In 2005, a consortium of Brooklyn hospitals, nursing homes, home health providers, and health insurers led by Maimonides Medical Center set out to develop a regional health information exchange (RHIO). Reflecting Brooklyn's socioeconomic and cultural diversity, the group sought to improve the quality of care for the borough's 2.5 million residents within facilities and across multiple health care settings.  Through the development of an IT infrastructure supporting clinical data exchange, the right information would be available to clinicians in the right place at the right time.

In 2006, the consortium was awarded $4 million in Health Care Efficiency and Affordability Law for New Yorkers (HEAL NY) grant funds and became formally incorporated as the Brooklyn Health Information Exchange (BHIX), an independent, not-for-profit, non-governmental entity charged with managing day-to-day clinical and technical operations. From its inception, BHIX and its stakeholders have worked collaboratively to realize the project's vision, to design and implement a workable technical platform, and to develop a transparent governance structure promoting broad participation among Brooklyn-based health care providers.

In 2008, the health information exchange was activated and BHIX began to make significant contributions, enabling participating clinicians to access information from various clinical sources across the continuum of care.  BHIX has since received positive feedback from clinicians who cite the benefits from the availability of clinical data, especially as patients transition from one care setting to another.

As an organization built on trust, BHIX has taken steps to protect the confidentiality of patient information.  BHIX has put in place comprehensive consent policies and the technical architecture to protect and govern the flow of information. The recently adopted statewide consent policy is aligned with the BHIX consent model. To educate patients and the public, BHIX launched the first phase of a patient outreach program, developing a website (www.bhix.org) and educational materials to inform and engage the community.  Recognizing Brooklyn's cultural diversity, these materials have been translated into seventeen languages. As a result, BHIX has received overwhelming support from patients, having already collected over 20,000 patient consents in less than five months.  

Last year, BHIX's early achievements and future promise were further recognized by New York State when it was awarded two new HEAL NY grants totaling $12.7 million.  The first of the two State awards supports the development of personal health records, along with other patient-focused tools, eventually allowing individuals online access to their own patient information and the ability to designate which institutions may access that data.  The second grant supports a pilot program to improve the management of geriatric patients and those coping with chronic diseases.  This program will actively provide clinical decision support for physicians, prompting follow-up and/or adjustments in care which is especially helpful when multiple specialists are involved in any patient's care.

BHIX has now expanded its membership to include additional hospitals, long-term and home care providers, health insurers, consumer representatives and the New York City Department of Health and Mental Hygiene. Central to this expansion is the further development of service-oriented, standards-based technical architecture which will enable different applications and systems to exchange a growing number and type of clinical data elements.  This will allow providers to better integrate the data exchange information within their workflows and business processes.  Finally, to achieve continuous quality improvement and reductions in medical errors, BHIX will be working to ensure that clinical information is actionable and meaningful through a proactive approach to alert patients and practitioners to potential gaps in medical care and deviations from best medical practices.  This strategic organizational and technical vision make BHIX uniquely poised to transform healthcare in Brooklyn and beyond.

The initial BHIX technical architecture allowed for the secure aggregation and sharing of patient health information to authorized and approved clinicians.  To accomplish this objective, BHIX implemented an electronic master person index, record locator service, data repository and clinical portal technology to achieve cross-enterprise interoperability.  Through full and robust participation in various BHIX committees, stakeholders guided the IT systems implementation process, thereby ensuring that the chosen technology incorporates critical clinical, technical, and privacy considerations.  This end-user driven process has been key to provider adoption and community support.

As BHIX requires that a clinicians' access to health information from other providers through BHIX be based on patient consent, each participating provider had to develop policies and procedures for recording and transmitting this consent.  To minimize unnecessary duplication and disruption during patient registration at each member facility, BHIX stakeholders modified and standardized their respective registration systems to record several consent data elements.  These consent data elements, in addition to patient health information, are transmitted to BHIX through HL7 messages, and are processed and stored in a federated manner. Through a secure web application acting as the front-end for authorized users, clinicians search for patient files and can then view aggregated patient information. To protect access to this data, BHIX authenticates and authorizes users either through a centralized user directory or a stakeholder's internal user directory.  After a user's security rights are authenticated, the authorized user can search for a particular patient by entering either a facility or medical record identifier or a set of demographics.  The probabilistic algorithm in the enterprise master patient index returns possible matching identities.  Once a patient is identified and his/her consent evaluated, the record locator service determines where the patient's data resides and the appropriate data is aggregated and returned to the user.

