications
infrastructure, with dangerous gaps between public of an individual’s hospital admission, discharge,
health and clinical care systems. Increasing focus on or transfer (ADT) are one type of specific informa-
health equity has highlighted the lack of data available tion that can be used to support care coordination
to support behavioral health and whole-person care, for patients with complex health needs. Provider
including addressing social needs. And sustained organizations can send these notifications through
momentum toward value-based payment continues private companies (e.g., Collective Medical), HIO
to focus both commercial and government payers’ services (e.g., Manifest MedEx), and secure mes-
attention on the need for data exchange as a founda- sage platforms (e.g., DirectTrust).
tional requirement for integrated systems of care.
$ Whole-person data exchange networks combine
Shared understanding of the current data exchange social and behavioral health data sharing to coor-
landscape in California can inform key decisions shap- dinate services across sectors. These networks
ing this landscape. include those established by California’s Whole
Person Care (WPC) Pilot Program, a $3 billion pro-
A California Health Care Foundation (CHCF) com- gram that supported 25 counties to integrate care
panion issue brief, Health Information Exchange for patients with complex health needs, and emerg-
in California: Overview of Network Types and ing efforts across the state to systematize referrals
Characteristics,1 describes data exchange activity between clinical and social service providers via
coalescing in four primary types of networks: technology platforms, such as Aunt Bertha, One
Degree, and Unite Us.
$ EHR-centered clinical data exchange networks
connect health care providers to each other and This report builds on that companion issue brief to
to their partners through electronic health records describe how these different forms of HIE play out
(EHRs). Enterprise health information organizations regionally. Given California’s enormous size and diver-
(enterprise HIOs), EHR vendor networks (e.g., Epic sity, variation in data-sharing activity at the regional
Care Everywhere), and national networks (e.g., level is to be expected. Such variation has significant
eHealth Exchange, Carequality, CommonWell) implications for California’s long-term approach to
enable information sharing within a hospital system, enhancing data exchange across the state over time.
across hospitals using the same EHR, and increas- To explore the dynamic interaction and regional varia-
ingly across users of different EHR and IT platforms. tion across these four HIE types, the authors surveyed
publicly available information and conducted 20
$ HIO-centered clinical data exchange networks interviews with statewide and regional leaders. Four
connect health care providers regardless of the regions were selected for this issue brief: Los Angeles
EHR system used and typically aggregate data at County, Fresno and environs, the Sacramento met-
the community level. Two examples of California ropolitan area, and Humboldt County. The regions
HIOs are Manifest MedEx and the Los Angeles represent a range of characteristics, such as urban
Network for Enhanced Services (LANES). and rural; they also align with the regions included
in CHCF’s Health Care Almanac Regional Markets
Study, which provides extensive data on local popula-
tions and market characteristics.2
Health Information Exchange in California: Assessment of Regional Market Activity www.chcf.org 3Collectively, these regional profiles paint a rich por- patients. Safety-net and ambulatory providers are
trait of the activity, progress to date, and barriers poorly positioned to grapple with overcoming data
encountered in efforts to share clinical or other data and workflow obstacles due to limited resources and
in California communities. The focus here is on local health IT expertise.
actors: provider networks and their use of EHRs and
specialized networks, as well as community-driven
data-sharing initiatives, such as HIOs and WPC pilots.
While more comprehensive and detailed than other
2 Local investment, collaboration, and trust
are important to overcoming technical, legal,
and resource barriers that often stand in the way
currently available analyses, the regional profiles are of data sharing, cross-sector exchange, and central-
based on a limited number of interviews and should ized data storage.
be viewed as a starting place for a broader and deeper
understanding of data exchange dynamics across the Without technical standardization, clear governance
state. structures, and explicit legal guidance — like those
developed over time to support the national net-
works — data sharing relies on agreements that are
developed locally. Without those agreements, efforts
Key Findings can be stymied. In Sacramento, implementation of
The regional profiles generated for this report indicate a data-sharing agreement for Pathways to Health +
significant and growing investment in data exchange Home (the WPC pilot run by the city of Sacramento)
infrastructure across settings in California, with sub- met with resistance, especially among the large hos-
stantial variation in which network types predominate pital systems; local CBOs, unfamiliar with handling
and how they interact based on local market dynam- protected health information, received robust train-
ics and characteristics. Overall, the assessments found ing on data privacy and security to address concerns.
the following: Similarly, the centralized data architecture that most
HIOs use to store data and enable population health
1 Though each form of HIE is complementary,
the sheer number of overlapping networks
creates a steep learning curve for providers trying
analytics may raise security concerns for some poten-
tial participants, as reported in Los Angeles County
with LANES. Thus, local anchor health organizations,
to access these systems to meet their needs, and such as county health departments and managed
the requirement to participate in multiple networks Medicaid plans, play a particularly important role
increases the administrative and IT burdens related organizing exchange networks and gaining participa-
to implementation. tion from ambulatory providers. North Coast Health
Improvement and Information Network (NCHIIN)
The University of California, Davis, for example, must benefits from support from Humboldt County and
join multiple networks to connect with local provid- Partnership HealthPlan of California (PHC)’s pay-for-
ers: Epic for local hospitals that are fellow Epic users, performance initiatives. LANES continues to grow
eHealth Exchange for government agencies like the with support from Los Angeles County Department of
Veterans Administration and the local HIO (SacValley Health Services (LACDHS) and L.A. Care, where affili-
MedShare), and Carequality and CommonWell for ated providers find value in being able to connect to
providers not using Epic. Similarly, community leaders LACDHS’s specialty and inpatient care.
