Two New Health Affairs-Published Studies Provide Intriguing Insights Into HIEs' Current Struggles

Oct. 4, 2016
Two studies of the health information exchange phenomenon, published as articles in this month’s Health Affairs, offer important insights on gaps, problems, and challenges facing HIE development going forward

Healthcare policy researchers have published two very important articles in the current, July issue of Health Affairs, that look at aspects of the health information exchange (HIE) phenomenon. Both are thoroughly researched, with a great deal of detail and of nuance, and I would strongly encourage Healthcare Informatics readers to read both articles very carefully and thoughtfully. What’s more, both sets of (overlapping) researchers come to conclusions which, though stated with great diplomacy, are quite significant in their implications. So let’s plunge in and consider both articles.

The two articles are entitled “The Number of Health Information Exchange Efforts Is Declining, Leaving The Viability Of Broad Clinical Data Exchange Uncertain,” authored by Julia Adler-Milstein, Sunny C. Lin, and Ashish K. Jha; and “Engagement In Hospital Health Information Exchange Is Associated With Vendor Marketplace Dominance,” by Jordan Everson and Julia Adler-Milstein. Both articles were extremely carefully researched (with very detailed explanations of study data and methods in both); I won’t go into the very complex details here.

But let’s begin by summarizing them as saying, essentially, that, per the first article, HIE appears to be a fairly fragile phenomenon in the wake of the loss of most federal and state funding in the past two years—something that has been widely known—with a strong need for operating HIEs to prove strong market value (though that term is not used) in order to survive; and, per the second article, even more diplomatically stated, intense market dominance by a few large electronic health record (EHR) vendors is having a huge impact on how HIE is pursued in markets in which a single vendor dominates. Fascinatingly, the authors of the second article do make it clear that the impact of market dominance on the part of the Verona, Wis.-based Epic Systems Corporation is quite different from that of market dominance on the part of any of the other largest EHR vendors—the Kansas City-based Cerner Corporation, the Chicago-based Allscripts, or the Westwood, Mass.-based Meditech. With regard to that second article, as much is left unsaid as is said—but more on that shortly.

The first article, by Adler-Milstein, Lin, and Jha, is in some ways the more straightforward, though the arithmetic involved is a bit mind-numbing. As the authors state in their abstract, “The diffusion of health information exchange (HIE), in which clinical data are electronically linked to patients in many different care settings, is a top propriety for policy makers. To drive HIE, community and state efforts were federally funded to broadly engage providers in exchanging data in ways that improved patient care. To assess the current landscape,” they write, “we conducted a national survey of community and state HIE efforts that, as a group, engaged more than one-third of all US providers in 2014. However, the number of operational HIE efforts is down from 119 in 2012, representing the first decline observed since the tracking of these efforts began in 2006. Only half of operational efforts reported being financially viable,” they note, “and all efforts reported a variety of barriers to continuation. These findings raise important questions about whether the current vision for HIE efforts will allow for the broad exchange of clinical data, or whether alternative approaches would be more successful.”

Adler-Milstein, Lin, and Jha go into very extensive detail writing about the current landscape of HIE in the U.S.; suffice it to say that the bottom line is one that has become clear to everyone in the HIE world, though it is highly commendable that these researchers have documented the phenomenon in such detail. Essentially, they find that HIEs are stumbling in attempting to sustain themselves now that federal and state funding have for the most part evaporated, with not enough hospitals, physicians, or health insurers willing to actually pay for simple sharing of summary of care documents. “Developing a sustainable business model was the most prevalent barrier to HIE progress in both 2012 and 2014,” the authors note. “This was closely followed by integration of HIE into provider workflow, a barrier that we asked about for the first time in 2014. Lack of funding, a second financial barrier, was reported as substantial by almost the same percentage of respondents in 2012 and 2014. Two other barriers asked about for the first time in 2014—limitations of current interface standards and lack of resources to implement interface standards—were also identified as substantial barriers by roughly one-quarter of the respondents,” with 20 percent of respondents also citing “competition from health information technology vendors offering HIE solutions as a substantial barrier in 2014—and increase from 2012.”

Wading into some of the statistics around the finances and operations of HIEs as documented by these researchers is an important, if somewhat dispiriting exercise. But what is more heartening is the authors’ points of analysis around where HIE leaders might productively head next. “Our results suggest that key stakeholders—such as imaging and lab facilities, the public health sectors, and payers—are participating at low rates, which may limit the value achieved… Together, these factors suggest that HIE efforts may need to offer value beyond facilitating the transmission of clinical data—which, although clinically important, is not something provider or payer organizations have been willing to pay for at a meaningful level. Instead, HIE efforts will likely need to generate value from that data, perhaps through analytics, decision support, and patient engagement.” That conclusion matches perfectly what I found in interviewing leaders of successful statewide HIEs—organizations that are thriving because they are providing real-time or near-real-time alerting of patient events and other data and information that is of timely value to providers (and sometimes payers). I wrote about this in our 2015 Top Tech Trends, interviewing leaders from the Maine, Michigan, Ohio, and Colorado statewide HIEs; I and my fellow editors have also written particularly extensively about Devore Culver and his and his colleagues’ particularly strong success with Maine’s HealthInfoNet. That HIE’s groundbreaking innovations with notifications to providers of patient events, speak strongly to the potential that these authors point to in their analysis.