In order to achieve interoperability in an industry where the migration from paper to digital records is incomplete, BHIX also recognized the need to support the digitalization of documents.  In doing so, BHIX established a technical architecture in which structured data and scanned documents can be aggregated across facilities and presented to the clinician via a secure Internet-based application.  For example, in the BHIX portal, a discrete indicator of whether a patients living will is available may be accompanied by a scanned version of the living will document itself.

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BHIX regularly receives positive feedback from many of its users. An Emergency Department physician from Maimonides Medical Center recently reported that BHIX allowed him to understand a patient's medication history faster and more accurately.  Instead of relying on the contents of a brown bag which the patient hastily gathered from his/her medicine cabinet, the emergency physician accessed BHIX and received reliable past medication histories from several stakeholder members. The Medical Director of Sephardic Skilled Nursing and Rehabilitation Center, Dr. Paul Rosenstock, notes that "from my perspective, accurate transition of care information is paramount in coordinating appropriate continuity of care for our nursing home residents and patients. The efforts of BHIX towards the development and implementation of a comprehensive patient portal have ensured that our doctors and nurses have access to the most accurate and recent patient data, eliminating the errors and confusion that hinder quality health care delivery."

The project has educated patients and other consumers about the benefits of health information exchange and they, in turn, have been willing to trust BHIX to share confidential clinical information about their health status and care.  BHIX outreach efforts, coordinated centrally and deployed locally, have successfully informed thousands of patients about the benefits of health information exchange.  Through these efforts, BHIX has obtained consents from over 20,000 patients who have now taken the first steps in allowing their electronic health information to be viewed by trusted providers.  These consents, and patient trust, are essential as BHIX grows to include personal health record functionality, with its promise of better communications between patients and clinicians and improved patient self-management. BHIX has enabled healthcare practitioners to more efficiently access patient health information.  Prior to BHIX, physicians and other clinicians needed to retrieve health information either from the patient or by tracking down other providers.  Not only was this time-consuming, it could also mean that critical clinical information was missing when needed.  This piecemeal and haphazard collection of paper records has been both inefficient and ineffective in maintaining continuity of care. Through BHIX, clinicians are now able to access more of the right information in a timely fashion at the point of care.  In the coming years, as BHIX develops, the timely provision of additional critical clinical information to providers and patients will increasingly transform the delivery of care in Brooklyn.  

"A system that provides an abundance of complete, reliable information to the point of care and to the home can reduce waste, error, and frustration while improving diagnostic accuracy, the quality of communications, and even the ability of family members to care for each other" (Markle Foundation, Achieving Electronic Connectivity in Healthcare: A Preliminary Roadmap from the Nation's Public and Private Sector Healthcare Leaders' Technical Report, Connecting for Health, July 2004)

By providing clinicians with a more complete view of a patient's overall health and current treatment regimens, BHIX will identify opportunities for improved care management, reduce adverse drug interactions, eliminate duplicate prescriptions as well as repetitive laboratory and radiology tests, reduce hospital admissions, lower lengths of stay and avoid needless re-admissions due to uncoordinated care plans.  Even in its initial phase, BHIX clinicians have noted the value of the health information exchange.  Dr. David I. Cohen, MD, Vice Chair of Medicine and Senior Vice President for Clinical Integration at Maimonides Medical Center stated that the health information exchange provides the infrastructure to support patient care transitions which have historically been difficult and inefficient with paper systems. "BHIX ensures good communication among our provider teams, regardless of the care setting,  by providing real-time actionable clinical information necessary to provide efficient, coordinated care management."