like the Community Clinic Association of Los Angeles
County (CCALAC) encourage their member clinics
to join multiple forms of HIE (e.g., national networks,
LANES, and Collective Medical) to best serve their
California Health Care Foundation www.chcf.org 43 EHR-centered exchange is the predominant
means of HIE in three out of four regions —
Los Angeles, Fresno, and Sacramento — driven by
access to the national networks directly into their
products at no additional cost, such that bidirectional
data exchange can be enabled with the “flip of a
the need to access external clinical records at the switch.” Many HIOs have begun to join them as well,
point of care. and the California Trusted Exchange Network (CTEN),
California’s local HIO data governance framework,
Health care providers use their EHRs to access exter- functions as a gateway to the national networks for
nal data through vendor and national networks. Epic some of its members. HIOs joining the national net-
operates the leading example of an EHR vendor net- works represent a potential breakthrough for data
work, while it and most other major EHR vendors and sharing in California. An HIO’s full patient records
health systems participate in national networks for become available to providers within the workflow
broader data sharing. Widespread participation gen- of their EHRs. This development brings together the
erates positive “network effects” that drive others to strengths of the national networks (i.e., embedded
join and discourages the use of HIOs in regions where within EHRs, standards-based, information available
EHR networks predominate, like in Sacramento. at the point of care) with the strengths of the HIOs
(e.g., high-quality data consolidated from multiple
EHR networks have limitations. In addition to broad sources with local buy-in).
gaps in behavioral health and social needs data,
the quality of clinical data sets can be unpredictable
because of variation in how those data are configured
at their source. Just as importantly, the volume of data
4 HIOs are uniquely positioned to aggregate
data for population health and may serve as
the primary enabler of clinical data exchange when
delivered via the national networks overwhelms many no one large hospital system or EHR dominates the
providers, with significant effort required to pinpoint local market, such as in Humboldt County.
actionable information. Some health systems have
invested in translating this flood of data into relevant The value of an HIO depends upon the complete-
information to support clinicians at the point of care. ness of the data they provide, which, in turn, relies on
In general, the larger and better-resourced health sys- the level of participation by providers and others in
tems are more likely to make these investments. the HIO network. Where participation is robust, HIOs
can consolidate data across organizations, improve
Others, especially ambulatory and safety-net providers data quality, and facilitate data exchange supporting
with limited resources and health IT expertise, grapple multiple use cases. HIOs can be more flexible than
with how to overcome data and workflow obstacles. EHR-centered networks in meeting local needs, espe-
Large health systems, such as Providence or Cedars- cially if they build valuable use cases incrementally with
Sinai in Los Angeles County, support their network community buy-in. For example, in Humboldt County,
of ambulatory providers by providing enterprise HIO a region without a well-established EHR exchange net-
services that aggregate data from national networks, work, NCHIIN worked with community stakeholders to
ADT feeds, and laboratories. But many providers with build an alert system for clinicians registering patients
access to external data through an EHR-based net- already receiving specialty mental health services from
work simply do not use the functionality or may not other providers within the county. The population
even be aware that it exists, as is true of some provid- health and event notification tools offered by HIOs may
ers in Fresno that were interviewed for this report. be especially useful to provider organizations bearing
financial risk for a defined patient population because
Despite their limitations, the national networks rep- they support key tasks, including identifying high-risk
resent a critical superhighway for data exchange in patient cohorts, managing chronic care, monitoring
California today. EHR vendors increasingly integrate transitions, and following up after hospital events.
Health Information Exchange in California: Assessment of Regional Market Activity www.chcf.org 5HIOs, however, struggle for a variety of reasons, providers. Nevertheless, provider organizations today
including provider perceptions that adoption is more must grapple with the integration of these focused
difficult than accessing the national networks, HIO data streams into their EHRs or other data systems,
tools do not fit easily into provider workflow, data are which takes both effort and financial resources.
incomplete, and HIOs’ underlying business models Innovative application programming interface (API)
may not be sustainable. While methods for submitting approaches such as SMART on FHIR, a set of open
data to HIOs are largely standardized, the methods for specifications to integrate apps with EHRs and other
accessing HIO data are variable; some HIOs primar- health care IT systems, may streamline and standard-
ily push data into their participants’ EHRs while others ize the ways that these issues are addressed in the
make data available via a portal. These different meth- future.
ods impact how well received an HIO is by its users. In
the absence of workflows, staff, and resources dedi-
cated to getting the most out of the network locally,
providers are often not able to take advantage of the
6 California’s county-led WPC pilots have dem-
onstrated the viability of cross-sector data
exchange between health care and social service
data and tools they offer. providers, and large health systems are invest-
ing heavily in technologies that enable referrals
5 Specialized clinical data exchange, specifi-
cally event notifications, complements other
data exchange use cases and is used extensively by
between hospitals and CBOs, but these initiatives
are in the early stages.
hospital systems and increasingly by ambulatory Of the four regions profiled for this report, only
providers, although uptake by ambulatory provid- Humboldt County has achieved extensive participa-
ers is slow (e.g., in Fresno). tion in whole-person data exchange, with the local
county government and HIO taking active roles, and
These services, which are provided both by HIOs data sharing would have to expand significantly to
and private networks such as Collective Medical and realize its full potential related to community health. In
PatientPing, are especially impactful when they deliver Humboldt as in a number of Whole Person Care pilots,
notifications into providers’ workflows in their EHRs. care management systems that enable distributed
Collective Medical and PatientPing initially gained teams to collaborate in providing “whole-person”
momentum as services linking emergency depart- services for the individual patient have proven essen-
ments in different hospitals to provide alerts. These tial for success. A recent CHCF publication, Breaking
organizations’ capability to route ADT messages to Down Silos: How to Share Data to Improve the Health
support multiple use cases, such as hospital-to-pri- of People Experiencing Homelessness, looks more
mary-care notifications and — at least in Collective closely at initiatives in California with an emphasis on
Medical’s case — COVID-19-related test results, has data exchange between health care and homeless-
fueled their growth. Similarly, effective HIO data deliv- ness systems. The report found that local efforts, like
ery services go beyond hospital notifications, such as those in Humboldt County, were essential to strength-
NCHIIN’s “mental health summary” alerts or LANES’ ening cross-sector relationships and building trust to
Patient Synopsis, putting actionable information in overcome technical and legal challenges.3
front of providers.