The authors also suggest another intriguing possibility. “Given that federal funding for state and community HIE efforts is unlikely to become available in the future,” the authors write, “policy makers might consider new ways to help existing entities succeed. States could support them in serving as the source of HIE for all state Medicaid patients and as the warehouse for clinical data on these patients.” That, to my mind, is a very solid suggestion with great sustainability potential. In any case, the authors of the article point up very articulately the many challenges, and smaller number of opportunities, going forward.

Now, when it comes to the second article, there are even more implications. “Health information exchange (HIE) is intended to enable better, more efficient healthcare by electronically transferring patient data across provider organizations,” authors Everson and Adler-Milstein write. “Many policymakers, including members of Congress, are concerned that some electronic health record (EHR) vendors may be impeding this effort by making cross-vendor HIE difficult. We used national data to assess how market dominance by EHR vendors was related to hospitals’ engagement in HIE in 2012 and 2013,” they write.

“Across all levels of vendor market dominance, hospitals using EHR systems supplied by the dominant vendor engaged in an average of 45 percent more HIE activities than hospitals not using the dominant vendor,” the authors continue. “However, when the dominant vendor controlled a small proportion—20 percent—of the market, hospitals using the dominant vendor engaged in 59 percent more HIE activities than hospitals using a different vendor. Conversely, when the dominant vendor controlled 80 percent of the market, hospitals using that vendor engaged in only 25 percent more HIE activities than hospitals using a different vendor. In markets with low vendor dominance, hospitals may engage in less HIE with hospitals using other vendors’ systems, compared to markets with high vendor dominance, because of high costs and competitive barriers. Policies designed to promote cross-vendor HIE may need to take local market competition into account,” they state.

Now, here’s where things get really interesting: Everson and Adler-Milstein performed detailed analysis looking at four EHR vendors—Epic, Cerner, Meditech, and McKesson—and the impact that their relative dominance in different markets had, on HIE development. The analysis was necessarily complex. And by the way, their statistics on relative market dominance are quite valuable, and ones that I’ve never seen elsewhere: the authors find that Epic accounted for 23.5 percent of all hospital beds in the 2,924 hospitals they studied, while Cerner accounted for 19.9 percent of beds, Meditech, for 15.9 percent of beds, McKesson for 9.3 percent of beds, Allscripts, for 6.9 percent of beds, and Siemens, for 6.4 percent of beds. I’ve not yet seen this kind of breakdown, and it shows Epic’s EHR-market dominance in concrete terms that get beyond the current-hospital-implementations figures we so often see, but which don’t fully convey Epic’s growing U.S. healthcare market dominance.

In any case, what the researchers found in this study was interesting. Essentially, it boils down to this: in the markets in which Epic is dominant as an EHR vendor, its dominance is having a what some might consider to be a counter-intuitive impact, in effect suppressing HIE development among hospital organizations that aren’t Epic customers. Here’s how the authors put it: “We found that, overall, hospitals that used the dominant vendor in their market engaged in more HIE than hospitals that used a different vendor. This was counterbalanced by our finding that greater vendor dominance was associated with greater hospital engagement in HIE for hospitals that did not use the dominant vendor. However, that positive spillover effect held for only a subset of vendors, and not the largest vendor (Epic). These results suggest that concerns about EHR vendors’ dominance impeding HIE may be merited, and that dominant vendors in competitive markets may be least likely to facilitate HIE with other vendors.”

This is, indeed, a phenomenon that is being widely spoken of these days. As Epic sweeps implementation bid contests and puts a vendor stranglehold on numerous metropolitan and regional healthcare markets, the use of its pseudo-HIE capability known as Care Everywhere is actually making it less likely that hospital organizations that are not customers of Epic will work to architect local and regional HIEs of their own. That reality makes sense, if one thinks about it. As one vendor becomes the 800-pound gorilla in a local market, the ability to convince potential end-users (especially practicing physicians) to participate in a trans-organizational HIE when the market already has a dominant one, becomes that much more difficult.

Kudos to those researchers for doing thorough analysis and offering analysis and insights that policymakers need to consider as they attempt to stimulate HIE nationwide, at a moment of fragility and risk. Let’s be clear: there’s no “magic bullet” to any of this, and any vendor that becomes as dominant as Epic is becoming in many, many healthcare markets, creates distortions in certain developmental patterns in those markets. But for federal policymakers to ignore some of the market-driven changes taking place in the HIE landscape could also ultimately prove counter-productive.

In the end, both of these articles should prove important to all those involved in the broad enterprise of health information exchange. And the editors of Health Affairs should be congratulated for devoting as much space to the topic of health information exchange, a subject that doesn’t always get the attention it deserves on a policy-analytical level.

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