In the next phases of BHIX expansion, the consortium intends to deliver clinical informatics services that aggregate and analyze data and deliver powerful and clear action-driven care considerations, thereby effectuating measurable quality improvements.  BHIX will involve and empower patient self-management by providing access to clinical information through a personal health record.  The BHIX personal health record will include up-to-date test results and treatment information, individualized disease management tools, prevention and wellness reminders, and patient-specific health education based on their diagnosis and treatment profile.  
With these innovations, clinicians will practice better medicine with improved outcomes, patients will be able to take charge of their care in new ways, and the public will save health care dollars.

While there are other regional health information exchanges throughout the country and in New York, BHIX has already become a model for others and attracted major state grant support.  Through an intense and sustained focus on the requirements of end-users by individual stakeholders and joint committees, BHIX has implemented a technical solution which uniquely meets the needs of clinicians and healthcare organizations.  As BHIX stakeholders are hospitals, nursing homes, homes care agencies and payers, the BHIX technical architecture has also been designed for a broad user group.  

The distinctive implementation of its technical architecture is evidenced in the BHIX portal design.  Data elements on the portal are organized, structured, and grouped in a manner designed by the BHIX Clinical Committee, not IT specialists.  For instance, medications may be displayed in a sorted order or grouped depending on the needs and wishes of individual practitioners.  Moreover, the BHIX architecture allows for exchange of digital information, scanned images, and unstructured reports and is therefore able to incorporate existing clinical records as well as newly digitized information.  Further, as previously noted, BHIX has modeled its consent process and architecture to minimize the impact to our stakeholders daily workflows.   BHIX plans to include community-wide clinical decision support, situating it on the cutting edge of health information transformation powered by HIT.

In the evolving world of health information technology, BHIX sought to implement a technical solution based on the needs of its local service area, while adapting to state and federal standards.  In doing so, BHIX overcame numerous technical, legal, and cultural obstacles.  Among the technical difficulties faced during implementation, BHIX had to resolve technical networking problems in which some BHIX stakeholder systems were unable to consistently securely connect to the BHIX system. Today, all initial BHIX stakeholders securely connect to BHIX and routinely transmit patient health information.  Further, BHIX had to balance the desire for a complete set of discrete, standardized data with data quality issues from legacy systems.  To overcome these and other technical issues, BHIX also had to coordinate with stakeholders' own internal IT projects and resource limitations.

Patient privacy concerns and federal and state law and policies have greatly influenced BHIX.  In order to avoid obstacles in obtaining patient consent that could minimize the usefulness of the system, BHIX recognized the need to educate patients  as well as develop a technical architecture capable of transitioning to new and evolving privacy standards for clinicians.  The diversity of the Brooklyn community also created complications for obtaining patient consent.  BHIX's multicultural and multilingual environment meant that BHIX educational materials and consent forms would be needed in seventeen languages.  

BHIX has grown in a New York State environment favoring innovative health information technology projects.  BHIX has been fortunate to have received the largest total state grant funding of any regional health information organization in New York State.  Further, the members of the BHIX consortium and its leaders eagerly came together to support this initiative and look forward to participating in future state and federal programs to support the exchange of health information.

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While BHIX's efforts have focused on Brooklyn, the lessons learned have positioned BHIX to provide a model as well as support in other communities.  As BHIX has demonstrated, collaboration and innovation can integrate and improve quality, efficiency and safety of medical care.  In the future, BHIX looks to continue to broaden and deepen its utility to patients and clinicians by using a standard-based exchange of data to more easily integrate with a broader range of (now) separate provider systems.

Fifty clinical champions immediately adopted use of the BHIX portal.  These early adopters represent the full range of practitioners who will eventually utilize the BHIX system as it expands and develops over time.  Along with physicians and nurses, many other health care practitioners, such as pharmacists, case managers, and patient representatives received training on the BHIX portal.  By implementing the planned expansion of the BHIX architecture and more direct integration with electronic medical records, BHIX looks to extend the number of users and the ways in which the timely provision of data and clinical informatics influences the delivery and management of care.