Meanwhile, health systems and payers have invested
The cost of specialized data exchange networks influ- in social service referral platforms, enabling coordi-
ences their pattern of adoption. When HIOs bundle nated handoffs between health care and social service
these data delivery services with their core offerings, providers. In large communities like Los Angeles
there is generally no additional charge. Services of County, there are multiple competing platforms estab-
the private networks, such as Collective Medical, may lished by anchor health organizations. Because these
be covered by health plans, especially for ambulatory platforms are not integrated and do not share data,
California Health Care Foundation www.chcf.org 6some worry that an undue burden is being placed on more efficiency, leveraging local HIOs where possible
Federally Qualified Health Centers (FQHCs), CBOs, to support these integrations.
and primary care providers that may be expected to
use multiple platforms for patient and client manage- Table 1 characterizes the use of each network type
ment. Some communities are starting to work together and the need that network serves in each region, as
to evaluate the impact on local CBOs and are chal- indicated by research for this report.
lenging the technology platforms to collaborate for
Table 1. Mapping Data Exchange Network Types to Provider Needs
LEVEL(S) OF USE, BY REGION
NETWORK TYPE / VALUE/CHALLENGE PROMISING
PROVIDER NEED Los Angeles Fresno Sacramento Humboldt TO PARTICIPANTS TRENDS
EHR-Centered Clinical Data Exchange
Access to external Extensive Extensive Extensive Growing Value. Workflow integra- HIO participa-
clinical records for tion via a single existing tion in national
Predominant Predominant Predominant
patients at the point IT platform. networks has
(locally) (locally) (locally)
of care. potential to
Challenge. Significant
improve data
resources required to
quality and
participate and configure
access in the
data, that may exceed
safety net.
safety-net and ambula-
tory provider capacity.
HIO-Centered Data Exchange
Data aggregation for Growing Growing Limited Predominant Value. Flexibility to meet COVID-19
population health and (locally) local needs and to facili- pandemic and
access to clinical data tate information sharing CalAIM initia-
when EHR exchange outside of EHR networks. tives make need
is limited. for population-
Challenge. Variable
level data more
integration into existing
apparent to
IT systems and provider
state decision-
workflows, and incom-
makers.
plete data depending on
network participation.
Specialized Clinical Data Exchange
Real-time notifications Extensive Limited Growing Growing Value. Specific actionable Clinical event
of critical clinical events information for providers notifications are
(e.g., ADT) at the point of care. now required
Challenge. Narrow versus by new federal
comprehensive data, with interoperability
rules.
incremental expense for
access and use.
Whole-Person Data Exchange
Access to comprehen- Growing Very Limited Limited Extensive Value. Focus on cross- Ongoing
sive patient information, sector collaboration and prevalence of
including behavioral data to support care for risk-bearing
health and social needs. patients with complex arrangements
care needs. and CalAIM will
drive continued
Challenge. Robust barri-
growth.
ers to scale including
distinct data standards
and legal requirements
across sectors.
Health Information Exchange in California: Assessment of Regional Market Activity www.chcf.org 7Interviews with Los Angeles County respondents
Los Angeles County revealed a divergence of perspectives. Some view
regional HIOs as a cornerstone to enable data
Overview exchange, particularly for safety-net providers. Others
Los Angeles County is home to 10 million people, anticipate that new federal interoperability standards
which represents one in four California residents. and data-sharing requirements will facilitate data
More than 3 million Angelenos are enrolled in Medi- exchange and allow market participants to leapfrog
Cal, about one-third of the county’s population; L.A. the need for HIOs in the region. Organizations with
Care and Health Net are the Medi-Cal managed care this perspective believe that the key is connecting
plans in Los Angeles’ two-plan model. Six major health EHRs through national networks, standard APIs, and
systems account for almost half of the county’s acute other standards-based approaches.
care hospital discharges, but none of those systems
dominate the market. Medical groups and indepen-
dent practice associations (IPAs) have long played a Hospitals and Health Systems
key role in the Los Angeles market, accepting financial In Los Angeles County, private health systems have
risk and clinical responsibility for professional services; developed enterprise HIOs based on EHRs that actively
several large physician organizations in Los Angeles use national networks to facilitate exchange. Among
take global risk for hundreds of thousands of members. hospital systems, Epic and Cerner are dominant.
Los Angeles County Department of Health Services Extensive effort has been invested by some systems
operates an integrated delivery system of four public in data exchange with an array of providers and other
hospitals and 27 county clinics, as well as the county’s community partners. Some large health systems have
WPC program. FQHCs play a major role in the safety built out major data exchange networks, both inter-
net; 60+ health centers with 350+ sites operate in Los nal-facing to support providers tightly affiliated with
Angeles County, serving as a key partner to Medi-Cal the system and external-facing to facilitate data shar-
managed care plans for primary care services and as ing with contracted network partners, vendors, and
the provider to those without insurance. For a detailed loosely affiliated facilities and clinicians. In general,
portrait of the health care market in Los Angeles, see salaried physicians affiliated with health systems use
CHCF’s Regional Market Study.4 the enterprise HIO; affiliated physicians are offered
an opportunity to adopt the system EHR, often on a
Data exchange is multifaceted in Los Angeles County. subsidized and supported basis. Some of the hospital
EHR-centered networks form the core of clinical data systems are making extensive use of national network
exchange, with health systems leveraging EHR ven- data via Carequality and CommonWell, investing sig-
dor networks and national networks. There is a limited nificant resources in pulling data from many sources,
but growing role for regional HIOs, particularly in the integrating it into the system EHR, and delivering it
safety net. The Los Angeles Network for Enhanced to clinicians for use at the point of care. Some other
Services, the local HIO, has gained traction in recent systems participate in national networks but have dif-
years with strong support from Los Angeles County ficulty integrating and using data accessed via these
and L.A. Care. Participation is increasing: 42 FQHCs networks in a way that would make it actionable by
and 33 hospitals have joined. Manifest MedEx has 28 clinicians at the point of care.
participating hospitals, with all now sharing at least
ADT data. Competing HIOs present a challenge for Table 2 displays information on the EHR vendor, HIO
market participants. participation, national network participation, and
clinical event notification used by several large health
systems in Los Angeles County. More detailed infor-
mation on select provider organizations follows (see
page 9).
