The federal government is spending a significant amount of time and resources on encouraging the development of health information exchanges (HIEs) and is enabling physicians to participate in these systems. But could the goals of these efforts -- which include decreasing costs through limiting duplicative testing and improving care coordination -- be accomplished through market forces?
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That question was debated at the latest meeting of the Health IT Policy Committee's meaningful use workgroup. Members agreed encouraging doctors to transfer data electronically could have major benefits for the health care system, but disagreed on how best to achieve this goal. Some said regulations are needed, while others thought emerging payment models, such as accountable care organizations (ACOs) -- which demand a high level of data exchange -- could set up market imperatives that force physicians to participate in health information exchanges, regardless of any government regulations.
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Neil Calman, M.D., a member of the workgroup and CEO and president of the Institute for Family Health, said physicians will participate in HIEs to the extent their communities do. It doesn't make sense to require a doctor transfer a certain number of patient records if that physician's partners are not participating in HIEs. Regulations won't be what drive participation in exchanges, he said.
"Once the capability exists within the local communities for people to be able to exchange information, people [are] going to do that because there's going to be no reason not to do it," Calman said.
But workgroup member Amy Zimmerman, the Rhode Island state health IT coordinator, disagreed. She accepted that accountable care organizations and other payment models that require enhanced levels of collaboration will eventually encourage greater participation in HIEs, but didn't feel it was a reason for regulators to take their foot off the gas pedal when it comes to encouraging participation.
Zimmerman said the surest way to guarantee goals for HIE participation are achieved is to put in place multiple factors that encourage participation. Regulations could complement market forces to make sure all physicians start exchanging data in a meaningful way.
"My opinion is that you need multiple drivers all converging toward the same point," she said. "The more alignment in the divers, the more convergence; the more you can give someone a reason to do something, the more you're going to get it done."
The comments could have implications for future stages of the meaningful use rules. The workgroup was discussing how best to encourage HIE participation through the Stage 3 rules. Getting more physicians to transfer data electronically has been a major goal of the electronic health record incentive program from early on. But if the industry moves toward HIE on its own, it may not be necessary for the regulations to require it.
One possible outcome is the future stages of the meaningful use could put in place broad frameworks that describe the format data must be in to be exchanged through HIEs, while not necessarily requiring physicians exchange data.
Once the capability exists within the local communities for people to be able to exchange information, people [are] going to do that because there's going to be no reason not to do it.
Neil Calman, M.D.,
CEO, Institute for Family Health
For example, Paul Tang, M.D., vice president and CMIO for Palo Alto Medical Foundation and chair of the meaningful use workgroup, said future regulations could mandate that all summary of care documents contain specific data fields with information entered in a standardized format. However, the rules may not necessarily require all fields be filled out in all cases or that physicians submit summary of care documents at a specific threshold.
Zimmerman said regardless of what is happening in the private sector to drive participation in HIEs, this kind of regulation is necessary to ensure standardization. Otherwise, it will be difficult to guarantee all physicians in the country will be able to access the records of all patients -- which is one of the ultimate goals of the program. Additionally, foregoing standardization in a health care environment that emphasizes coordination could place extra burden on electronic health record (EHR) vendors, who would have to support many different standards.
"I would assume that if the market is going that way it's helpful to have some standardization, because you're going to get a lot of apples to oranges otherwise," Zimmerman said. "I would assume it would put a significant extra burden on vendors."
Putting in place some form of data transfer standards could also make it easier for private organizations, states and regional groups to start their own HIEs. For example, Tang said it takes most HIEs many months and sometimes years to draw up data use agreements. The legal considerations that go into developing these frameworks can be complicated. Each new HIE takes the time to develop these rules, but future meaningful use rules could put in place a standardized data use framework, which would save groups time.
"We're all reinventing the same thing, having the same discussion," Tang said. "If we had a federal floor then all of a sudden we could bypass a lot of that work."
The panel concluded any discussion of HIE regulations must account for changes taking place in the health care system. With the Stage 3 rules not set to take effect until 2016, many new developments are likely to emerge. Projecting the level of care coordination that will naturally enter the health care system will play a large role in getting future HIE regulations right.