Spotlight on HIEs and EHRs

Jack L. Buxbaum

Healthcare IT is rapidly gaining attention thanks to the spotlight on healthcare reform, which partially revolves around the development of health information exchanges (HIEs) and leveraging electronic healthcare records (EHRs). Many healthcare organizations are challenged to find a way to transform HIEs and EHRs from concept to reality. By integrating an HIE into existing technology, a healthcare organization or public health entity can have one cohesive healthcare system that delivers more value from the technology investment.

HIEs: A look back

HIEs are essentially the creation, deployment and operation of technologies that support the exchange of healthcare information electronically. Thanks to healthcare legislation, HIEs are receiving a lot of attention. However, they've been around in some form or fashion for 30 years.

The first semblance of an HIE capability was in the 1980s, when there was a proliferation of clearinghouses that offered a service to route claims and other financial and administrative transactions between providers and payers for a fee. Many healthcare organizations justified the costs in order to streamline business operations and improve revenue cycle management. Eventually, this process became automated and standardized across the industry, thanks to the introduction of HIPAA and the adoption of electronic data-interchange standards.

In 1987, non-profit organization Health Level Seven (HL7) was founded to provide a comprehensive framework and standards for the exchange, integration, sharing and retrieval of electronic health information in support of clinical practice and the management, delivery and evaluation of health services. At the time, efforts to establish information sharing between caregivers focused on a linear linkage between physicians and their affiliated hospitals. Later, community health information networks (CHINs) emerged to support a “many-to-many” relationship between caregivers within a community — a precursor to today's HIEs.

Challenges

While HIEs undoubtedly facilitate safer, faster, more efficient and effective patient-centered care, they're not without challenges.

Since inception, there have been obstacles in standardizing clinical data exchanges throughout the healthcare information landscape. This is in large part due to the fact that the language used in patients' medical records is not standardized, making it difficult for HIE systems to interoperate and to identify patients and locate their records across numerous provider organizations. Another factor contributing to this challenge is the lack of a unique healthcare identifier for every individual in the U.S.

Additionally, a number of non-technical challenges have applied pressure on the emergence of exchanges — from the days of CHINs to present-day HIEs — including:

• Governance — what entity will take ownership of oversight and operations? What governing board and constituents will participate in formulating its strategic direction? How will the many competing interests within a community be corralled and focused on a common interest in information sharing?

• Operating model — developing and executing a model to manage the technology, the user support, contracts, subscribers, financials, etc.

• Provider outreach and adoption — engage physicians and other caregivers to join the exchange as both data source providers and as users. Assure provider adoption of the exchange. Align with other influencers.

• Economic sustainability — how will the exchange remain viable after exhausting start-up funding from public and private sources?

• Policy and enforcement — opt-in and opt-out policy decisions, managing privacy and perceptions, assuring uniform adherence to policies across a large region, etc.

• Participation agreements — development of agreements to be signed by participants using the exchange that takes into consideration the various and at times conflicting interests of stakeholders within a community, region or state.

• Data use and reciprocal support agreements (DURSA) — similarly, development of agreements to be signed by data source providers (e.g. commercial reference laboratories, hospitals, health systems and diagnostic imaging centers).

Where to start

Creating an HIE generally starts with a planning exercise, followed by defining business, technical and functional requirements of the HIE and EHR capabilities. As in the business world, the planning phase is also essential to secure early funding to jumpstart the initiative and identify future funding sources to sustain operations.

Success of the HIE will largely depend on balancing the need to plan and execute all of the “soft” as well as the technical aspects of an HIE. The key is to be sure many of those softer items are addressed simultaneously with the selection of technology. Absent from that approach, the soft items will very likely bog down the deployment of the technology, features and functions — and certainly its adoption and the long-term viability of the HIE entity.

Synergies with EHRs

For providers looking to integrate EHRs into HIEs, there are a few things to consider. Since the advent of the American Recovery and Reinvestment Act (ARRA) and the funding it appropriated via the Office for the National Coordinator of Health Information Technology (ONC) to eligible providers for adoption of EHR applications, there was the need to agree upon a standard definition for EHRs and meaningful use. The ONC settled on an EHR definition and selected several firms to confer ONC certification to vendors' EHR application suites.

In order for eligible providers to avail themselves of ONC funding derived from the ARRA program, they need to acquire a certified EHR. ARRA funds are meant to defray a portion of the investment necessary to acquire and deploy an EHR solution suite. Providers also need to demonstrate meaningful use of the EHR they acquire. The criteria for meaningful use necessitates that the EHR is electronically interconnected with other healthcare entities in order to share information among caregivers, order diagnostic services (such as laboratory tests and radiology exams) review the results of those diagnostic tests and exams, and order prescriptions.

This has led to the need to interconnect any number of provider organizations and other healthcare entities, such as reference labs and public health entities, via HIEs. These HIEs must be capable of integrating with both ONC-certified EHRs and other nonstandard healthcare applications.

Help through outsourcing

It often makes sense for an organization pursuing an HIE implementation to engage a strategic partner to support its planning effort and assist in identifying opportunities for HIE alignment with the interests of its community. A good partner provides support in selecting and managing HIE vendor selection. It can assist in establishing a governance model for the HIE and provide a baseline of best practices associated with other successful HIE initiatives.

While partners help in these areas, it is prudent for an organization to work directly with a vendor on the creation of an operating model, adoption programs and development of an economic sustainability model. The best vendors are very experienced in the provision and deployment of an HIE, as well as the ongoing operation of information technologies that underlie and comprise an HIE and EHR program. The vendor selected should be experienced in the rigors of establishing policies, developing participation agreements and DURSA, creating and supporting provider outreach and adoption (including meaningful use) programs. Successful vendors also have the collective knowledge of best practices in establishing various economic sustainability models.

Case in point: Kentucky

The Commonwealth of Kentucky has been integrating various data source providers, such as large integrated delivery networks, into its HIE framework. The commonwealth's Cabinet for Health and Family Services, which sponsors a statewide HIE across Kentucky, has outsourced to ACS, a Xerox company, the design, deployment and maintenance of the technical and application foundation of the statewide HIE and “EHR Lite” program. What sets Kentucky apart from many states across the nation undertaking such complex initiatives is the attention to detail in matters only indirectly related to information technology.

Kentucky took steps very early in the planning and execution of its statewide HIE to address many considerations, including:

• Determining the governance and operating models of the HIE;

• How it would be sustained over time; and

• Socialization and development of the many policies and procedures, including areas such opt-in/opt-out, the development of stakeholder and user agreements and alignment of state legislation to the strategic direction of the HIE.

These early steps have significantly enhanced the pace with which the HIE is embraced and adopted by the commonwealth's stakeholders, participants and users.

Jack L. Buxbaum is vice president, HIE services,
ACS, a Xerox company.
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