California Health Care Foundation www.chcf.org 8Table 2. EHR and Data Exchange Network Participation Among Select Hospital Systems in Los Angeles County
NATIONAL NETWORK CLINICAL EVENT
EHR VENDOR HIO PARTICIPATION PARTICIPATION NOTIFICATION PROVIDER*
Kaiser Permanente Epic Not participating eHealth Exchange, Carequality Collective Medical
Cedars-Sinai Health System Epic Joined LANES eHealth Exchange, LANES
March 2021 Carequality, CommonWell (in the coming months)
(not yet sharing data)
Providence Epic Providence HIE eHealth Exchange, Providence HIE,
(see text for details), Carequality, CommonWell Collective Medical
Manifest MedEx
County of Los Angeles Cerner LANES Considering CommonWell LANES
Department of Health Services
Dignity Health Cerner Manifest MedEx (only eHealth Exchange, PatientPing
in the Inland Empire) CommonWell, Carequality
UCLA Epic LANES eHealth Exchange, Carequality LANES, Collective
Medical
Adventist Cerner LANES, Manifest CommonWell LANES, Manifest MedEx,
MedEx Collective Medical
* A key use case for data exchange is notification of providers caring for patients when those patients experience clinical events, such as hospital admission,
discharge, or transfer (ADT).
Cedars-Sinai Health System prior to affiliation with Cedars-Sinai Health System, so
The Cedars-Sinai Health System is the second largest the effort on data exchange with Torrance Memorial
hospital system in Los Angeles County based on acute has focused on connections between Epic and Cerner.
care hospital discharges in 2018. In addition to Cedars-
Sinai Medical Center and Marina Del Rey Hospital, If physician practices affiliated with Cedars-Sinai pre-
affiliation with Torrance Memorial Medical Center was fer not to switch to Epic, Cedars-Sinai will reportedly
completed recently and is pending with Huntington invest the resources required to connect each prac-
Hospital. The hospital’s affiliated physician network tice’s EHR to Carequality — and has done so with
includes the Cedars-Sinai Medical Group and nine more than 20 different EHRs to date. Those practices
other single-specialty medical groups; Cedars-Sinai are then able to obtain patient data from Cedars-Sinai
Health Associates, an IPA with 100 primary care physi- Health System. Cedars-Sinai (with a total of 137 net-
cians and 500 specialists; and 400 faculty physicians.5 works to date) reports that they will share data with
any organization that meets their standards (among
Cedars-Sinai Medical Center and Marina Del Rey them, data will not be sold or monetized, and data will
Hospital are both on the Epic EHR system; assuming not be cumulatively stored due to security concerns).
the affiliation with Huntington Hospital is approved, In case none of those pathways of connectivity work,
Epic will be deployed there as well. Salaried physicians Cedars-Sinai continues to operate a large fax system
affiliated with Cedars-Sinai are also on Epic, and any- that sends out thousands of faxes every day.
one on the medical staff (IPA-affiliated physicians and
the faculty for the residency programs) is eligible for Cedars-Sinai Health System joined LANES in March
80% subsidization of Epic system. Torrance Memorial 2021 and data exchange will begin in the coming
had just completed an installation of Cerner’s EHR months. Cedars-Sinai also actively participates in
Health Information Exchange in California: Assessment of Regional Market Activity www.chcf.org 9the HL7 Da Vinci Project, through which payers and Providence participates in the national networks to
providers are collaborating to shift away from legacy share data with facilities that are not connected to its
approaches toward standardized FHIR-based APIs private HIE, such as Kaiser Permanente, MemorialCare,
intended to streamline data exchange. Initial efforts and Sutter Health. Providence also participates in
have focused on providing event notifications for pri- Manifest MedEx and is reportedly considering joining
mary care physicians and delivering quality measures LANES.
to Anthem.6
County of Los Angeles Department of
Providence Health Services
Providence operates six hospitals in Los Angeles The County of Los Angeles Department of Health
County, with a strong presence in Orange County Services operates an integrated delivery system of
and multiple facilities in Northern California — part four public hospitals and 27 county clinics throughout
of a 51-hospital system headquartered in Washington Los Angeles County, caring for about 450,000 empan-
State.7 Providence’s Los Angeles region has adopted eled patients. LACDHS also runs Los Angeles County’s
Epic and deploys a specific team dedicated to sup- WPC program and a program called My Health LA,
porting internal data integration. targeting those without health insurance and provid-
ing health care for the county’s juvenile justice system
Providence accesses all the national networks and jails.9
(e.g., eHealth Exchange, Carequality, CommonWell)
through Epic Care Everywhere as well as Collective LACDHS has adopted the Cerner EHR throughout the
Medical for ADT data and hospital event notifica- integrated delivery system, in all hospitals and clin-
tions to partners throughout California. Providence ics; expansion of the Cerner integration into the Los
has created its own HIO, the Providence HIE, provid- Angeles County jails is underway in 2021. LACDHS
ing clinical data and services to ambulatory providers, is a strong supporter of LANES, actively participat-
postacute sites, and others. Data are aggregated ing in the HIO and supporting participation of other
from multiple sources: real-time clinical data, includ- providers, particularly in the safety net. Many FQHCs
ing labs and imaging; claims data (with a lag); data participate in the My Health LA program, provid-
from Collective Medical and the national networks; ing primary care for those without health insurance;
and other sources. The data are made available on a LANES supports data exchange between the primary
robust Providence HIE clinical portal, ShareVue. The care providers in FQHCs and the specialist care pro-
Providence HIE has built tools, such as dashboards, vided by LACDHS.
