Community-Based Information Exchange

EXECUTIVE SUMMARY

Mark R. Anderson

Many health providers have focused on community-based health information exchanges (HIEs) as a useful platform to help them take the next steps in implementing electronic health information. Recent research by a healthcare technology advisory firm is an attempt to characterize various HIE models, with an eye on achieving that goal.

Throughout history, major milestones have marked the evolution of modern medicine. Galileo's development of the microscope. Louis Pasteur's findings that airborne microbes, germs, cause disease. Roentgen's identification of X-rays. Fleming's discovery of the antibiotic attributes of penicillin.

COLLECTING AND STORING CLINICAL INFORMATION IN STANDALONE EHR SILOS CANNOT, IN AND OF ITSELF, SUPPORT DATA SHARING. FORWARD-THINKING HOSPITALS AND HEALTH SYSTEMS ARE GOING A STEP FARTHER AND DEVELOPING A FORMAL HIE INFRASTRUCTURE.

Each of these breakthroughs has had a transformative impact on healthcare, advancing providers’ understanding of the disease process, generating highly effective treatments, and improving the health and wellbeing of the population as a whole.

We stand on the edge of similar revolution today. The advent of health information technology (HIT) and newly enacted government regulations are forcing the industry to evolve. The model that has shaped care delivery and reimbursement in the past is undergoing unprecedented changes. Stakeholders along the entire continuum of care-beginning with the patients themselves, and progressing through physicians, provider organizations, health plans and payers-are altering how they view and manage the care processes.

Healthcare reform and meaningful use requirements under the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act have triggered accelerated interest in “next steps.” Many providers have rushed to implement electronic health record (EHR) systems, believing them to be the key to federal funding and effective data sharing.

They are quickly finding, however, that EHRs don't take them far enough down the path towards genuine health information exchange, which is vital to meaningful use and, therefore, government incentives. Collecting and storing clinical information in standalone EHR silos cannot, in and of itself, support data sharing. Forward-thinking hospitals and health systems are going a step farther and developing a formal HIE infrastructure. This strategy definitely represents progress, but it too has limitations. While some accessibility is clearly better than none, the typical hospital-to-provider HIE model creates a fortress of information, impenetrable outside of the hospital's network.

The approach that makes the most sense-and provides the greatest opportunity for scalability-is the community-based HIE, designed to facilitate interoperability among disparate EHR and other clinical information systems. Community-based HIEs provide the infrastructure and platform to share data not only across, but also beyond, a single enterprise. With comprehensive solutions in place, healthcare will be able to achieve truly patient-centric, multidisciplinary care coordination that will address the challenges facing the industry today: lowering healthcare costs while improving access and quality.

The Five Types Of HIE Functionality

Based on its research and ongoing dialog with community-based HIEs, AC Group categorized specific products and platforms according to five types of functionality. After doing so, it compared 16 HIE vendors to these five categories to assist healthcare organizations in matching system capabilities with their specific needs. For example, a single hospital looking for a federated system that will allow only its physicians to access information would require a Type 1 HIE, while a community of competing hospitals and provider organizations desiring to exchange discrete patient data throughout a region should consider a product categorized as Type 5.

Healthcare communities endeavoring to develop a fully functional HIE meeting HITECH requirements and enabling the effective flow of health information should ensure that their chosen solutions will meet long- and short-term goals. Implementing an interoperable product will create a sustainable system that, ultimately, will lead to improved patient outcomes through a higher quality of care coupled with controlled costs.

Types of HIE Functionality

Type 1	Provides physicians with access to hospital-based patient data. Traditionally governed by a single hospital. Provides sharing of hospital data with local providers. Does not allow for data sharing between providers nor provide a common patient portal, a patient specific personal health record (PHR). Does not enable advanced community reporting of clinical outcomes. Does not track community disease management protocol. Designed for a single hospital or a hospital exchange that wants to seamlessly provide hospital specific data to its providers in one common view. Traditionally, the data is viewed within the HIE. Data is not transferable into a provider's specific EHR product as discrete data.
Type 2	Facilitates data sharing between different practices utilizing the same EHR product. Through a specific vendor's data exchange protocols, specific patient data can be exchanged between multiple provider organizations. Can receive data from hospitals and laboratory facilities. Traditionally does not exchange data with other EHR vendor products. Can provide PHR capabilities, but only among practices using the same EHR product. Is usually governed by one hospital organization, or by a smaller local provider community.
Type 3	Provides data sharing between different practices that are utilizing a short list of different EHR products. Traditionally distributed by an EHR vendor claiming it can connect other EHR vendors with its product. Exchanges data using one specific vendor's data exchange protocols. Generally built from the ground-up, and utilizes multiple point-to-point interfaces. Can receive data from hospitals and laboratory facilities and provide PHR capabilities, but only with other organizations using the same EHR product.
Type 4	Has the ability to exchange discrete patient data, following CCD methodology, between multiple practices with selected EHR products, hospitals, radiology centers and laboratory facilities, even if they are on separate healthcare products. Provides a community master patient index (MPI) and a community patient portal for patient communications with each care provider. Data is able to be transmitted seamlessly into each provider's EHR as discrete data. Provides e-prescribing capabilities for those providers that have not embraced EHR technology. Often governed by a community of competing hospitals and provider organizations throughout a region.
Type 5	Has the ability to exchange discrete patient data, following HITSP C32 version 2.5 or higher CCD record format, between multiple practices with different EHR products and with hospitals, radiology centers and laboratory facilities, even if they are on separate vendor systems. Provides a community MPI and a community patient portal for patient communications with each care provider. The data is able to be transmitted seamlessly into each provider's EHR as discrete data. Should possess a community PHR capability, designed to provide each patient with a centralized location for demographics and clinical history. Provides e-prescribing applications for those providers that have not embraced EHR technologies and offers extensive disease management and outcomes measurement data capture and reporting. Is governed by a community of competing hospitals and provider organizations throughout a region. The goal is to improve the quality of healthcare in the community while reducing costs via patient data coordination.

