From meaningful use requirements to participation in accountable care organizations, there is no shortage of pressure on health care providers to share information more effectively. In fact, payment reform can be considered the major stimulus behind the increase in health information exchange.
Payment arrangements that reward high-quality, cost-effective management of a patient's care over time and between various care venues will incent providers to invest more deeply in HIE. Yet, to date, the level of exchange across the country is well-below our collective aspirations. According to recent industry data, 30 percent of U.S. hospitals and 10 percent of ambulatory practices send and receive data through HIE.
While the barriers to widespread HIE have been well-documented — most notably, maintaining a sustainable business model and working with immature interoperability standards — the Office of the National Coordinator for Health Information Technology has defined a sound framework for both accelerating HIE and advancing standards and interoperability.
Additionally, meaningful use criteria for Stages 2 and 3 will ask more of providers with regard to HIE, attempting to spur greater demand for and participation in exchange efforts while challenging providers to overcome the roadblocks.
Improving Care across the Continuum
Health information exchanges come in a variety of flavors and exist through various types of organizational arrangements. In some cases, an HIE could be provided by a regional or state organization that facilitates a public exchange among all providers in a geographic area. In other cases, the exchange likely will be provided by a hospital or health system that wants to initiate targeted interoperability with ACO participants or to simply increase information exchange (and, thereby, affinity) with community physicians.
Regardless of the organizational structure or technical platform used to support the exchange, there are notable benefits for a health system participating in HIE:
- establishing, managing and expanding referral and test/procedure order patterns within the ambulatory community;
- growing physician affinity through technical connectivity and marketing activities, regardless of the physician's electronic health record technology;
- improving physician access to clinical information, including lab results, radiology studies, discharge summaries, etc.;
- increasing connectivity between specialists, post-acute care and primary care;
- messaging across transitions of care, supporting care planning and other patient coordination activities;
- engaging patients in their own care and connecting them with providers;
- supporting the efforts of public health agencies and purchasers of care to understand disease patterns and changes in care quality and efficiency.
A successful, sustainable HIE's economic model and business structure often is based on self-interest. While some cooperative models based on altruistic intent succeed, they are, unfortunately, the exception rather than the rule. Successful ones usually are directed by strong leaders and run by a supportive community with a passionate, patientcentric commitment that combines self-interest and benevolence in a manner that provides sustainability.
One such HIE is run by Inspira Health Network, a community health system comprising three hospitals in southern New Jersey, with more than 5,000 employees and 800 affiliated physicians.
With nearly 40 EHRs connected to the exchange and more than 600 providers using its clinical portal capabilities, Inspira's HIE has strengthened the ties of its physician community to the organization. Since Inspira competes for ambulatory practice business, the HIE makes it easier for physicians to get data into their electronic health records, providing access to the latest information on their patients from member providers practically anywhere. Whether they're in the hospital or in the office, physicians see the complete picture of the patient as aggregated among these members.
Beyond the physician community, Inspira boasts some creative connections to its HIE, including its fitness center, which may receive physician referrals and can deliver an electronic report back to the practice and even notify a physician if a patient doesn't show up as expected.
Additionally, Inspira's home health agency gets lab results delivered right to its EHR — a huge benefit when nurses go to a patient's home and have the latest patient information right at their fingertips. Inspira case managers also use the HIE to help coordinate care and identify patients who need to be placed into rehab centers or long-term care facilities. The exchange enables them to proactively provide relevant information about a patient through secure electronic transmissions to applicable facilities that service their area. This can lead to more efficient and effective discharge planning and, thereby, help to reduce patient length of stay.
Operating a private HIE does not preclude a provider from joining other exchange services. Inspira is also a member of its regional HIE, which was formed with two other health systems in the southern part of the state. Participating in the regional network enables Inspira to share data in a broader area and jointly pursue federally funded grants to offset HIE expenses.
While streamlined, secure information exchange prepares health care organizations for payment reform, it is also key to realizing the desired quality and efficiency gains to be derived from the nation's substantial investment in electronic health records.
Like Inspira Health Network, a number of providers have done some terrific work getting their exchange efforts off the ground. Key learnings from their experiences are worth sharing:
Try a phased implementation. Resist the temptation to bite off more than the exchange can chew at the launch. Cast a wide net to all care community members, concentrating on simple initial use cases (e.g., sharing clinical information originating in the hospital) and grow from there. A phased approach allows the HIE to deliver immediate value, generate support and enthusiasm, and make learn-as-you-go adjustments.