that render data access and visualization to support
care management and population health manage- LACDPH shares an EHR with LACDHS to document
ment. Data can be tailored for clinician needs (e.g., health care service delivery (e.g., in their immuniza-
physicians can request that test results be deliv- tion, sexually transmitted diseases, and tuberculosis
ered directly to the EHR or can request alerts for a clinics), resulting in shared medical records across
set of attributed patients.). According to its website, LACDHS and LACDPH. LACDPH participates in
Providence HIE provides secure electronic clinical data LANES but is not yet sharing data pending an assess-
exchange among participants in California, Texas, and ment of what data can be shared. The Los Angeles
Alaska, including 36 hospitals, 699 practices, and County Department of Mental Health (LACDMH)
4,801 providers for an average of 49,852 daily patient actively participates in LANES and is sharing data sub-
encounters. Connections are available to 79 EHRs.8 ject to relevant restrictions.
California Health Care Foundation www.chcf.org 10Ambulatory Care (Cal-HOP) funding.11 L.A. Care, the largest Medi-Cal
FQHCs play a key role providing primary care in Los managed care plan in Los Angeles with more than 2
Angeles, particularly to Medi-Cal members and those million members, encourages contracted providers,
without health insurance. Southern California is home including FQHCs, to connect to LANES but does not
to many capitated, delegated physician groups; 93 require or subsidize participation. LANES is useful for
risk-bearing organizations were operating in Los FQHCs caring for uninsured patients because LACDHS
Angeles County in 2020, 18 with enrollment of more specialists and county hospitals provide specialty and
than 75,000 lives.10 While large, well-resourced phy- inpatient care for those without health insurance in Los
sician organizations may invest substantially in data Angeles, and all participate in LANES.
exchange infrastructure, smaller practices are more
likely to struggle with the level of investment required. CCALAC has acted as a catalyst and bridge between
FQHCs and LANES to facilitate greater data exchange
Federally Qualified Health Centers and to ensure the FQHC perspective is represented
The Community Clinic Association of Los Angeles and understood by LANES. The HIO’s decision to
County claims 65 FQHC members with more than implement a centralized data system has created
350 clinic sites, caring for 1.7 million patients annually. several barriers that LANES leadership is working to
Collectively, those FQHCs have more than 15 differ- address to get more FQHCs on board, such as secu-
ent EHRs; eClinicalWorks and NextGen are dominant rity concerns in the case of a breach (including the
(see Table 3). Most of the FQHCs using Epic have belief that centralized data could be compromised
connected through OCHIN, a national health IT orga- more easily). CCALAC encourages members to join
nization (see sidebar on page 22 for more information). the national networks, Carequality and CommonWell,
in addition to LANES, and Collective Medical for hos-
pital event notifications, to leverage data exchange
Table 3. D
istribution of EHRs in Los Angeles County’s
Federally Qualified Health Centers across EHRs, though that exchange has not been as
seamless as expected.
EHR TYPE FQHCs
eClinicalWorks 26 Optum
NextGen 19
Optum, part of UnitedHealth Group, acquired DaVita
HealthCare Partners (HCP) in 2019, including its signif-
Epic (All but two are through OCHIN.) 8 icant footprint and full-risk contracts for almost a half
million people in Los Angeles. Combined with prior
Other 12
acquisitions in Orange County, Inland Empire, and San
Total 65 Diego, Optum employs or affiliates with more than
7,000 physicians across Southern California.12 Optum
Source: Community Clinic Association of Los Angeles County.
is working toward integrating its Southern California
physician organizations for data and clinical care.
As of March 2021, 42 of CCALAC’s 65-member orga-
nizations had joined LANES. Of those, 21 have a Los Angeles physicians participating in the employed
bidirectional interface to exchange data with LANES, model use Allscripts and NextGen EHR platforms;
meaning the technical integration of LANES with the physicians affiliated through the IPA may use other
health center’s EHR is complete (i.e., the clinic can EHRs. As a provider taking global risk, Optum has a
send data to LANES and can query LANES and retrieve tremendous amount of patient data to support care
data via the EHR [versus through a separate portal]). coordination. Optum’s primary data-sharing efforts
Increasingly, health centers are moving toward con- are geared toward population health and delivering
necting to LANES with support from the California information on quality and gaps in care to contracted
Health Information Exchange Onboarding Program providers at the point of care — generally delivered
Health Information Exchange in California: Assessment of Regional Market Activity www.chcf.org 11via a provider portal (i.e., versus integrated directly FCS has developed an array of different programs to
into the provider’s EHR). improve care and meet the needs of its patients, none
of them integrated with the EHR. FCS runs a residency
Optum only shares clinical data with its internal HIE, training program and uses a separate platform for
not with national networks or regional HIOs. Over the secure communication with residents. Likewise, FCS
last decade, Optum has developed point-to-point has adopted a program for secure texting to patients
interfaces for ADT notifications and select clinical that is HIPAA compliant — but not integrated. Yet
documents (e.g., discharge summaries) with 25 part- another program is used for reaching patients with-
ner hospitals and health systems in Los Angeles and out access to the internet or a smartphone. FCS uses
Orange Counties; those systems are reportedly anx- three different portals to obtain social services data to
ious to decommission these unidirectional interfaces support patient care and referrals, none of which are
and shift toward bidirectional exchange between integrated with the EHR. All of these programs fill a
Optum/HCP and local HIOs, but that has not yet specific need for a specific group but add significantly
occurred. to the administrative burden of managing the flow of
data for patient care.
