A study of health information exchanges (HIEs) across the U.S. reveals that 56 percent plan to participate in the government’s Trusted Exchange Framework and Common Agreement (TEFCA) framework that aims to connect islands of electronic data sharing.
The research, conducted by Julia Adler-Milstein, Ph.D., a professor of medicine and director of the Center for Clinical Informatics and Improvement Research, School of Medicine, at the University of California San Francisco (UCSF), and others at UCSF and the Office of the National Coordinator for Health IT (ONC), was published in the May issue of Health Affairs.
The researchers noted in their piece that the TEFCA national framework creates new potential opportunities and challenges for state and local HIEs. As such, they undertook their sixth national survey to assess the current state of HIEs and to newly examine anticipated responses to TEFCA. They identified 89 operational HIEs—or as the authors refer to them throughout the article, HIOs (health information organizations)—down from 106 in 2014. Although more than half of these health information exchanges struggled with financial viability and competition from health IT vendor–based HIE networks, many are large in scale, offer a breadth of services to diverse participants, and engage in network-to-network connectivity, they concluded.
Looking ahead, 56 percent of HIEs reported that they plan to participate in TEFCA, and 41 percent were unsure. As the Trusted Exchange Framework and Common Agreement advances basic network-to-network connectivity, HIEs that have experience with such connectivity while also offering value-added services will be well positioned for sustainability and growth, the researchers opined.
TEFCA was released by ONC in January of 2018 in a first-draft form and in April 2019 in a second-draft form. Broadly, it is intended to provide a common set of rules and operating procedures with the intent of having a single “on-ramp” to nationwide connectivity. One element in TEFCA is its vision of Qualified Health Information Networks, or QHINs, which would be entities that the federal government would authorize as transportation mechanisms to route information between participant organizations. In other words, QHINs will connect directly to each other to facilitate nationwide interoperability, such that once a participant—such as a hospital, health system or an HIE—signs up with a QHIN, they will be able to connect with other participants in the TEFCA network.
One of the unanswered questions in this landscape is what types of organizations might become QHINs in that framework. Some of the activity taking place right now with statewide HIEs building multistate networks or entities might potentially position those collaboratives for QHIN status down the road.
Indeed, as the researchers wrote, “A federal approach that moves toward connecting HIOs to each other and to national networks (such as eHealth Exchange) comes at an already dynamic time for HIOs. There is a growing trend of HIO consolidation, perhaps in response to tremendous pressure to demonstrate a robust value proposition—particularly one that goes beyond simply moving data across participating organizations. Therefore, TEFCA offers opportunities (in terms of offering HIO participants expanded connectivity) as well as risks (in terms of more directly competing with other HIE networks that offer the same connectivity). Because participation in TEFCA is voluntary, it is critical to assess the current HIO landscape and how HIOs anticipate participating in TEFCA, to gain early insight into progress toward nationwide connectivity under the Common Agreement.”
For the study, the researchers set out to answer multiple key questions, including: What is the current state of HIEs in the U.S. in terms of number, financial viability, geographic coverage, size, and scope of services? What are the key barriers to their ongoing development? To what extent are they connecting to each other and to national HIE networks as early signs of readiness for TEFCA? What proportion of HIEs plan to participate in TEFCA, and how do they differ from those that are not?
To ascertain which organizations met the researchers’ criteria to be classified as an HIE, the screening questions asked respondents to determine whether, as of Jan. 1, 2019, the organization was supporting operational electronic HIE among independent entities. Those who met this criterion went on to complete questions that covered organizational demographic characteristics, such as: the number and types of participants involved in data exchange; the types of data exchanged; geographic coverage; information about the organization’s current connections to other networks, as well as their plan to participate in the proposed TEFCA; and barriers to development. Of the 151 organizations on their initial list, the researchers concluded that 89 HIEs met their inclusion criteria.
HIEs by the numbers
According to the study data, while the number of operational HIEs increased from 2007 to 2012, researchers found that this number decreased by approximately 25 percent from the peak of 119 in 2012 to 89 in 2019. Similarly, the number of financially viable HIEs increased from 2009 to 2014 but decreased by 6 percent between 2014 and 2019. However, the proportion of operational HIEs that were financially viable increased from 24 percent (28 of 119) in 2012 to 46 percent (49 of 106) in 2014 and 52 percent (46 of 89) in 2019.
