Health Information Exchanges, Part 1: Follow That Patient
One of the goals of improved healthcare in the U.S. is to ensure that health insurance is portable. The idea is that people should be able to change jobs, move around the country, and still be enrolled in the same health insurance plan.
Still, when a person from Texas relocates to California and changes physicians, the new doctor may know a more about that person's health insurance than his or her physical condition. To obtain information about the new patient's health usually calls for the doctor to conduct a complete physical exam, perhaps order a few tests, and depend upon the patient's recollections to create a medical history.
If the doctor could somehow click into a database and find information about the new patient, it could possibly eliminate the time and cost of a new exam, prevent the ordering of unnecessary tests, avoid duplication of shots such as tetanus boosters, and provide a clinically more accurate patient history. In an emergency situation, the database could provide information critical to successful treatment.
Making personal health records more portable and more accessible is a major goal of the U.S. Health and Human Services Department (HHS). The American Recovery and Reinvestment Act of 2009 (ARRA), designed to stimulate economic activity, authorized HHS to launch a major financial assistance program to promote the electronic transfer of health records.
Goal: Transferring Patient Data
"The whole idea is to be able to get the data to follow the patient, whether it's within a local or regional setting or around the country," Chris Muir, senior program analyst with the Office of the National Coordinator for Health Information Technology, told CRM Buyer.
The mechanism for making health records more portable is a process called "Health Information Exchange." The process involves the use of electronic networks for transferring records through links between and among healthcare providers. HHS views the "exchange" part of HIE as "fundamental to realizing the promise" of health related IT.
HIE programs are not new, but the federal effort will help provide critical support to develop such programs at the local, regional and national level. Some programs were begun as long as 10 years ago, and have achieved success, while others have failed due to the lack of resources to sustain them. Others are still in the formative stage.
There were 193 HIE "initiatives" at various stages of development around the U.S., according to a 2009 survey conducted by eHealth Initiative, a group representing healthcare sector IT professionals and vendors. Of those, 53 were fully operational. While eHealth's 2010 figures have not yet been released, the development of HIEs has remained active, and the availability of federal assistance has provided a welcome boost.
"We have certainly noticed an increase in interest for HIE programs, and the HHS grant program has provided an incredible opportunity to demonstrate the value of HIE," Jennifer Bordenick, CEO of eHealth Initiative, told CRM Buyer.
The HHS program is directed toward using state governments as the focal point for implementing HIE. The emphasis on states was directed by Congress, Muir explained, adding that state government involvement makes sense.
"The states are already heavily engaged in healthcare at various levels, including Medicare and Medicaid," he said.
HHS is sponsoring three major programs related to HIE development:
- State Cooperative Agreements. These grants are designed to foster appropriate and secure information exchange across the healthcare system. Recipients are charged with developing the necessary governance, policies, technical services, business operations and financing mechanisms for HIE over a four-year period.
The program will build from existing regional and state level HIEs while moving toward a nationwide exchange capability. HHS completed the awards process last March and has provided US$548 million to states or to state-designated entities.
The grants, however, are not open-ended.
"We have various standards that recipients must meet, and we have a mechanism for measuring performance. Failure to meet the standards could result in losing the grant," Muir said.
- Regional Extension Centers. HHS has awarded $642 million to 60 Regional Extension Centers -- modeled after the federal agricultural extension service program -- to provide technical assistance for creating and sustaining HIE programs.
RECs will enable healthcare providers to use a local resource for technical assistance, guidance, and information on best practices, especially related to community requirements. Some recipients are traditional academic institutions such as universities, while others are nonprofit entities such as the Community Health Centers Alliance in St. Petersburg, Fla.
- Beacon Communities. Grants will be provided to selected communities to act as beacons, or pilot projects. HHS awarded $219-million to 15 communities in May, and another $30 million will be awarded later.
One Beacon example is a $12-million HHS grant designed to help 1,600 Tulsa, Okla.-based health providers utilize a community-wide information system to better monitor and improve treatment for obese and type-2 diabetic patients transitioning from one care setting to another.
The program is expected to boost referrals for cancer screenings, increase access to care by using telemedicine, and reduce unnecessary hospitalizations and emergency room visits by 10 percent for conditions that could be better handled in clinical settings. The project could yield cost savings of $11 million per year.
Electronic Exchange Challenges
Federal support of HIE development, however substantial it may be, will not necessarily guarantee the sustained success of organizations developing portable electronic health records. One critical technology goal will be the development of networks that can link healthcare providers within a locality, and then link local, regional, and state networks together.
Each HIE may select different data generation and transmission platforms from different vendors, and resolving technical issues will not be easy. The federal grants program is based on recipients meeting national standards for facilitating data exchange -- that is, achieving interoperability.
While the federal initiative calls for national standards on data exchange, the program allows flexibility in terms of the actual structure of HIEs. Thus, the sizes HIEs -- in terms of participating physicians and hospitals -- may differ significantly, and the components within a given HIE will vary as well.
Some may only involve physicians and hospitals, while others may add pharmacies, clinical labs, and insurance providers. Directing federal assistance through states doesn't mean that the federal program is aimed at eventually at creating 50 statewide HIEs.
"Communities will be free to organize whatever structure is appropriate," Muir noted.
The structure of currently existing HIE organizations reflects these differences. In addition to finding great variation among HIEs, a recent KLAS Research market analysis concluded that only 89 were functioning at a level where they were significant users of commercial information technology products and services.
No template for establishing an HIE has yet emerged, and it appears that differences in size and structure will remain a factor -- and a challenge -- in the evolution of such organizations.
Also, successfully establishing the means to link healthcare providers through networks, as impressive as that may be, is just the beginning.
"Laying pipe isn't enough," Jason Hess, general manager of clinical research at KLAS, told CRM Buyer.
"You still need some ground rules related to data access, data safety, other legal issues and ease of use," Hess added.
Currently, some health sector standards organizations, as well as HHS, are wrestling with various legal and technical issues related to HIE development. In addition, the creation of state entities, with differing goals and different levels of IT capability, could pose implementation problems at the local and regional levels.
"There's a risk of too many cooks in the kitchen," Hess said.