Family Care Specialists
In four Los Angeles locations, Family Care Specialists
Medical Group (FCS) provides care for about 25,000 Regional HIOs
patients — 66% of whom are low income and 40% of Two HIOs operate in Los Angeles: Manifest MedEx
whom are covered by Medi-Cal. FCS’s EHR needs to and LANES. Manifest MedEx has 28 participating hos-
be replaced, and the practice will opt for one of the pitals in Los Angeles County, with all now sharing at
major systems if financial support is available through least ADT data. LANES was launched with seed fund-
a health plan partner or national IT economic stimulus ing from Los Angeles County and L.A. Care. After
to offset the cost. FCS uses many different platforms several years of dormancy and technology develop-
and systems for data exchange in support of patient ment, LANES is working to establish itself as a regional
care — and few of those systems seem to talk to HIO for all payers and providers in Los Angeles County
each other. The practice frequently must find creative — not just the safety net.13 With only the four LACDHS
solutions to connectivity problems, acting as a data hospitals and eight private hospitals participating in
exchange “MacGyver.” 2018, LANES has grown to 33 data-sharing hospi-
tals in 2021, including Cedars-Sinai Medical Center,
FCS faces challenges sharing data with all four hos- Huntington Hospital, and the hospitals in the UCLA
pitals to which the practice admits patients. Some of and Adventist Health systems. As one respondent
those hospitals have access to the national networks shared, “LANES is finally getting ready for the big
and ADT alerts through Collective Medical but have time; it took forever.”
not structured them to deliver data to the physicians
in support of patient care. Specialist access and refer- In early 2020, LANES was planning to connect
ral is also a challenge. FCS has created a portal for with eHealth Exchange, and through eHealth
specialists to whom they refer so that those physicians Exchange, with both Carequality and CommonWell.
can obtain relevant patient information, but many However, LANES delayed this integration, prioritizing
specialists serving Medi-Cal patients prefer to call and connecting to the Veterans Administration in 2021 and
request a fax rather than log into a portal that is not CommonWell in 2022. LANES rolled out clinical event
integrated into their EHR. Likewise, after the patient notification in September 2020, along with a new
consultation, the specialists frequently do not enter Patient Synopsis application that provides key health
the results into the portal so FCS must call to request indicators (e.g., number of Emergency Department
a fax of the visit summary. [ED] visits, medications, laboratory results) and can be
customized for users and settings (e.g., ED providers,
California Health Care Foundation www.chcf.org 12hospitalists). Four FQHCs are using the tools to moni- Outside of the WPC pilot, data sharing to address
tor ED visits, and adoption is expected to increase. social determinants of health is fragmented but rap-
According to LANES, more than 200 public health idly expanding in Los Angeles, as it is in many regions.
nurses are using Patient Synopsis to track the health LANES is reportedly working toward incorporating
records of 40,000 foster children. Through a collab- social needs data. PRAPARE, a tool developed to
oration with LACDPH, LANES will make COVID-19 help providers collect data on social needs to sup-
vaccination data available to its participants. port patient care, is embedded in the NextGen and
eClinicalWorks EHRs, but there is no consistent route
L.A. Care has transitioned from grant funding for for exchange of that data.
LANES to paying roughly $1 per member annually for
its 1.1 million members not delegated to plan part- With social service referrals between health care
ners. L.A. Care can log into the LANES portal and providers and CBOs becoming more common, a
see data on its members — if the providers caring for proliferation of competing technology platforms has
those members are connected to LANES and con- emerged in Los Angeles to enable these transactions
tributing data. The centralized system architecture to and collaborations. While promising, this creates com-
which LANES has transitioned, and which most HIOs plications for health care providers, including FQHCs,
in the country have also adopted, has raised security and for social services providers and CBOs. In Los
concerns with some potential participants. However, Angeles County, L.A. Care and Cedars-Sinai Health
this model more efficiently enables access to consoli- System use Aunt Bertha, LACDHS uses One Degree,
dated, historical records of the sort that is valuable to and several large plans and providers — including
L.A. Care and provides a foundation for population Kaiser, Dignity Health, and Blue Shield of California
health analytics uses. — have adopted Unite Us. Each platform has a sepa-
rate portal with varying degrees of EHR integration,
Several interviewees raised questions about a sustain- requiring some providers to log in and out to gather
able business model for both LANES and Manifest information or make referrals from each one. In addi-
MedEx. Some hospitals and health systems are tion, providers crossing county lines may need to
reluctant to incur the financial and resource cost of check multiple county portals for information on hous-
sharing data with multiple HIOs, while others — such ing and other social services. The ability to make and
as Adventist Health — participate in both. Ambulatory accept referrals by any network participant and track
providers are interested in joining the HIO that has the referral’s status and outcome is in the early stages
signed on the hospitals most often visited by their of implementation; several of the social services refer-
patients. ral platforms provide at least some aspects of this
functionality. Some providers have expressed con-
cerns that they may refer a patient for social services
Whole-Person Data Exchange and discover weeks later that the organization was
Networks overbooked and unable to accept the referral.
LACDHS’s WPC program uses a platform called
CHAMP for data exchange, which is built specifically
for the initiative to enable data sharing across mul-
tiple WPC service providers. Unlike other platforms,
CHAMP can share data with WPC-affiliated housing
navigators, correctional health, and mental health
team members, and other social services. However, it
is not integrated with LACDHS’s Cerner EHR or other
platforms.
