With all the talk about electronic medical records (EMRs), electronic health records (EHRs), ICD-10 and meaningful use, it’s tempting to put health information exchanges (HIEs) on the back burner. But that’s not an option. Communicating in a digital healthcare environment without HIEs is like trying to navigate a highway system without freeways.
In a perfect world, HIEs would facilitate the sharing of data between doctors’ offices, hospitals and laboratories; everyone with a viable need would share records, and security levels would be determined by the type of information and who was asking for it. These free-flowing, robust systems would allow proprietary laboratory information systems (LIS), picture-archiving communications systems (PACS), EHRs and more from different vendors and hospitals to communicate seamlessly.
But if there’s one thing upon which we can all agree: The world is far from perfect. Motivated by a governmental push, HIEs are happening; it’s up to the vendors and end users to figure out how to best facilitate the process – from development to selection to implementation and, finally, the logistics of day-to-day use.
For our April issue, Health Management Technology reached out to several industry experts to round up their perspectives on some of the major issues involved with successfully implementing and utilizing HIEs.
Keys to HIE success, growth
Many HIEs are capable of helping providers exchange electronic messages. It’s a step in the right direction and certainly a welcome use of technology when it’s 2 a.m. and emergency department clinicians are trying to figure out something – anything – about the health history of the unconscious patient who has just been wheeled through the double doors.
But much more is needed to enable long-term, self-sustaining HIE success. Indeed, HIEs need to not only exchange information but need the “deep interoperability” that allows them to aggregate data, run business analytics queries, apply best practices from evidence-based medicine and then proactively deliver alerts and recommendations across an entire patient community.
To enable this more sophisticated exchange, the following are required:
- Participants who are willing to exchange comprehensive and critical patient data, as they trust that secure messaging protocols that comply with all regulations will prevent unauthorized access to private information.
- Technology that supports “semantic interoperability” that stretches beyond simple data exchange to actually harmonize data from different sources, making it meaningful for doctors and patients, rather than just moving the data around.
- Sustainable business models, ensuring that HIEs have the financial resources needed to procure technical components and services required to seamlessly integrate all participants.
- Alignment on the concept of data sharing among competing organizations, where leaders realize that exchanging information will result in the improved patient care that will be so critical under value-based purchasing models, while also addressing the underlying business needs of healthcare organizations.
With these elements in place, HIEs will realize success. Perhaps just as important, they will likely experience growth as well.
HIPAA final rule increases need for security
With this “Omnibus Rule,” which goes into effect later this year, organizations that have worked as business associates for covered entities must now review and update their security policies and procedures for handling protected health information (PHI). When sharing or transmitting PHI, additional security must be applied, or the risk of a data breach can have direct consequences, including civil liability and fines up to $1.5 million per breach or incident. To comply, business associates should:
- Ensure their record-keeping practices are sufficient to provide compliance reports to HHS;
- Be able to provide a PHI to patients who request it;
- Have a notification procedure in place in case a breach occurs; and
- Follow the HIPAA confidentiality requirements, and limit the use and disclosure of PHI.
Business associates will most likely need to update their agreements with covered entities – as well as with subcontractors – to comply with the Omnibus Rule by Sept. 23, 2013 (Sept. 22, 2014, for “grandfathered” business associates).
EHR vendors should collaborate with HIEs
Remember playing “telephone” and the funny, garbled messages that emerged at the end of the communication chain? Unfortunately, sending and receiving healthcare data can have the same outcome.
HIEs are a foundational element for the success of many health reform and HITECH Act initiatives. The variability and complexity of healthcare data offers unique challenges in exchange. For example, code sets for lab results have a high degree of variability; during the exchange process that variability poses problems when attempting to populate an EHR. Unless all data shared by HIEs is “normalized” and mapped to standardized medical terminology, such as SNOMED-CT, and transcribed notes and other free text are converted into structured text, these problems will continue.
Amped-up interoperability requirements under Stage 2 of meaningful use should fuel quick action. As early as Oct. 1, 2013, hospitals must have the ability to send discharge summaries to a patient’s primary care provider. This can be achieved through an HIE that can directly populate their EHRs with report data and test results. Eligible professionals will be subject to the same requirements starting Jan. 1, 2014, and will have the entire calendar year of 2014 to upgrade their EHR technology and adjust workflows to comply with the Stage 2 regulations.
To achieve HIE success, EHR vendors should collaborate with HIE connectivity vendors and HIEs to develop turnkey interfaces that enable seamless interoperability, which allows physicians and other healthcare providers to have access to the most complete patient data. e-MDs is working with the Bipartisan Policy Center, which published a report that identifies what’s needed to address some of these problems. The report can be accessed at BPC’s website, www.bipartisanpolicy.org.
HIE: 2013 trends and opportunities
With time, the concept of the HIE as a noun has gradually morphed into a verb. The organizational construct concerned with policies and procedures has become an actionable reality. Today, HIEs are literal networks across which patient data is actively transmitted securely to healthcare professionals in disparate geographic locations. The corporate structure – whether integrated delivery network (IDN), accountable care organization (ACO) or formally structured health information organization (HIO) – matters less than the value offered by data exchange.
This year will see HIEs continue to grow for two important reasons: interoperability standards and value toward sustainability.
Interoperability standards: Nationally adopted interoperability standards now have been incorporated by HIT vendors to facilitate the seamless exchange of patient data, irrespective of an organization’s specific EHR system. The Direct Project, for example, which enables the transmission of encrypted health information over the Internet, also makes it possible for physicians to participate in HIE even without an EHR.
Value proposition: Now that enough clinical information systems are collecting data, there is sustainable value in HIE the verb – from both patient care and operational standpoints. In addition to creating efficiencies in clinical workflow, HIE enables organizations to adapt more easily to emerging value-based reimbursement models.
