Speak to enough people embarking on health information exchange (HIE), and it becomes apparent that there is no single way to get it done.
There are state HIEs, which received funding under the Health Information Technology for Economic and Clinical Health (HITECH) Act, and thus far have achieved varying degrees of success. In addition, there are dozens of regional health information exchanges, many of which predate the HITECH Act and focus on smaller geographic areas or individual health systems.
Beyond that, there are different ways to share patient data. The American Health Information Management Association has identified four models of health information exchange, which vary depending on where the data is stored and whether members push it to other participants, pull it from a central clinical data warehouse, or do both.
At the Healthcare Information and Management Systems Society's HIMSS 2011 conference, it was clear that willing participants in information exchange aren't necessarily waiting to plug into state HIEs and their purported successor, a nationwide health information exchange -- especially because, in the words of one industry analyst, federal HIE remains a "pipe dream" with "countless hurdles."
HIE technology brings focus to patient-centered care
For Dr. Thomas Deas, a member of the North Texas Specialty Physicians (NTSP) board of directors, it's a critical time for health information exchange. "Technology is not the inhibitor at this point," he said. "It's the politics."
The traditional method of obtaining patient data -- calling another physician's office to have records faxed, if they were even retrievable -- was both "sporadic" and ineffective, Deas said. To that end, NTSP, a privately owned group based in Fort Worth, developed its own HIE technology, known as SandlotConnect, in 2008.
SandlotConnect lets physicians exchange patient data, such as diagnoses, medications, allergies and lab results, Deas said. Users also can access discharge summaries, X-ray reports and a list of all the providers a patient sees. The SandlotConnect module can be accessed via a Web portal -- Deas has used it on an airplane and in a hotel room -- or directly through an electronic health record (EHR) system.
Deas was at HIMSS 2011 in part to promote SandlotConnect, which NTSP now is making available as a commercial product and which now includes dashboards for quality reporting and clinical decision support. It's not uncommon for institutions to sell a product they have successfully developed and deployed internally, he noted.
Organizations focused on patient-centered care, especially as it is defined in the accountable care organization model, would start to see information exchange as "something they need to do," Deas said, adding, "The focus is coming around to where it should have been all around."
Need drives private health information exchange initiatives
Patient-centered care also demonstrates that physicians are far from alone in administering care, noted Lorraine Fernandes, global health care industry ambassador at Initiate, which IBM acquired last year. Nurses, nurse practitioners, registered pharmacists and even medical equipment companies also play a role -- and they need the information that until recently always resided in data silos at the doctor's office.
Like Deas, Fernandes said health information exchange initiatives succeed when participants first accept that patient data indeed belongs to patients, not to physicians. From there it becomes a matter of governance: identifying who has access to which data, and establishing a clear audit trail, because patients have a legal right to know who has seen their personal health information.
"You need to spend a lot of time building that trust and collaboration model," she said.
Fernandes sees two related reasons for the growth of private HIEs, including those at UMass Memorial Health Care in central Massachusetts, CareSpark in northeastern Tennessee and University of North Carolina Health Care. With many states' HIEs not yet off the ground, private exchanges meet their more immediate needs -- and in doing so, these organizations will be ready to participate in the state HIEs when they do come online.
All in all, there is a "common road" with "many on- and off-ramps" to health information exchange, Fernandes said. "None is right or wrong; it's simply based on an organization's goals and objectives."
Technology is not the inhibitor at this point. It's the politics.
Dr. Thomas Deas, member, board of directors, North Texas Specialty Physicians
Three key goals of HIE technology
By and large, the goals of health information exchange are threefold -- monitor patient health, enhance patient care and reduce the cost of care.
Shortly after the Washington, D.C., regional health information organization (DC RHIO) was formed in 2007, the Center for Health Information and Decision Systems (CHIDS) at the University of Maryland's Robert H. Smith School of Business conducted research on behalf of the organization to learn how established HIEs met those goals.
The research, presented by CHIDS Associate Director Kenyon Crowley during an education session at HIMSS 2011, looked at three health information exchange initiatives that began in the late 1990s: Cincinnati-based HealthBridge, the Delaware Health Information Network and the Michiana Health Information Network, which serves southern Michigan and northern Indiana.
In studying those three networks, CHIDS found that the most important use cases for health information exchange focus on "replacing intensely heavy administrative process[es]," particularly those that involve a series of phone calls, Crowley said. Linking to imaging systems, though difficult, benefits all participants as well, he said: "[Labs] are one of those key pieces of information that provide value to physicians within a community."
Using health information exchange to foment trust, collaboration
The CHIDS study also identified a number of pitfalls to health information exchange. For starters, a lack of comprehensive research can make the sales pitch to potential participants difficult, Crowley said. Incorporation of immature or "disappointing technology," such as personal health records, also poses a challenge, he said.
In addition, profitability and even the sustainability of an HIE organization are a challenge. Initially, neither physician nor payer participants can be counted on as substantial funding sources, so grants should be considered. (DC RHIO, for example, was funded through a three-year grant that drew from tobacco settlement funds.) From there, contracts should include both up-front and quarterly fees, with additional charges placed on more premium services, Crowley said. The quarterly fees will provide funding for additional IT investments, he said.
Finally, like Fernandes, Crowley touted the importance of governance. Achieving a "broad representation of stakeholders" -- one that includes payers, IT firms and small providers, in addition to larger integrated delivery networks -- should drive governance, as well as community engagement, he said.
With broad support, DC RHIO, and other health information exchange initiatives, can appeal to additional stakeholders, such as private practices and commercial labs, Crowley said. That can boost trust and collaboration both within DC RHIO and in the patient population, and those connections can turn the focus to patient-centered care -- where, as Deas said, it should have been all along.
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