The Next Frontier

As these new exchanges take off, challenges surface around the inherent differences in data standards and structures

With meaningful use requirements mandating the act of health information exchange, HIEs are set to evolve forward rapidly to meet myriad needs for the exchange of vital data and information going forward. Yet even as HIE development picks up pace, the “elephant in the room” around their development remains the overarching, yet unavoidable, question of sustainability.

What's more, the rapid pace of HIE development of late has also led to a proliferation of data exchange models and protocols, further fragmenting an already fragmented sector. Among the numerous elements in the HIE constellation include the still-emerging framework of the National Health Information Network (NHIN), the various state-level cooperative agreements, and a galaxy of different types of local HIEs, which may encompass just a single healthcare delivery system, or alternately may include numerous competing local health systems, according to Marc Overhage, M.D., Ph.D., CEO of the Indiana Health Information Exchange.

Still, as far as the overarching issue of sustainability is concerned, some industry observers believe that things are looking up at the moment. For example, Cynthia Porter, president of the Atlanta-based Porter Research, finds the current climate promising, with a recent survey her organization produced finding 250 reported HIEs in the country, 18 of which are self sustaining. “What this really suggested that was exciting was that HIEs can be self sustaining, without grant funding and the benefits of HIE are being demonstrated,” she says.

A HYBRID APPROACH

As if HIEs weren't already wildly diverse on many levels (including governance, funding, and organizational membership), their leaders are taking diverse approaches to data architecture, as well. Some, like Maine's statewide HIE HealthInfoNet, have implemented a central repository model, while others, like the Indiana Health Information Exchange, are taking a federated approach, and still others are blending the two models. John Druke, a partner at KPMG, and Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, both believe that the federated model will win out as the standard, as they believe that a repository model can be too unwieldy to manage. Jason Hess, general manager of clinical research at the Orem, Utah-based KLAS Research, believes more HIEs will adopt a hybrid approach. “Wouldn't it be better [to share information] with an edge server approach, where that data is behind each entity's firewall, but then certain elements be easily shared?” he asks.

WHAT THIS REALLY SUGGESTED THAT WAS EXCITING WAS THAT HIES CAN BE SELF SUSTAINING, WITHOUT GRANT FUNDING AND THE BENEFITS OF HIE ARE BEING DEMONSTRATED.-CYNTHIA PORTER

THERE'S NOT A MODEL TODAY THAT'S PROVEN COMPREHENSIVELY TO WORK. THE TRANSITION POINT TO SUCCESS WILL INVOLVE HIES PROVIDING VALUE BACK TO THEIR PARTICIPANTS.-MIKE BEATY

At the same time, Hess sees the crowded vendor market growing in maturity, noting that a few years ago, many HIE vendors had only one or two clients, and now the same ones have four to five clients. He and others interviewed for this story cite the recent acquisitions of Axolotl (San Jose) and Medicity (Salt Lake City), by United Health Group's Ingenix Division (Eden Prairie, Minn.) and Aetna (Hartford, Conn.), respectively, as a bellwether for more consolidation and health plan participation in the future. “I believe the recent acquisitions are clear indicators of their [payers] interest in health information exchange either as a host of an exchange or as a beneficiary of the information flowing through it,” says Druke. “It's not clear exactly how they plan to use those assets, but I believe they view themselves as a part of any major exchange.”

Tripathi wonders who may be next in what he calls a move toward vertical integration in the HIE vendor space. “And are there other entrants who might think of this, like a pharma company,” Tripathi speculates. Hess brings up a concern echoed in provider and patient circles about privacy issues and what information health insurers will have access to. He doubts if putting up a firewall will be enough to set the minds of providers at ease, and recommends insurers embark on a clear public relations mission to assuage the fears of the community.

THE ELEPHANT IN THE ROOM

After all is said and done, whatever data models and vendor approaches continue to emerge, sustainability remains the major question mark in this whole area, including in the eyes of HIE participants themselves. Doubtless, there are different roads to this destination, but all those interviewed for this article agree that HIEs must provide value back to their participants to remain relevant. “There's not a model today that's proven comprehensively to work,” says Mike Beaty, managing director, KPMG Healthcare. “The transition point to success will involve HIEs providing value back to their participants.”

Tripathi points to the Indiana HIE's Quality Health First program, which uses data to get better compensation for physicians and better performance measures for health insurers, as a good example of how HIEs should leverage their data. “We synthesize the data from claims that those payers [Wellpoint, United, among others] provide, plus the clinical data that the providers provide and deliver that to physicians every month, and the payers use that as a basis for their quality improvement incentives,” says Indiana HIE's Overhage.

Beyond sustainability, Overhage sees other challenges that could stymie this burgeoning market.

For one, organizations must be willing to trust each other and break down their institutional barriers to share data. Another difficulty he cites is breaking down the actual barrier between information silos and mining data out of legacy data systems, which can be very expensive and time-consuming. “Today, the only solution I know of is hard work,” Overhage says. “It's not technologically difficult work, but there's a lot of it.”

KPMG's Druke also sees the very nature of HIEs, an amalgam of many large, complex projects with numerous stakeholders, coupled with supporting infrastructure that is still maturing, as being extremely onerous. Hess also notes that HIEs lack a set of data standards-some HIEs still use CCD, while others use HL7-that would make interoperability much easier.

ACOS AND BEYOND

Overhage sees the future of HIEs as significantly linked with that of ACOs. “It creates a real driver for organizations to commit to health information exchange, because it's the only way they are going to have the data they need to take care of their patients,” he says. Hess concludes, “It's not technology-everyone can do that. It's all of the rules and the value you derive from the HIE. That's where a vendor who is savvy can come in really help.”

Healthcare Informatics 2011 March;28(3):18-22