Today’s trends focus on making current processes more efficient, and all of the elements are in place for an industry-wide tipping point. We are just now getting a glimmer of where the trends of 2013 are headed: toward data analytics. The emergence of HIE data captured in a way for analytics and decision support to be layered on top will not just improve care, but completely transform it.
Three key steps to improve HIEs
Exchanging relevant healthcare data is becoming increasingly important to care coordination and quality improvement efforts. These three key steps can help healthcare organizations improve the usefulness of HIEs for providers:
- Acquire meaningful data. While technology has made obtaining patient information easier, delivering information relevant to providers still poses a challenge. EHRs often require providers to pore over large amounts of data to glean the most important clinical information, which is not an efficient use of valuable time or resources. To make HIEs more effective, filtering mechanisms can be leveraged to pull the most meaningful information from an EHR, enabling providers to have the most up-to-date and salient clinical and demographic information available during a patient visit.
- Standardize data terminology. There are multiple ways to document many clinical terms. “Myocardial infarction,” “MI” and “heart attack,” for example, all indicate the same diagnosis. When two providers document the same event in the EHR using different terms, data duplication can result. While this minor duplication may seem harmless, these redundancies dilute effectiveness and muddle the HIE process. To improve HIEs among disparate providers and platforms, organizations must continue to work toward semantic interoperability in an effort to standardize clinical terminology.
- Increase technology adoption. Tools that allow healthcare organizations to enter and access clinical data in real time – including EHRs and patient portals – enhance the accuracy, detail and overall quality of data exchange. Since change is always difficult, healthcare organizations must work to encourage technology adoption by implementing solutions that are easy to use, explaining potential benefits clearly and making the technology convenient by aligning it with providers’ workflows.
The future of HIEs lies in the power of the network
HIE has been around for more than a decade now, but it really found its stride in the market with the passage of the HITECH Act in 2009. Since that time, the HIE conversation has tended to focus on the nuts and bolts of connectivity and integration – basic messaging transactions, formats, standards and terminologies.
I count myself among the HIE wonks who can have an impassioned conversation about things like HL7, CCD, IHE profiles and Direct. But the future of HIEs is not found in these discussions of how to build a standards-based network. We should have that figured out by now. The future of HIEs lies in how organizations can use the network to improve business operations and the quality of healthcare.
When all stakeholders in the healthcare continuum – regardless of their levels of technology sophistication – become part of a network where information flows freely and securely, healthcare organizations will have the power to solve long-standing challenges. Not only can they reduce medical errors by improving data sharing, they can also:
- Reduce waste at transitions of care;
- Drive consumer and provider engagement; and
- Gather insights for administrators and providers operating in a post-reform era.
A powerful network doesn’t just connect. It filters out information noise to deliver meaningful insights and drive quality improvements. It enhances patients’ understanding of their care. It helps physicians better serve their patients. And it helps health systems entering the realm of accountable care ensure their patients receive quality care. The future of successful healthcare reform will be network driven.
Unlocking the hidden value of HIEs
It’s time to apply the power of HIEs to the elusive goal of transforming population health. While HIEs are recognized as a critical enabling technology for EHRs, they also have enormous potential to impact care delivery and outcomes well beyond individual patients.
Secondary use of the vast amount of data captured across the healthcare ecosystem – including EHRs, claims/billing systems, research databases, clinical systems and laboratory systems, to name a few – will be essential to enabling and accelerating a new paradigm of population health. However, the largely transactional systems in place today were not designed with broader initiatives in mind and instead primarily support individual silos across the healthcare and health sciences ecosystem, which has precluded the integrated view that is essential for collaboration and secondary use of health data.
HIEs can address these fundamental challenges and, when combined with context-specific analytics, these foundational technologies hold the key to enabling productive secondary use of healthcare information and the advent of a new era of healthcare delivery.
To advance secondary use of health data, HIEs must support de-identified patient information, secure document exchange, clinical document indexing, a standard message format and an auditable document trail.
With these capabilities, healthcare organizations can begin to easily share data with public health registries and enterprise healthcare data warehouses focused on advancing population and epidemiological research, extending the volume and richness of available information. From there, advanced analytics – with retrospective as well as predictive capabilities – can drive productive use of secondary health data on a wide scale.
By investing in a comprehensive HIE infrastructure, organizations extend their ability to share data with other partners, which, in turn, can drive innovation in population health and new opportunities for collaboration.
Delivering compelling value to providers is key to HIE success
Today, most HIEs create value by aggregating and moving textual data, such as lab results and discharge summaries. However, this alone isn’t enough for them to get over the value hurdle, as evidenced by the number of HIEs struggling to reach critical mass and sustainability. To attain those goals, HIEs must offer greater and more immediate value by providing data and services that are difficult for physicians and hospitals to obtain quickly, easily and efficiently on their own.
One area where HIEs can deliver more value is through image exchange. Doctors can deliver better coordinated and patient-centric care across the continuum by seamlessly accessing, viewing and collaborating on their patients’ diagnostic quality images with a single click from within the context of the patients’ record. According to a September 2012 report from the Institute of Medicine, 25 percent of patients reported their providers had to reorder tests to have accurate information for diagnosis. Pioneering HIEs have integrated one-click access to diagnostic-quality images to promote care continuity and meet image-sharing requirements of MU stage 2. They are beginning to report that image exchange is enabling them to significantly minimize duplicate tests, enhance quality of care, improve physician and patient satisfaction, and reduce patient exposure to radiation.
Image-enabled HIEs have seen imaging increase the participation in their exchange, which is also aiding sustainability. Additionally, HIEs are indispensable partners for ACOs as they improve coordination, communication and continuity of care. And with images as an added value component, they are quickly thriving by saving additional unnecessary costs.
