LaPHIE demonstrates that real-time, bidirectional electronic information exchange can bridge public health and healthcare delivery, effectively leveraging EMR-based public health alerts, and linking patients into care. Preliminary analyses of LaPHIE reveal its efficacy at increasing linkage and retention in care, systematically improving individual and public health in one of the states most heavily impacted by the HIV epidemic.
Providers are responding to LaPHIE alerts at a higher rate than usually observed. Previous research has demonstrated that clinicians responded to ‘public health situational awareness’ alerts at rates of 2–65%.19
One critical factor identified as most influencing response to alerts is specificity.20
Furthermore, integrating contextually relevant information at the point of care has been shown to improve compliance with preventive care measures.21–23
LaPHIE alerts are patient specific, only issued on those in need of treatment and integrated into the work flow. Use of the iterative prototype design approach incorporating usability study findings has ensured LaPHIE meets all of the goals of any reminder system: ‘right information, right time, right person, right format.’21
More formalized qualitative interviews evaluating system value will examine implementation, utilization, integration in and impact on work flow, use of the LaPHIE Intervention Note, impact on patients, and overall system satisfaction. A purposive sample of at least 10% of clinicians exposed to LaPHIE alerts will be interviewed as part of the demonstration evaluation methodology.
The costs of the system are currently being evaluated. After development and initial evaluation efforts, resources (minimal personnel) to monitor the functioning of the system at the healthcare delivery and public health sides of the exchange are needed as are resources to grow the system as new opportunities to expand use are identified. Costs associated with all directly funded and in-kind personnel as well as infrastructure costs (hardware, network management) have been documented; the cost savings and cost effectiveness of the program have not yet been determined given that evaluation is still ongoing. Models to be used to quantify these will include cost savings associated with prevention of morbidity from patients entering care at an advanced stage of HIV disease as well as costs saved through the prevention of HIV transmission. Discounted lifetime costs to provide treatment for a patient with a CD4 cell count of <350 are estimated at $385 200 and undiscounted costs as high as $618 900 ($2100 per month, life expectancy 24.2 years).24
There is evidence that the annual costs of treatment and care are less for those who initiate treatment with higher CD4 counts.25–27
Potential savings per HIV infection prevented have been estimated at $266 600 (2004 dollars).24
Efforts such as LaPHIE will require additional public health and healthcare resources which are expected to contribute cost savings associated with healthier HIV patients and fewer new infections.
HIE defined as ‘organized entities that specialize in facilitating electronic HIE among a diverse group of often competing healthcare system stakeholders, such as hospitals and physician practices’16
has yet to be achieved in Louisiana. Nascent efforts are underway at the state and regional levels. Ideally, a public health informatics solution such as LaPHIE should reside within the infrastructure of a formalized HIE as the broker which could ‘serve up’ LaPHIE logic and CDS components on identified patients. LSU HCSD and OPH have built a system to address the issues of linkage and retention in care for persons with HIV which now can be customized to address other public health issues. The future system evolution will allow this approach to be scaled to a larger population base as disparate healthcare providers join a state or regional HIE and are identified as targets for this strategy.