|By the Innovations Exchange Team, based on an interview with J. Marc Overhage, MD, PhD, Chief Medical Informatics Officer at Siemens Healthcare, Health Services|
Although estimates vary depending on the data source, there are as many as 280 health information exchanges (HIEs) in the United States that enable the electronic sharing of health-related information. One-half of the nation’s hospitals are now participating in a regional, State, or private HIE, and 71 percent plan to buy new HIE technology in the next 2 years.1 Furthermore, nearly one-half of the nation’s physicians plan to join an HIE.2
Innovations Exchange: What are some of the differences among HIEs?
J. Marc Overhage, MD, PhD: HIEs differ depending on their purpose, governance, and funding. Regional and State HIEs are often publicly financed, whereas local HIEs are privately financed. For example, Dignity Health, a provider in California, created an HIE to be used only by its hospitals and providers. In contrast, Geisinger Health System in Pennsylvania received Federal and health system funding to create the Keystone HIE, which is currently used by physicians and other health care professionals from several hundred hospitals and health care facilities in a 31-county region of Pennsylvania.
How would you describe a mature HIE?
A mature HIE has good financial operations. The funding can start with Federal or foundation grants, which should be treated as capital investments rather than operating expenses. The goal is to generate new services that can become self-sustaining once the grants end. The HIE also should have a good model for protecting privacy, engaging with patients, and gradually expanding its range of services.
A mature HIE has two other important dimensions: the number of patients and organizations that exchange data, and the level and type of functionality that is deployed. A mature HIE can expand the scale of its operations by offering a high level of services to a modest number of participants, or by offering a moderate level of services to a large number of patients. The services can include routing of orders based on a patient’s insurance status, or providing quality reporting information across patients with multiple payers. However, to obtain funding for HIE development, it is often necessary to have a large number of participants.
What is the value proposition for providers and patients to participate in HIEs?
HIEs enable clinicians to have tremendous access to patient data, which ultimately improves patient care. By populating the HIE with their data and thereby creating a robust exchange, providers gain access to crucial data about patient care. Patients benefit from having better access to their information and from making the information available to a broad array of providers participating in the HIE.
For HIEs to work well, they must find a way to use patient data to create value early on and to save money for the health system. For example, HealthBridge in Cincinnati began with a simple value proposition, which was to leverage their large volume of patient data and deliver clinical laboratory results to physicians faster and at a lower cost, compared with the expense of mailing or faxing the results. After achieving these costs savings, the HIE was in a position to provide additional services.
In Indiana, once we financed the delivery of clinical results, we added a community-wide repository of clinical data, public health reporting, and quality measure reporting, all of which added to our value proposition and brought new participants into the system. When we did quality measure reporting, health plans saw the value of the HIE and started sending their claims data to us. The health plans brought both dollars and data, which, when combined with our clinical data, created a powerful value proposition for all HIE participants.
For patients, a key value proposition is that HIEs deliver clinical results in a more efficient, reliable manner than previous methods such as fax, telephone, and e-mail. In some cases, patients have been surprised to receive their laboratory results within 30 minutes of having their blood drawn.
How have HIEs achieved benefits in the following areas?
- Reduction of duplication and operational costs: Good evidence in the literature suggests that making patients’ results accessible to providers decreases the likelihood of unnecessary repetition of tests. Other data have shown that the use of an HIE is associated with reductions in the number of computed tomography scans and chest X-rays.
- Improvement of quality and health outcomes: Emerging evidence suggests that measuring quality through standardized quality measures or qualitative assessments across a population is effective at improving the quality of patient care by feeding information back to physicians. This effort, combined with cost savings from decreased tests and increasingly targeted services, shows how HIEs can improve value when they work.
- Improvement of public health surveillance: HIEs have demonstrated improvement in the degree and timeliness of surveillance of public health events, including infectious disease outbreaks at the community level.
- Strengthening of links between health-related research and actual practice: In 2004, pediatrician Dr. Mark Roseman in Indiana heard a case report stating that pyloric stenosis, which creates stomach blockage, was more common in babies receiving erythromycin eye drops than in those not receiving the drops. Dr. Roseman verified that finding by reviewing data in the Indiana HIE, and the new evidence led to changes in treatment recommendations.
What is the fastest-growing segment of HIEs?
In general, privately funded HIEs are growing at a much faster rate than publicly funded HIEs. From 2010 to 2011, the number of live public HIEs in the United States rose from 37 to 67, whereas the number of live private HIEs more than tripled from 52 to 161.3
Most statewide HIEs have been slow to mature. One common problem is that health care markets are not limited to State borders. For example, patients in northwestern Indiana often travel to Chicago for hospitalization and specialty care, and patients in Ohio are likely to travel to Fort Wayne, Indiana, for health care. You can’t draw an Indiana border and say, “Patients stop there.” Statewide HIEs also need to start smaller to succeed. In Indiana, the HIE grew from 12 hospitals in the center of the state with approximately 5,000 physicians, to 93 hospitals out of 114 in the state and more than 14,000 physicians in Indiana. We achieved this over a decade by demonstrating financial success, functionality, and engagement with patients.