Even with simple information exchange capabilities, caregivers have easier access to more comprehensive information to improve treatment planning and optimize care transitions. With a staged feature deployment approach, the exchange can progress from simple results distribution to multidirectional communication and eventually coordination of sophisticated workflows.
Keep the patient front and center. One of the thorny parts of participating in an HIE is the myriad decisions members will need to make regarding their shared information. For example, what data need to be exchanged for an ACO to perform well? Who's ultimately responsible for data security? How much do we share and with whom?
Indeed, HIE members will need to think long and hard about whether they prize cooperation and transparency over competition and secrecy. Despite the devil living in all these details, most operational HIEs have found that if they keep a focus on what's best for the patient, many seemingly complicated decisions become much easier.
Know your community and stay connected. Designating an outreach coordinator who knows the community and its key health care stakeholders can make a huge impact on the success of the HIE.
It's also important for all members to work collaboratively to understand the data flow needs and changing requirements of other participants. As such, instituting regular HIE user group meetings for decision-making, progress reporting, issue resolution and ongoing community outreach efforts will help to ensure that the HIE continues to meet the needs of all participants.
Get creative with connections. Facilitating secure information exchange with a broad community of health system participants will help organizations to deliver more coordinated care, increase the productivity of staff members and, ultimately, improve the economics of care delivery.
When you're thinking about where information gaps exist within the community — where time and money are spent on calls, faxes and postage — look beyond practices to include other members of the health care continuum whose information needs are not being met. Additionally, each time a connection is added, use the opportunity to redesign and optimize processes, especially during care transitions between providers.
Tap physicians to help with expansion. If physician response to the HIE is lukewarm, cultivate practice champions or physician liaisons to inspire their peers by discussing the benefits they're seeing from using the exchange.
Working with the HIE outreach coordinator, practice champions can serve as excellent trainers for those who need help getting up to speed.
Don't overlook non-EHR users. Health systems initiating an HIE may be hesitant to offer Web-based clinical portal capabilities, for example, to practices not using an EHR, fearing that such capabilities would delay EHR adoption in a practice that perceived its clinical IT needs were being met adequately through the HIE.
This was a key inspiration for Inspira, which does not hesitate to roll out HIE capabilities to practices that are still planning an EHR implementation. With the benefit of hindsight, Inspira leaders now know that the HIE can deliver immediate efficiencies to even paper-based physician offices — and could very well help steer them toward EHR adoption as they desire increased functionality.
Check your sources. Those initiating an HIE are wise to work with their vendor and participating partners to perform a thorough data analysis of all source data. This will help to ensure that the exchange can consume, transform and distribute a broad range of transactions in a variety of formats.
A Critical Linchpin for Better Care
Health information exchanges, which enable disparate organizations to share patient data securely, have emerged as a core element of health care reform and the delivery of high-quality, safe and efficient care. HIEs can deliver tremendous value by facilitating more coordinated care among hospitals, physician practices and key members of the health care continuum, such as skilled nursing homes, home health agencies and durable medical equipment suppliers.
Although we've seen considerable growth in the number of HIE efforts, particularly over the past two years thanks in part to HIE-related meaningful use criteria and ample state and federal funding, substantial challenges still exist.
Overcoming technical and legal matters, addressing privacy and security concerns, and tackling the sustainability issue will continue to be a key focus for policymakers, purchasers of care and providers that engage in their own HIE efforts. Furthermore, to derive maximum improvement in care quality and efficiency, our health care organizations and public institutions will need to expand beyond local- and state-level HIE efforts to achieve a more widespread adoption of HIE across state lines.
This expansion will be made possible by current and future payment reform efforts and meaningful use requirements focused on exchange and patient engagement capabilities, driving continued growth in local HIEs. When those exchanges join regional or state HIEs, the result will be a larger system of providers from which to pull data and, therefore, greater benefits for patients. For example, with such expansion, we open possibilities to use the data aggregated and generated by HIEs to facilitate comparative effectiveness research or to enable syndromic surveillance reporting in support of a more rapid response to public health threats.
But, as we know, there is no running without first walking. And when it comes to truly overhauling the nation's health care system, there is no such thing as a sprint.
As such, we should applaud all those health care communities across the country — communities like southern New Jersey — as well as state-sponsored HIEs that already have achieved some potent gains in improving care coordination and efficiency. Indeed, with the industry's collective goal of becoming meaningful users of health information technology, now is the time to heed the call for HIE.
John Glaser, Ph.D., is the CEO of the Health Services business unit of Siemens Healthcare in Malvern, Pa. He is also a regular contributor to H&HN Daily.