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About the series

As health care moves rapidly toward a value-based delivery model, a greater emphasis will be placed on care coordination. We must ensure that patients not only get the right care at the right time in the right setting, but also that every part of the delivery system is connected and understands that a patient's need will be critical going forward. Information technology will be instrumental in making sure that these connections take place and in providing clinicians with valuable new decision support tools.

H&HN, with the support of AT&T, has created this yearlong series called Connecting the Continuum to explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans. Each month, we will examine such topics as health information exchange, mobile health and transitions of care. Follow the Connecting the Continuum series in our magazine and in our e-newletter H&HN Daily.

It was once about the technology. Health information exchange — that set of activities concerned with getting clinical documentation from the places where it was created to other places that could really use the information — lacked some basic components: a critical mass of computer systems to create discrete data; standards allowing data from one electronic health record to be taken in by another; and routine methods to transmit the data anywhere it needed to go.

The federally stimulated push for providers to adopt EHRs and use them meaningfully, along with maturing efforts to standardize both the content and the transport of clinical documents, lowered the technology barrier but elevated a new issue for health care leaders. There are now distinct approaches to planning and executing HIE, each with its own pluses and minuses:

Regional or statewide: a public-private endeavor to extend data-sharing across many or most health facilities in a market, with all the governance, legal and cost-sharing implications.

Enterprisewide: a private approach to getting HIE going relatively quickly within the confines of a health care organization, covering all aspects of its growing continuum of care including independent physicians, post-acute sites, home care services and so on.

Direct: the use of a new standard for securely transmitting data via text and attachments using standard email technology adapted specifically for health care. Called direct, it's dependent on compiling and maintaining directories of electronic addresses for participants.

Regional initiatives have been a challenge just to get started. "You're trying to convince fierce competitors to come together and share information for the benefit of the community, to advance population health and seek efficiencies," says Keith Kelley, a vice president of the Indiana Health Information Exchange. "That's a much tougher sell" than using the private or direct approaches, he says. But the alternative of enterprise-level exchange, he adds, doesn't solve how to manage patients who get care outside that organization. IHIE is among a handful of regional exchanges succeeding at that level.

The shift in reimbursement and overall care delivery toward taking on more risk for the health status of defined populations has created incentives to speed up development of HIE. Requirements for cross-organization data-sharing in the next phase of meaningful-use criteria have punctuated the need. That might rule out regional ambitions in favor of simpler enterprise-level efforts, but HIE technology and legal best practices have evolved to the point that "the time to get from nothing to a full-fledged regional HIE wouldn't have to be years, it could be months," says Marc Overhage, M.D., chief medical informatics officer of Siemens' health care services business unit and former CEO of IHIE.

That said, private HIEs are an easier first step for organizations to tie care units together, using commercially available technology and take advantage of prototype legal agreements among new partners, which had been "one of the harder things to get right," Overhage says.

The quickest route to information exchange, though, is the direct route, says Kenneth Kleinberg, a managing director with the Advisory Board Company. "We want to be able to send an electronic document in a standardized format to any other provider, whether in our network or not. If we have the address, we can do that," he says. "That covers an awful lot of the gaps [in exchange capacity] that we've had in the past." Direct also "can be used to meet a lot of the criteria of meaningful use just by itself," he adds.

Technologically, a tiered approach can incorporate the quicker options and move to the regional scope over time. "We're advising most clients to take care of their own first, including a private HIE to make sure they're connected with their key stakeholders," Kleinberg says. "And then we ask them to consider what value there would be in participating with regional and/or state initiatives."

A lot depends on what's going on in a health system's area of coverage, says Linda Reed, R.N., vice president and CIO of two-hospital Atlantic Health System, Morristown, N.J. Atlantic began with an internal HIE plan using a certain vendor, discovered that competing providers with overlapping coverage were doing the same, and engineered an initiative called Jersey Health Connect.


For those who doubt that HIE on a large scale can be plausible and sustainable, IHIE's Kelley points to the 18,000 medical providers in Indiana and 2,000 others across the Illinois state line, that are paying for a service that gathers clinical reports and results from various sources and routes them expeditiously to their intended destinations.

Another service aggregates patient data from more than 60 hospitals and sorts it to compile clinical abstracts on patients seen in emergency departments. IHIE is connected with other HIE nets at the northern, eastern and southern boundaries of Indiana. And it's racing to implement a backlog of new contracts for participation, which will bring a total of 90 hospitals online. Other services create clinical performance reports from the stored data.

The aggregation aspect is key for organizations seeking to take risk for populations, he says, because a private HIE can't cover all bases. Out-of-network care surely will beset ACOs without the means to track it. Kelley cites a recent study by the Regenstrief Institute of 7.4 million Indiana ED visits that showed more than 40 percent involved patients with data at multiple institutions — just one indicator that organization-specific HIE will come up short.


New Jersey had no HIE in the works at the state level, so Atlantic Health six years ago started using a commercial HIE network builder and operator called RelayHealth for things like secure messaging and prescription orders or renewals, and gradually added services for its health care providers. Interest from other provider systems, and a $3.3 million federal grant funneled through the state, have made RelayHealth the de facto HIE tool for the northern part of the state with 18 member systems, up from 13 two years ago, says Atlantic CIO Reed.

But if a regional HIE effort is in place, "then you have a different decision set: Do you continue to roll out something within your organization that might be different … or do you not put in something at your facility level and go with what the regional tool is? It really depends on what you've already got in place," Reed says.

Some members of Jersey Health Connect had begun internal HIE development with other vendors, but the now-regional HIE service has been able to deliver data to the doorsteps of those organizations and has the existing infrastructure to take it the rest of the way, she says.

Stages of HIE Development

  1. Starting: Recognize the need for HIE in a community or region.
  2. Organizing: Define shared goals and objectives; address funding, legal and governance issues.
  3. Planning: Turn goals and objectives into tactics and a business plan; secure funding.
  4. Piloting: Technical, legal and financial implementation is well under way.

Advanced initiatives

  1. Operating: Fully operational organization, transmitting data used by health care stakeholders
  2. Sustaining: Fully operational, according to a sustainable business model
  3. Innovating: Fully operational, sustainable and providing added value such as advanced analytics, quality reporting and decision support