Vendors Categorized Within Five HIE Types

HIE	Federated	Non-Federated
Type 1	Medicity Quest HIE Microsoft HIE Oracle HIE
Type 2	HIEweb Noteworthy Medical	NextGen eClinicalworks Medical Communication Systems
Type 3	dbMotion Intelichart Noteworthy Medical	NextGen Medical Communication Systems Intelichart
Type 4	Browsersoft Microsoft HIE Oracle HIE	Axolotol (Ingenix) HealthVision
Type 5	Wellogic	Health Access Solutions Excelicare

The tools developed to support this advanced functionality will no doubt be regarded as one of healthcare's most significant milestones.

Of course, any time of change is characterized by chaos. Healthcare leaders from coast to coast and border to border are seeking HIE solutions that are affordable and will help them make the transition from today's healthcare delivery model to those of tomorrow. Many vendors and service providers have jumped into this fertile market and offer a plethora of options-so many, in fact, that it is difficult to distinguish the grain from the chaff.

To sort through the options, the AC Group Inc.'s California office spent time both in 2009 and 2010 researching the value and limitations of various HIE models, and identifying solutions most likely to deliver the results healthcare stakeholders require to achieve the objectives set before them. The study involved 114 community-based HIE projects and input provided in a clearer picture of the benefits that HIEs expect to realize, the most common models coalescing through the country, and types of functionality that should be considered as an HIE is developed.

HIE PARTICIPANTS EMPHASIZE THE IMPORTANCE OF A FAILSAFE SYSTEM TO TRACK INDICATORS FOR ALL PROVIDERS TREATING THE SAME PATIENT. THUS CLINICAL DATA CAPTURED BY ONE PROVIDER CAN BE USED TO MEET THE MEANINGFUL USE REQUIREMENTS FOR OTHER PROVIDERS.

COMMUNITY-BASED HIE BENEFITS

The overall value that community-based HIEs expect and have begun to experience comes as no surprise. First and foremost, they demand timely data-sharing among all providers of care and the establishment of one centralized health record that can be assessed by the patient and authorized family members. As a corollary, HIE participants want to ensure that patients have complete control over the dissemination of their clinical information, in compliance with the Health Information Portability and Accountability Act (HIPAA).

Likewise, HIE participants emphasize the importance of a fail-safe system to track indicators for all providers treating the same patient. Thus clinical data captured by one provider can be used to meet the meaningful use requirements for other providers.

Cost savings is also an important and desirable outcome, HIE participants note. Well-structured HIEs, for example, can eliminate redundant form completion. Patient information such as demographics and coverage can be entered once and populate multiple databases, saving data-entry time and staff resources while reducing errors that carry their own price tag.

As part of its research, the AC Group also studied the liability healthcare organizations assume for uncompensated care provided in the ED. The findings indicate that HIEs have the potential to reduce uncompensated ED costs by as much as $500,000 for every 20,000 visits. Reviewing 3,120 ED visits, it determined that if clinical data were available to the ER physician at the time of encounter, patient time in the ED could be decreased by 26 percent and test costs reduced by 31 percent.

ESSENTIAL FUNCTIONALITY

Foundationally, the study revealed that community-based HIE solutions must exhibit three primary features, both to qualify for HITECH funding and to create a sustainable system that provides real value to both provider and patient:

The ability to create a community information hub that allows collaboration by multiple parties and create a master patient index developed from the subsequent information sharing;

Extensive clinical functionality, such as e-prescribing, an electronic health record (EHR), a lab reporting system, and an interface for imaging centers and hospitals; and

A common patient health record to involve patients in their care plans.

All three components combine to create a coordinated healthcare community, supporting advanced information sets such as order tracking, results, allergies and problem lists, as well as advanced reporting. To provide real value, HIEs striving to connect communities must follow the national Health Information Technology Standards Panel (HITSP) c32 Version 2.5 Continuity of Care (CCD) standard between multiple care providers and among varying EHR systems.

The $2 billion allocated from the HITECH stimulus package for the development of community-based HIEs has prompted communities and state organizations to actively search for the right vendor with the most appropriate functionality. The AC Group has found that community-based HIEs must display the capacity to interoperate with diverse provider systems. Likewise, an HIE's platform must be vendor agnostic relative to the various EHRs and clinical systems already in place.

When establishing a community-based HIE, leadership must consider whether to implement a federated (point-to-point data sharing with no centralized repository) or a non-federated model (based on a central repository for data). Each has its strengths and weaknesses, and a final decision is typically based on which approach is more tenable to the majority of participants.

Mark R. Anderson is CEO of AC Group Inc., Montgomery, Texas. He is a self-described healthcare IT futurist and a national speaker on healthcare, who specializes in the evaluation, selection, and ranking of vendors in the health information exchange and practice management system/electronic health record healthcare marketplace. Healthcare Informatics 2011 January;28(1):28-34