Health Information Exchange in California: Assessment of Regional Market Activity www.chcf.org 13The regional hospital market achieves a somewhat
Fresno Region integrated data-sharing environment among the four
large health systems due largely to their common use
Overview of the Epic EHR; ambulatory providers not on Epic
The cities of Fresno and Clovis form the metropoli- reportedly experience challenges accessing hospital
tan center of this otherwise largely rural region, which data. The Central Valley HIE (CVHIE/Manifest MedEx)
includes the counties of Fresno, Mariposa, Madera, is a local affiliate of Manifest MedEx and uses the lat-
Kings, and Tulare. More than one in five of the 1.8 mil- ter’s technical and governance infrastructure coupled
lion residents have household income below 100% of with a local priority-setting user group to drive regional
the federal poverty level (FPL). Four major regional collaboration and HIE use. CVHIE/Manifest MedEx
health systems are dominant at the urban center of presents an important resource for data sharing in the
this region: Kaiser Permanente, St. Agnes Medical region but is viewed as secondary to EHR-based data
Center (part of Trinity Health), Valley Children’s exchange for supporting treatment at the point of
Healthcare, and Community Medical Centers (CMC), care. There is limited sharing of behavioral health and
with two-thirds of residents having records in one of social services data in this region, with no major WPC
these systems. FQHCs play a critical role in primary pilots or social services’ data-sharing initiatives.
care delivery in the region; across the five counties,
FQHCs saw more than 400,000 Medi-Cal patients in
2018. For a detailed portrait of the health care market Hospitals and Health Systems
in this region, see CHCF’s San Joaquin Valley Regional Table 4 displays summary information on the EHR
Market Study.14 vendor, HIO participation, national network participa-
tion, and clinical event notification providers. All four
of the major health systems in the region — Kaiser,
Table 4. EHR and Data Exchange Network Participation Among Select Hospital Systems in the Fresno Region
NATIONAL NETWORK CLINICAL EVENT
EHR VENDOR HIO PARTICIPATION PARTICIPATION NOTIFICATION PROVIDER*
Kaiser Permanente Epic Not participating Carequality, eHealth Collective Medical
Exchange
St. Agnes Medical Center Epic CVHIE/Manifest MedEx Carequality CVHIE/Manifest MedEx
(Trinity Health)
Valley Children’s Healthcare Epic CVHIE/Manifest MedEx Carequality CVHIE/Manifest MedEx
Community Medical Centers Epic CVHIE/Manifest MedEx Carequality, eHealth CVHIE/Manifest MedEx
Exchange
Adventist Health Majority Cerner CVHIE/Manifest MedEx CommonWell Collective Medical,
(Some smaller, rural (new member, sharing ADT CVHIE/Manifest MedEx
hospitals use legacy data with the HIO, as of
EHR systems.) April 26, 2021)
Kaweah Delta Health Care Cerner CVHIE/Manifest MedEx CommonWell CVHIE/Manifest MedEx
District
Veterans Health VA Health Record Not participating eHealth Exchange No external service
Administration
*A key use case for data exchange is notification of providers caring for patients when those patients experience clinical events, such as hospital admission,
discharge, or transfer (ADT).
California Health Care Foundation www.chcf.org 14St. Agnes, Valley Children’s, and CMC — are using Epic Manifest MedEx as a statewide participant and is now
(or migrating to it). As a result, Epic Care Everywhere sharing ADT information with the HIO, which may help
is a major infrastructure for clinical data exchange. The it effectively exchange data with participating partners
four major health systems all participate in Carequality in the region.
and rely on it in conjunction with Epic Care Everywhere
to access clinical data; two of the four also participate Other Small Hospitals
in eHealth Exchange. However, hospital-based pro- Two smaller area hospitals — Kaweah Delta Health
viders view the national networks as a blunt instrument Care District and the local Veterans Administration
for clinical data exchange, reporting that their provid- (VA) hospital — are not currently on Epic; without
ers often must sift through so much clinical information participation in Epic Care Everywhere, they remain
that is it hard to know which information is most useful relatively siloed from other hospitals. While Kaweah
and up-to-date. All major systems except Kaiser par- Delta participates in CVHIE/Manifest MedEx and
ticipate in CVHIE. CommonWell, both ambulatory care providers and
hospitals report difficulties in consistently obtaining
Community Medical Centers clinical data from Kaweah Delta. The VA operates two
The largest health system in the region and longtime facilities in the region and relies on eHealth Exchange
Epic user, CMC has a sophisticated understanding for external data exchange.
of the various national networks and where to look
for data from a particular external organization. Staff Small independent hospitals, many of them rural and/
leverages internal IT resources to reduce burden or critical access hospitals, play an important role in
on providers by providing workflow guidance and the region but tend to engage in less data exchange
semi-automated local customizations to the EHR and than the larger systems, most often not participating
supporting IT systems. Despite staff efforts, however, in either CVHIE/Manifest MedEx or the national net-
data coming through the national networks report- works. These organizations tend instead to rely on
edly often overwhelms providers and limits its utility point-to-point data exchange with specific partner
for clinical decisionmaking. Epic Care Everywhere, organizations — often only when patient referrals are
viewed as more reliable and curated than informa- sufficiently frequent to support the effort required to
tion retrieved via the national networks, is by far the establish a connection.
preferred method for discovery of external clinical
information.
Ambulatory Care
Adventist Access to and exchange of clinical data among ambu-
Adventist uses the Cerner EHR and primarily partici- latory providers and between ambulatory providers
pates in HIE through CommonWell (and its network and hospitals in the region are fragmented and face
bridge to Carequality) and through multiple direct significant hurdles because of constrained resources
interfaces with provider organizations and smaller and HIE expertise. Few connect to the national net-
hospitals in the region. Adventist also connects with works even though these networks are natively built
its facilities that are not on its enterprise version into their EHRs, and even fewer participate in any
of Cerner via a product called Cerner HIE, which is HIOs. For example, neither LaSalle Medical Associates
similarly connected to the national networks. Some nor Santé Physicians — the two largest IPAs in the
ambulatory care providers in the Fresno region have region — participate in the CVHIE/Manifest MedEx or
reported problems accessing Adventist data through participate in a national network.