How have the Federal meaningful use regulations enhanced the development of HIEs?
The certification process for electronic health record (EHR) systems that support meaningful use of the technology has advanced the use of clinical standards by HIEs. The Health Information Technology for Economic and Clinical Health (HITECH) Act required that most EHR systems translate whatever clinical terminology laboratories used internally to a clinical terminology called Logical Observation Identifiers Names and Codes (LOINC) produced by the Regenstrief Institute. Now, most EHR systems can transmit data with standard codes attached, so the information will be recognized on the receiving end.
Although most EHR systems have had the ability to export data in a standard format (such as HL7 V2) for a long time, there was a lot of variation among systems that reduced their ability to “plug and play.” The HITECH Act emphasizes the need to specify and test message formats that move between systems, to bring them closer to “plug and play.”
Finally, the HITECH Act has created many more potential HIE participants by expanding the number of venues in which EHRs are used by providers to generate data in a usable format. We are making headway on the hospital side, but we still have a long way to go on the ambulatory side.
What challenges did you face as head of the Indiana HIE?
We created a not-for-profit HIE from a health information technology research project that the Regenstrief Institute had started at Indiana University. The Regenstrief Institute’s research mission includes the development and evaluation of health information technology. We faced two critical HIE governance issues: First, how were we going to manage patient data in a way that protects patients’ privacy and ensures high-quality health care? Second, what was our value proposition for engaging providers in making their patient data available?
What are the lessons learned from HIEs in the past 15 years?
It helps to have a “disinterested” third party such as a nonprofit entity manage the HIE and develop a reliable process that is transparent to patients, especially regarding the protection of their data.
HIEs also need effective leadership—people who won’t take no for an answer and who continuously engage stakeholders in the community and solve problems. One such leader is Dr. Micky Tripathi, President and Chief Executive Officer of the Massachusetts eHealth Collaborative (MAeHC), a nonprofit collaboration of 34 leading Massachusetts organizations. Dr. Tripathi worked tirelessly to resolve issues at the Federal, State, and local levels to foster robust exchange efforts. You see this pattern repeated throughout successful HIEs.
What are some of the barriers to HIE implementation?
Trust is a barrier. Providers and patients need to trust that their data will be held securely and will be used for the clinical benefit of patients. The issue of trust can be addressed with good leadership, as well as with a disciplined approach to financing that aims to create value. The providers who find HIE financing to be challenging often lack a clear and simple value proposition, and they make the mistake of trying to create an HIE that immediately provides multiple services.
Technology is often cited as a barrier to HIE participation, but those challenges can be resolved. It takes more patience, commitment, and willingness on the part of stakeholders to work through terminology and governance issues.
How will HIEs look a decade from now?
There will be continued growth in privately funded HIEs; when those exchanges join regional HIEs, the result will be a larger system of providers and benefits for patients. I also expect to see a reduction in the hard work that has been required to implement HIEs, along with greater “plug and play” capability between EHR systems.
Finally, we will use the data generated by HIEs more effectively. We don’t have enough data right now to answer the most interesting questions in health care, such as the best way to manage a patient after a heart attack or whether a drug causes a significant side effect. To answer such questions, we need to be able to pool data on at least 100 million patients. In addition, we will have better ways to conduct distributed statistical analysis and modeling across multiple data sets, rather than requiring that all data be brought together in a single large data system.
About J. Marc Overhage, MD, PhD
Prior to joining Siemens, where he leads product strategy and research, Dr. Overhage was the founding Chief Executive Officer of the Indiana Health Information Exchange and Director of Medical Informatics at the Regenstrief Institute, where he also served as Principal Investigator for the Indiana Network for Patient Care (INPC), an operational health information exchnage in central Indiana sponsored by an AHRQ State and Regional demonstration project. He is also a Sam Regenstrief Professor Of Medical Informatics at The Indiana University School of Medicine. Over the last decade, Dr. Overhage has played a regional and national leadership role in advancing HIE policy, standards, financing, and implementation.
Disclosure Statement: Dr. Overhage reported that he received payment related to the work described in this article from Siemens Healthcare Health Services, Indiana’s Health Information Exchange, the University of Indiana’s School of Medicine, and the Regenstrief Institute.
1 PRWeb. 71% of U.S. hospitals plan to purchase new health information exchange (HIE) technology solutions; 2012 CapSite U.S. Health Information Exchange (HIE) Study; September 14, 2012.
2 McCann E. HIEs see rise in physician enrollment; demonstration of Stage 1 gains similar traction. PhysBizTech. 2012 Oct.
Prestigiacom J. Private HIEs on the upswing. Healthc Inform. 2012;29(3):24, 26. [PubMed]