The Louisiana Public Health Information Exchange (LaPHIE) is a partnership between the Louisiana Department of Health’s Office of Public Health (LDH OPH), several large hospital systems, and the Louisiana State University (LSU) Health Care Services Division. The bidirectional exchange connects hospital system electronic health records (EHRs) with state surveillance data. Providers use the exchange to identify and relink people with HIV who are out of care to clinical and supportive services. Since LaPHIE was implemented in 2009, thousands of people with HIV who were out of care have been identified, with a significant number being successfully linked to care. During an 18-month period from December 2020 through May 2022, alerts were triggered for 873 people with HIV based on the LDH-OPH out-of-care list. Of these, 673 (77%) had a subsequent care visit where a CD4 or viral load test was conducted.
While engagement in regular medical and supportive services, receipt of antiretroviral therapy (ART), and viral suppression are associated with improved outcomes and reduced HIV transmission, retention in care for people with HIV remains a challenge. However, individuals with HIV who are not in care may still engage with the healthcare system, particularly emergency departments or clinics, for other health issues, but traditionally there is no system in place to identify these individuals when they access services at other medical facilities. The LDH and LSU team implemented a real-time bidirectional information exchange between the hospital systems and LDH OPH to create opportunities for linkage and reengagement to HIV primary care.
“LaPHIE taps into electronic health systems and illustrates just how effective the coupling of surveillance and EHR systems can be.”
LaPHIE optimizes the use of EHR and surveillance data infrastructure. When clients are admitted at a participating facility including Our Lady of the Lake Hospital System, Lallie Kemp Regional Medical Center, and University Medical Center, an electronic notification is sent to LaPHIE, which compares registration data to the out-of-care dataset to identify a match. If a match is found, (based on first name, last name, date of birth, and social security number), an electronic message is immediately returned via the facility’s EHR system, and email notifications, an alert, and action prompts are displayed for the authorized physician, nurse, or medical facility staff.
Once notified, the clinician is prompted to take a series of suggested actions, including clinical support recommendations. The prompt also includes a structured documentation tool to record in the EHR which actions have been taken.
Key staff members may take suggested actions, including:
- Discuss LPD OPH alert and underscore the importance of HIV treatment.
- Re-order a confirmatory test.
- Assess stage of illness.
- Schedule or refer the client for a follow-up appointment with the appropriate provider.
- Counsel pregnant client(s).
- Document any client report of HIV treatment receipt at another facility (and the name of that facility).
- Confirm client is not interested in treatment at this time.
Once a client is successfully linked to HIV care and supportive services, a message is returned to LDH OPH to update the out-of-care dataset, determining which individuals should be considered for linkage and re-engagement. If no new viral load test is performed and received by LDH OPH, the client will remain on the LDH OPH out-of-care list, and clinicians will continue to receive linkage prompts each time the client presents for medical services.
During the original evaluation conducted between February 2009 and July 2011, 549 alerts identified 419 unduplicated individuals with HIV who did not have a CD4 count or viral load in over one year. A more recent analysis revealed that of 873 out-of-care people with HIV identified through LaPHIE, 673 (77%) had a recent CD4 or viral load test, indicating a return to care.
The OPH LaPHIE database interfaces with the participating facilities’ EHR system to create the LaPHIE dataset, which contained thousands of records of people with HIV who appeared to be out-of-care, as defined by the absence of CD4 or viral load data within the last nine months.
Initial Evaluation (February 2009–July 2011)
Recent Evaluation (December 2020–May 2022)
Sources: Magnus M, Herwehe J, Gruber D, et al. Improved HIV-related outcomes associated with implementation of a novel public health information exchange. Int J Med Inform. 2012;81(10):e30-e38. (original evaluation), and verbal communication (recent evaluation)
“A significant number of clients with HIV who were out of care have been effectively linked back into care and treatment thanks to LaPHIE.”
- Public health department-hospital collaboration. The success of LaPHIE depends on the close collaboration between a public health agency (LDH OPH), and several participating healthcare facilities, to facilitate the use of surveillance data to inform medical personnel of needed clinical care.
- Confidentiality protection. Privacy and confidentiality remain critically important considerations for LaPHIE's continued operation. The implementation team convened a legal compliance and ethics workgroup that included medical ethicists, physicians, nurses, public health experts, attorneys, and people with HIV. The workgroup helped inform the development process and made sure project activities fell within legal parameters, were ethical, and benefitted the people it served.
- Community input. Community focus groups were coordinated by an independent market research firm and included potential clients, clinicians, and public health staff. The focus groups gauged public support and acceptance of LaPHIE.
- Staffing. Key project staff included a project coordinator, responsible for oversight of the project activities and design; surveillance manager, responsible for oversight of surveillance, HIV and sexually transmitted infection care, and prevention programs, data entry and analysis; technology manager, crucial in ensuring that data was encrypted, transmitted, and stored securely, and that only the minimally necessary information was shared. Later, staff added systems analysis for integration, application development for system enhancements, and database support for overall database architecture.
- Stakeholder buy-in. LSU and LDH OPH engaged in several efforts to secure buy-in from key stakeholders: agency leadership, attorneys, clinicians, clients, and the public. These efforts included key informant interviews, focus groups, workgroups, provider and healthcare system conversations, and trainings.
“The intervention has to balance individual rights and protection of the public’s health."
- LaPHIE success is contingent on connecting with the healthcare facility’s EHR. With the ever-changing improvements within the technology sector, this poses its own unique set of issues. Coordination of system improvements need to be planned and discussed with all LaPHIE participants and stakeholders.
- LSU and LDH OPH collaborated with an unaffiliated private hospital to expand implementation of LaPHIE beyond its initial scope.
- Several system-level changes at LSU, including the privatization of most LSU system hospitals, has impacted the continued growth of LaPHIE. OPH has recruited and hired necessary staffing with available program funding to continue this effort.
- Direct engagement with the managing organizations (notably Our Lady of the Lake Hospital System & University Medical Center) are ongoing and have been productive. University Medical Center efforts are ongoing and are expected to soon be on par with other participating facilities.
- A distinct advantage for sustainability and expansion is the large governing organizations (hospital systems) made up of multiple facilities. This approach from a “hospital system” perspective will reduce the resources required to integrate additional facilities that share system-level funding, EHRs, and technical resources.
- Close collaboration and coordination were essential to the success of LaPHIE. Complex technological projects depend on buy-in from multiple stakeholders, highly detailed planning, and several considerations pertaining to technical approaches, logistical strategies, and legal hurdles. Alignment of mission, vision, goals, and readiness among all key stakeholders is critical.
- Clinical staff in non-HIV care settings, such as emergency departments, may have limited experience providing HIV-related services and support. Education and training for these staff may need to be considered prior to implementation.
- Because of the complexity of the bidirectional data exchange and the sensitive nature of the data involved, rigorous testing was conducted to make sure all components of the information technology infrastructure worked correctly prior to implementation.
- Implementation involves getting data agreements in place, system planning, testing and scheduling of go-live for the production system.