CommonWell. Adventist reports that these issues are
typically due to a lack of understanding about where Multiple large FQHCs operate in the region, and
the data resides in the clinical workflow and patient many use the NextGen, Epic, and eClinicalWorks
identity matching issues. Adventist recently joined EHRs. Despite Carequality being a standard feature
Health Information Exchange in California: Assessment of Regional Market Activity www.chcf.org 15of these EHRs, many FQHCs do not connect to the The split among FHCN providers using Epic and
national network. A minority of FQHCs are connected eClinicalWorks creates challenges for those seeking
to CVHIE/Manifest MedEx in the region, with one a complete view of patient clinical records. FHCN
organization interviewed noting the lack of FQHC IT clinics using eClinical Works participate in Manifest
resources to plan and implement connectivity with MedEx and contribute data whereas clinics using
CVHIE/Manifest MedEx, together with the workflow Epic reportedly do not. Without full participation in
realignment that would be needed for providers to Manifest MedEx, data on FHCN patients may seem
use the tools, as important reasons. incomplete or inaccurate to providers. Broader partici-
pation in Manifest MedEx is also hindered if providers
Implementation of ADT alerting for ambulatory care are required to log into an external web-based portal
providers — generally seen as a critical use case for to access information, which is viewed as inefficient.
data exchange — is inconsistently available in this FHCN uses DirectTrust, a secure messaging service
region, according to ambulatory providers. The most built into EHR platforms and required for EHR certi-
consistent ADT alerting among ambulatory organiza- fication, for referrals to specialty care and views it as
tions is through Epic Care Everywhere for providers an important component of regional interoperability.
using Epic. Otherwise, ADT alerting occurs through Some area hospitals use DirectTrust to distribute ADT
a patchwork of solutions, which include Manifest information to ambulatory care providers. However,
MedEx’s notification service, Collective Medical, point- many ambulatory care providers in the region do not
to-point interfaces, and DirectTrust secure messaging. realize that they have access to DirectTrust or under-
While Manifest MedEx offers ADT alerts reflecting stand how to access and use it in their EHRs.
hospital events at all participating hospitals, adoption
may be low because CVHIE does not actively recruit
ambulatory care providers to take advantage of these Regional HIOs
services. Collective Medical provides ADT alerts for CVHIE serves as the local affiliate of Manifest MedEx
Adventist and now Kaiser Permanente. in the Fresno region. Its members use the Manifest
MedEx data-sharing infrastructure as well as its gov-
Family Health Care Network ernance structure; the role of CVHIE is to provide a
Family Health Care Network (FHCN) is a large FQHC local forum for determining regional priorities and
with 41 sites spread across the region and EHR use encouraging and coordinating new membership.
evenly distributed between Epic and eClinical Works. CVHIE members also work together to address data-
Carequality is built into both EHRs and is actively used sharing challenges and opportunities that extend
by FHCN. While FHCN reports that providers can beyond Manifest MedEx tools. CVHIE has historically
retrieve useful data via the connection to Carequality, been a strong presence for regional collaboration and
they often have to “hunt” for the right data due to governance. However, relatively few organizations —
the large volume of information that is discoverable. particularly ambulatory care providers — consistently
In addition, despite the availability of national net- participate in this local forum, limiting its impact.
works in the region, FHCN faces challenges accessing Notable participants are Valley Children’s Hospital,
patient records at the point of care from hospital sys- CMC, and St. Agnes. Priority topics for CVHIE mem-
tems. For example, FHCN does not receive data from bers include establishing a standard approach for
Kaweah Delta or Adventist via the national networks. predictive modeling of health care data at the popula-
FHCN providers would reportedly benefit most from tion level to supplement Manifest MedEx processes
data for patients who are post-hospitalization and and rules, developing better algorithms for shar-
for new patients who present with complex medical ing and ingesting data over the national networks,
histories. and standardizing the speed of national network
connections.
California Health Care Foundation www.chcf.org 16The CHCF San Joaquin Valley Regional Market Study
found that many local providers reported limited use of Whole-Person Data Exchange
Manifest MedEx despite the HIO’s continued growth, Networks
the platform’s features, and free services for physician Outside of a small WPC pilot program in Mariposa,
practices and other outpatient settings.15 Reported sharing of behavioral health and social services data
barriers to adoption included challenges integrating is limited in this region. In part due to unique char-
practice EHR systems with the HIO platform and a lack acteristics of the region, including small counties and
of resources for staff training and onboarding. The rel- limited health plan influence, the potential conveners
ative ease of accomplishing data exchange through for cross-sector data sharing have yet to invest sig-
other tools, like the national networks, which are gen- nificant effort in cross-sector data-sharing initiatives.
erally integrated into existing EHR systems, appealed Several respondents were unaware of any significant
to providers compared to logging into an external cross sector data exchange efforts. Early in 2021,
portal to use Manifest MedEx. however, social service referral platform Unite Us was
deployed across the region with support from Kaiser
Consistent with those findings, interviewees reported Permanente and Common Spirit Health and including
that local providers are already overwhelmed with a number of FQHC participants. In Fresno, St. Agnes
data from their EHR vendor and the national networks is leading an Adverse Childhood Experiences (ACEs)
and see little need to add yet another data source. Aware effort funded by the State of California, and
Confusion about which organizations are participat- is using Unite Us as one solution to screen and refer
ing in which data exchange networks also plays a role. children.
Manifest MedEx is seen as more difficult to imple-
ment and onboard than “built-in” features, such as
Carequality or Epic Care Everywhere. Moreover, many
providers in the region do not seem to realize that
the CVHIE/Manifest MedEx unified record may be
available to them through the eHealth Exchange or
Carequality national networks.
HIO participants see value in the platform to support
population health management, data analysis, and
public health use cases, which require longitudinal
patient records. Several respondents noted that while
CVHIE/Manifest MedEx provides limited utility for
point-of-care provider access to clinical information
today, the potential future population health benefit
from the aggregate data collected by the HIO warrants
continued support and participation in the network.
Health Information Exchange in California: Assessment of Regional Market Activity www.chcf.org 17You can also read