The data also showed that 45 states, including Washington, D.C., were covered by one or more operational HIEs that reported a statewide catchment area. There were six states without coverage (Idaho, Illinois, Mississippi, Montana, Nevada, and New Hampshire), which included 301 health service areas (9 percent) of the total 3,436 health service areas in the country. A total of 2,770 health service areas (81 percent) in the U.S. were in the catchment area of at least one operational HIE. Notably, 32 percent of health service areas had more than one HIE.
What’s more, several measures of maturity were examined. The largest group of HIEs had been operational for six to 10 years (57 percent). HIEs achieved scale in terms of the number of participants: the median number of hospitals providing data to the HIE was 24, and the median number of providers able to use the HIE was 3,000 (with an estimated 73 percent considered active users, on average). HIEs also achieved scale in connecting to multiple EHR vendors—the median being 12—and in facilitating data exchange for a large population of patients; the estimated median number of patients in the HIE’s master patient index was 2.49 million.
Meanwhile, the most prevalent data types exchanged by HIEs included medications (90 percent), problems (87 percent), laboratory results (84 percent), and immunizations (83 percent). The most prevalent general services offered by HIEs included receiving patient information via Consolidated-Clinical Document Architecture (C-CDA) documents (88 percent), alerting services (83 percent), and community health record (81 percent).
Value-added services—defined as those that go beyond the basic services needed to exchange and manage patient-level data—were offered less often, with “providing data to allow analysis by network providers” offered by 53 percent of HIEs. The next most prevalent value-added services were analytics (39 percent), generating quality measures (34 percent), and reporting quality measures to payers and programs on behalf of participants (30 percent), the data showed.
How many HIEs participate in national networks? More than half reported connecting to other HIEs in the same state (57 percent) and in different states (53 percent). Most HIEs also reported that they participate in a national network including eHealth Exchange (67 percent), DirectTrust (46 percent), and Strategic Health Information Exchange Collaborative Patient Centered Data Home (38 percent).
Specifically regarding TEFCA, the 56 percent of HIEs that plan to participate in the framework were similar to HIEs not planning to participate or didn’t know, in terms of size, duration operational, financial viability, selling or providing their infrastructure to other HIEs, buying or using infrastructure from another HIE, and connecting to other HIEs in the same state.
However they did differ on two characteristics: whether they connect to other HIEs in different states, with 64 percent of TEFCA participants saying they do, compared with 38 percent of those that were not planning to or not sure about TEFCA participation; and whether they participate in at least one national network, with 90 percent of TEFCA participants saying they do, compared with 72 percent in the other group.
Meanwhile, the most prevalent barrier to development reported by HIEs was competition from health IT vendors offering HIE networks, reported by 63 percent of HIEs. This was followed by integration of HIE into provider workflow (51 percent), competition from other HIE efforts (42 percent), and addressing federal government regulations and developing a sustainable business model (both 37 percent).
As far as stakeholder participation, the most commonly reported inpatient setting that contributed and viewed or received data were private medical and surgical acute care hospitals (contributing information in 93 percent of HIEs and viewing or receiving it in 91 percent). Among ambulatory care settings, the most common was hospital-owned or health system–owned physician practices (in 82 percent and 92 percent, respectively). Community health centers or federally qualified health centers contributed data in 78 percent of HIEs and viewed or received data in 90 percent. Similarly, independent physician practices or practice groups contributed data in 76 percent of HIEs and viewed or received data in 89 percent.
Other stakeholders that are considered to add value from engaging in HIE participated less often. These included public payers, contributing data in 43 percent of HIEs and viewing or receiving data in 58 percent of HIEs; private payers, for which the respective shares were 36 percent and 56 percent; long-term care providers, at 53 percent and 66 percent; independent laboratories, at 65 percent and 24 percent; and public health departments, at 38 percent and 69 percent.
In the end, the researchers concluded, on the HIE landscape in the U.S., “A subset appears particularly well positioned to take advantage of new opportunities under the Trusted Exchange Framework and Common Agreement, based on their experience with network-to-network connectivity and by offering a breadth of services to attract new participants.” But, they added, “persistent HIO concerns about competition from health IT vendors’ HIE networks suggest that some HIOs may struggle to participate in TEFCA and grow their base of participants and revenue unless they offer value-added services…. To offer value and remain financially viable, HIOs that do not already do so will likely need to provide services that go beyond facilitating the transmission of clinical data.”
They further asserted that identifying key benefits for HIEs to engage in efforts such as TEFCA will be critical. “With TEFCA, HIEs can connect to a variety of networks in a more seamless fashion, enabling their end users to limit the number of different networks in which they need to participate to exchange with others. For HIOs, this may minimize the need to create point-to-point interfaces and make it easier to access data from entities that may have previously had difficulty connecting.”
