To study the security and readiness of 21st-century health information exchanges (HIE), look at the Roman Empire, according to Robert Hudock, an attorney in the health care and life sciences practice of Epstein Becker & Green PC.
The Romans built an infrastructure of roads that facilitated communication, transportation and growth, but that system also served as the world power's downfall because invading armies could travel the roads as easily as Roman citizens, Hudock said last week in a keynote during the American Health Information Management Association's 2010 Legal Electronic Health Record (EHR) Summit in Chicago.
The creation of health information exchanges is on the rise as health care professionals use EHRs and adopt more health information technology in caring for patients. The eHealth Initiative, which monitors information exchange activity in an annual HIE survey, found a 28% increase in the number of operational HIEs, from 57 in 2009 to 73 now. Some 18 HIEs, in addition to being operational, have reached sustainability, where they are using revenue, not relying on federal funding, to survive.
The health care industry should consider the Romans' road system when it comes to national health information exchange. HIEs could lead to more effective communication among providers and stakeholders, but the networks also are a target for attackers trying to steal information, Hudock said. "We should be mindful in building this network that we don't make the same mistakes Rome did."
The growth in HIEs is tied in part to the federal meaningful use and EHR incentives, as dictated through the HITECH Act in the 2009 stimulus law. Doctors and organizations that adopt EHRs and follow meaningful use criteria will be eligible to receive incentive payments over the next five years of the program. Information exchange is a significant part of the program, with providers having to demonstrate in Stage 1 that they at least are able to transmit patient data electronically and send quality reports to other agencies.
HIEs responding to the eHealth Initiative's survey cited government mandates as the biggest challenge for their development. More exchanges also said some of their top data exchanges involved the information required under the meaningful use rule, such as delivering test results, electronic prescribing and discharge summaries.
Readiness is a key issue for organizations that want to exchange information. While the HITECH Act allocates funding to state-designated HIEs so they can be ready to meet meaningful use mandates, there are many more organizations working on their own exchanges before trying to connect to a state group.
The Fremont Area Medical Center is sponsoring a HIE for its 50 affiliated physicians in that Nebraska city of 25,000 residents. The goal is to connect the HIE eventually with the Nebraska Health Information Initiative in Omaha, the state's official HIE. To get there, however, the hospital first is helping the physicians implement EHRs and integrate those with its own system.
The medical center's three priorities are ensuring that the hospital meets meaningful use criteria, implementing EHRs in the ambulatory setting and developing the HIE, said Richard Beran, director of information services. "It can happen right from within."
The hospital has been working on its own IT systems since 2005, and believes it is on track to hit the targeted meaningful use criteria, Beran said. "I think the biggest concern today is getting the physicians' own EMRs[electronic medical records] up and running."
From a pure technical standpoint, we've done a pretty fine job.
Dr. Dan Martich, chief medical information officer, UPMC
While the hospital aids doctors there, it also is developing the HIE and discussing privacy, security, patient access and other exchange issues with the physician community. Doctors have expressed interest in the exchange and view it as a way of being able to communicate with one another about their patients, but it's not just about provider-to-provider information, Beran said. Fremont would like to keep information in a central repository to facilitate quality and population health reports, patterns and trends. "We see it as a huge advantage."
Fremont expects to create a subscription fee model for the information exchange. "We're going to make it reasonable to sustain the HIE," Beran said. "We see that as key."
The University of Pittsburgh Medical Center (UPMC) also is exploring the connection of internal and external exchanges. The health system has 42,000 registered users on its internal exchange, and is developing the western Pennsylvania HIE to broaden its reach.
UPMC believes its efforts complement the work of the state-designated HIE, said Christian Carmody, director of information services. "We've been closely monitoring those activities."
The western-region exchange is in the early stages, he added. The organization is working on developing exchange standards and structured data sets, and discussing trust and security issues among providers.
That standardization was key to ramping up internal interoperable efforts, said Dan Martich, a physician who is chief medical information officer for the health system. Before installing EHRs across the system's hospitals, UPMC determined structured data elements for such things as physician documentation and evidence-based order sets for computerized physician order entry (CPOE).
UPMC estimates it has deployed CPOE across about 79% of its hospitals and has 975 physicians on the ambulatory-setting EHR system. It feels on track for achieving meaningful use; but the evolving nature of health care means the work isn't done.
"From a pure technical standpoint, we've done a pretty fine job," Martich said. But installing the right processes, training people on new systems, and learning how to extract information from technical systems for things like quality measurement and comparative effectiveness are much harder to do. "It's what makes the lasting change."
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