Health Information Exchange
Health Information Exchange (HIE) refers to the process of reliable and interoperable electronic health-related information sharing conducted in a manner that protects the confidentiality, privacy, and security of the information. Electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care. Despite the widespread availability of secure electronic data transfer, most Americans’ medical information is stored on paper—in filing cabinets at various medical offices, or in boxes and folders in patients’ homes. When that medical information is shared between providers, it happens by mail, fax or—most likely—by patients themselves, who frequently carry their records from appointment to appointment. While electronic health information exchange cannot replace provider-patient communication, it can greatly improve the completeness of patient’s records, (which can have a big effect on care), as past history, current medications and other information is jointly reviewed during visits.
For perspective, a brief look at the Plan’s current position regarding HIE is essential, then moving forward to related initiatives being discussed for the coming years. The Plan has defined three implementation stages for HIT overall: Stage 1 (2011) – Focus on effective capturing and sharing of data, with providers demonstrating meaningful use. Stage 2 (2014) – Demonstrate health system improvement, with widespread adoption of data exchange and advanced care processes with decision support. Stage 3 (2015+/-) – Transform healthcare and population health through HIT, with improvements in care, efficiency, and population health. Health information exchanges (HIEs) are an appealing way of harnessing technology to improve care. Too often, doctors must make medical decisions based on incomplete clinical information.
Electronic health records are part of the solution, but their full value won’t be achieved until they’re connected to provide a cross-institutional, comprehensive, timely and accessible view of a patient’s medical history. Public and private HIEs are creating the connections and clearinghouses to make this possible. However, while everyone recognizes that better information can lead to better care, financing HIEs has proved to be very challenging. One hope has been that HIEs could pay off quickly in early cost savings. It stands to reason that doctors wouldn’t need to order as many tests if they knew the results of previous ones, and early studies led to very promising projections of costly tests averted.
While advances in treatments, surgery, and other procedures have improved health care services, these advances have not been accompanied by an increased use of information technology to improve the way health care is delivered. Information technology is widely used as a tool to support business processes, but the health care field lags behind in using information technology to improve the quality and efficiency of care. This means: Most doctors still use a paper chart. Most doctors, nurses, and other clinicians have no easy way to coordinate your care because they don’t have access to all of your health information including your various providers, test results, and medications. The information health care professionals need to make good clinical decisions very often is not available when and where it is needed, especially in emergency situations. Individuals have no immediate direct access to their own health care information.
Human errors made by your clinician, such as poor handwriting, unclear instructions, and selecting the wrong medications go unchecked even though these mistakes could be avoided by using the standardization and automation of patient records that HIT allows.
Managing a patient’s health care requires information from many sources, including patients themselves. Information technology is essential both to engage individuals in their health care and to enable clinicians and patients to work in partnership to achieve the safest, highest quality of care possible. For example: Labs, x-rays, and other test results could be available to your doctor during, or even before – your visit. Your laboratory results could be tracked over time in a program shared with your doctor, providing a more comprehensive view of your health.
You could go directly to the pharmacy after your doctor’s appointment and pick up your prescription without waiting because your doctor sent it electronically. July 2009 2You would have access to your child’s immunization records from your home computer and could send them to the school, after-school program, and sports program, all without leaving your home. You would have access to a complete list of your mother’s medications which is also shared with and updated immediately by staff at her skilled nursing facility and her primary care doctor. There are many reasons why our health care system is not connected electronically, and therefore cannot provide these benefits today. Some of these barriers are: Electronic systems are very expensive to implement and a medical office needs resource to train employees and restructure its business practices to accommodate the system change. Different electronic systems don’t work well with each other. People have concerns about protecting their privacy. State laws sometimes present barriers to sharing information across state lines.
The American Recovery and Reinvestment Act of 2009 (ARRA), more specifically the HITECH Act within ARRA, allocated funds to improve the quality of healthcare in the form of grants and reimbursements related to HIEs. Not only did the government provide the funds to help drive down costs, they also set the criteria around “meaningful use” of these interoperable EHRs, and established aggressive timetables that would both incent action and penalize inaction. To date, there are 193 active health information exchange initiatives underway in the U.S., with only 57 operational HIEs. This is a 40 percent increase since 2008, and with $564 million in HIE funding set aside in the ARRA, the number is expected to continue growing. The funding for those organizations creating HIEs will flow through the states to State Designated Entities (SDEs).
These SDEs have the daunting task of connecting provider organizations (hospitals and health systems) that have separate businesses, and often political agendas. Aligning these interests from the top down will take time, especially if the technology solution proposed by the HIE conflicts with any prior technology decisions made by the hospitals. Most organizations resist change, and particularly so when it has a price tag attached. Cost savings and efficiency without interruptions to care are the two prevalent benefits being reported by more than 70 percent of the operational HIEs. Cost savings were realized with reduced clinical and administrative staff time on tasks, as well as a decrease in redundant tests and medication errors.
Advantages of HIE:
1. Better Healthcare. The assumption is that providing health records from various sources to a provider at the time of care will enable the provider to make better medical decisions, resulting in better quality of healthcare. Better healthcare will be enabled through more information at the time of care; real-time test ordering; real-time receipt of test results, and up-to-date medication lists. It has been found that fewer medical errors are made due to electronic ordering of tests and medications. For example, pharmacists no longer need to struggle to read the handwriting on physician scripts. Electronic health record exchange is also an advantage to specific populations of people. For example, those who live in rural areas; people who are caregivers to others and need access to their health records; and people who care for foster children.
2. Consumer Control.
The capability of technology such as PHRs allows consumers to control and manage their own health information. The capability of HIE technology has the potential to allow consumers to choose which doctors will be able to access information in their health records. It also has the potential to allow consumers to decide which information in the health records can be viewed. This allows information that the consumer feels if very sensitive to be kept private. 3. Certification Standards. CCHIT (Certification Commission for Healthcare Information Technology) is an organization which has developed criteria for certification of electronic health records. This enables organizations who are purchasing these systems to make a comparative analysis based on specific and standardized features (CCHIT website).
Challenges with HIE:
1. Privacy and Security Concerns. The privacy and security of health records can be vulnerable as they are gathered, stored, transmitted, shared, and maintained.
2. Inconsistent Policies and Laws. Policies and laws between healthcare provider offices, hospitals, regions, and states are not consistent and need to be standardized.
3. Too Much Information. The fear of medical malpractice suits by patients because physicians feel they will have a lot more information to sort through and may miss important facts when making medical decisions.
4. Complete and Accurate Information? The assumption is that more information to make medical decisions doesn’t ensure that the information is accurate or complete. Who will be responsible for correcting inaccurate information that is received from referring physicians, for example? Who will be responsible for medical decisions made based on inaccurate or incomplete information?
5. Cost. They can be expensive to implement, especially for smaller practices. Not only the cost of the technology is an issue, but also the costs of training and maintenance are not well known.
6. Disruption to Workflows. Many providers’ office have expressed concern that adopting and installing HIE technology will cause too much disruption in their current workflow processes.
7. ROI? There is no proven ROI (Return on Investment) in monetary terms. Another concern is if it will actually enable providers to make better medical decisions. The assumption is that electronic sharing of information will benefit consumer by allowing for better healthcare. Few studies have examined long-term impacts of electronic healthcare information exchange.
8. The Impact of Socially Stigmatizing Conditions. Some patients with socially stigmatizing conditions may feel that their sensitive information may be used inappropriately and may avoid seeking care due to privacy concerns. For example, some consumers have been discriminated against because they have been diagnosed with certain illnesses.
9. Role of PHRs? Personal Health Record (PHR) technology is not designed to interact with the health record systems that physicians install. How will PHRs play a role in the exchange of information? PHRs also rely on consumers to maintain their own medical records. This is critical to ensure that medication lists and other information is accurate and up-to-date.
10. Inadequate Adoption of HIE for wide scale Information Exchange. There aren’t enough providers that have adopted HIE technology to enable health information to be exchanged on a regional basis much less at a national level.
11. Lack of Initiatives for Consumer Education and Engagement. Consumers aren’t aware of many of the disadvantages of exchanging health records. While they may have the right to control how their information is gathered and shared, this entails an associated responsibility to be informed about the decisions that need to be made.
Bringing It Together: Integration
Interoperability of healthcare systems is a challenge mainly because of rapidly growing expectations. Information exchanges, public health reporting, and in-hospital integration needs are placing increasing pressure on already stretched IT resources. Integration solutions must provide the advanced transformation and coding capabilities needed. Comprehensive support for communication protocols and message formats enables a mapping and translating mediator between virtually any systems.
Health Information Exchange: Truly Two-Way
Today there are new instances of the use of HIE for consumer-directed care that are especially interactive and timely. In some locations, individuals can now send blood-sugar or heart-related data from mobile devices to a caregiver and receive not only advice but also immediate changes in medications and treatment if needed, either for maintaining health or for preventing a more serious situation. This data falls into the category of “device-generated data.” In addition, the ONC recognizes “patient generated insights,” which are individuals’ observations and perceptions about their own health or care. These could come in the form of surveys, health journal entries, online blog entries, or any number of other media. This latter form of data will be valuable to the health system in measuring and rewarding for healthcare quality. Data of both types can become part of the patient’s EHR.
The secure sharing of health data across networks can help providers move toward a model of personalized healthcare whereby they can better meet patients’ expectations for transparency and privacy and securely utilize longitudinal patient information, such as disease states or reactions to certain medicines, to provide higher-quality care. In addition to the significant operational and business efficiencies that providers can realize over time through secure, effective HIE, their ability to offer patients more personalized care will also improve. Because more vital patient information will be shared between stakeholders— including physicians, labs, clinics, hospitals, and the patients themselves—caregivers will have a more complete, more accurate picture of their patients’ health history. This should mean smarter medical decisions as well as fewer errors, unnecessary tests, and prescriptions. This increased data liquidity can also support translational research by more quickly getting critical data to and from the point of care and establishing the consent management needed to deliver care that is more personalized.
Health information exchange has the potential to improve the quality, coordination, and efficiency of healthcare. If handled correctly, it can also help achieve the necessary level of trust among consumers. Complying with meaningful use criteria and achieving HIE with other healthcare entities is a daunting challenge for any organization. Nevertheless, today’s products, initiatives, and best practices have shown that the challenge can be met and that the benefits—including improved security and privacy, enhanced care, and consumer empowerment, as well as increased efficiencies for enterprises—are all attainable. Ultimately, when such efforts are well thought out, strategies are well designed, and implementations are successful, we as a country and consumers of healthcare services will benefit from better outcomes and greater quality of life.
CCHIT (Certification Commission for Healthcare Information Technology). Accessed August 2013 at http://www.cchit.org/hie
Health Information Exchange: From Meaningful Use to Personalized Health. Accessed August 2013 at http://www.oracle.com