In my column of March of this year, I described Health Information Exchange (HIE), how it is currently being used, some advantages and disadvantages, its importance for health centers and some lessons learned. This is the second of two followup columns to provide more details on HIE. In the first of these columns, I covered:

• Current policy regarding HIE;
• What information is actually exchanged; and
• Information on how HIE is accomplished.

This column will cover:

• More detail on how HIE is implemented and deployed;
• The gap between policy and the reality on the ground;
• Issues related to health centers and HIE; and
• The advantages, over time, of health centers moving to HIE.

More on how HIE is accomplished
I’ll start at the level of information sharing among health care organizations within a region. The goal of this information sharing among health care organizations is to increase the efficiency and effectiveness of operations and, most importantly, to improve outcomes for patients. An example of exchange is as follows: a person walks into a health center where she has not been seen before, although she has routinely seen another provider participating in the same exchange. Using the onsite EHR, the new CHC provider requests information about the patient.. A number of things happen: the patient is not found in the local data base, so the system routes the request to the exchange, the patient is located in the master-patient index and verified, the requester is authenticated as a provider known to the system and verified as approved to see this patient’s records, the requested information is located and sent to the requester who uses it as part of treating the patient. New data is stored in the system at the health center where the patient has now been seen and is available to the exchange the next time the patient visits.

The key points here are:

• Exchanges generally select vendors to provide information sharing capability
• The vendors provide products that integrate the applications already in use (or also supplied by the vendors)
• Security, especially with respect to identifying authorized providers, is an important aspect of these product sets
• Most vendors products are compliant with HIE standards

Recently (July 2009), HITSP issued new standards for EHR interoperability and HIE architecture and integration. In addition, HITSP aligned its 63 integration standards with the requirements of the HITECH section of the American Recovery and Reinvestment Act (ARRA) and also addressed the relationship of its standards to the ‘meaningful use’ goals and metrics proposed by ONC. These standards are crucial, and I’ll cover them again in a bit.

Many exchanges are part of larger, usually geographically based groups that may recommend a design or architecture for participating exchanges. An example of this is the New York eHealth Collaborative or NYeC. In order to be eligible for state HIT funding, NYeC requires that affiliated RHIOS use a specific architecture. One impediment to this is that the different vendors that have provided the information integration and sharing software for the RHIOs in New York State have systems that are more or less compatible with the NYeC architecture. RHIOs in NY need state funding, but they also need to deal with vendors who have HIE systems that work, regardless of their compatibility with proposed architectures and standards. This can be an issue for both RHIOs and individual health centers that participate in them.

What about at the level of information exchange among RHIOs? What if the patient we were talking about above is usually seen at the Morris Heights Health Center on East 183rd Street (a participant in the Bronx RHIO), but is visiting their cousin in Johnson City, TN and goes to the Johnson City Downtown Clinic (a participant in the CareSpark RHIO)? How would their information from Morris Heights be available? The National Health Information Network (NHIN) is the large-scale project funded by the ONC in the Department of Health and Human Services (HHS). This project has been going on since 2005. It has gone through several phases to develop prototype architectures, trial implementations and is now in a limited production phase. CareSpark is one of the RHIOs in the limited production phase. The NHIN has defined capabilities for a set of services to allow information sharing among RHIOs that are not geographically close and do not have similar software systems providing HIE. These services do such things as: connect disparate systems used by the RHIOs; verify providers and determine if they are authorized to see patient records; locate and verify patient identity and patient records; and deliver requested records to a provider, or other authorized user, at a remote participating health care organization. The NYeC architecture is standards-compatible with the NHIN, and CareSpark is an NHIN participant, so if everything works right, our patient’s records will be available at the CHC in Tennessee. It’s worth noting that HHS has made open source software for connecting to the NHIN available for free download. The NHIN provides the foundation for sharing of heath care information over long distances and across dissimilar software systems. This is the long-term technical objective of HIE.

Policy versus actual exchange
If we go back to the policy priorities we described at the beginning of this column, we can summarize them as improving the quality of patient care and outcomes by making health care information available to providers and using that information to facilitate clinical decision-making for individual patients and populations. The NACHC survey shows that only 7 percent of FQHCs share data through an exchange, so the first gap is that very few health centers participate in this kind of exchange today. The second is that the information being exchanged – i.e. lab and pathology results, demographics, medications, disease management and patient treatment data – is good as far as it goes, but additional information, particularly providers’ notes and clinical images, is necessary for clinical decision-making.

Finally, the NACHC survey also shows that 49 percent of the health centers who responded to the survey use an EHR (23 percent use all-electronic; 26 percent still use part paper) and 51 percent responded that they did not currently use an EHR, although half of these health centers said they expected to deploy an EHR within 12 months. This is important because participation in an exchange will generally require using an EHR, either one that the health center already has deployed and is integrated into the exchange, or one that the HIE vendor provides and deploys. Mitigation of these gaps will take time, effort and the effective use of stimulus and other funds.

Health centers have to adopt EHR, and possibly other technologies for information integration and sharing, become part of an exchange, and adopt their workflows and practices to the use of this technology. Experience shows that this process takes two to three years. Simply acquiring software technology does not allow exchange of information. Real work needs to be done to develop new ways of working and aligning those with the capabilities and concepts of information exchange.

Issues
There are many technical reasons why this might not work, at any of these levels. One of the most difficult is the issue of standards. How is it possible for a RHIO, HCCN, exchange, etc. to be using certified applications and standards-based integration but still not be able to exchange information with another standards-based provider organization? As mentioned before, there are many standards in this area from several different standards-issuing bodies. Even if two exchanges are using the same standard, it is possible that their vendors have implemented the standards differently, or used different aspects of them in their applications. I wrote about this back in January of 2008 .This problem is not unique to health care, but is an issue in all standards-based information sharing.

Another issue may be that the vendors selected by the exchange have a system that is effective for information sharing, but is not standards-based, or is only partially standards-based. Many standards have been developed recently, and several are more current than the products used to provide integration and information access for health care. Some vendor’s strategies still depend on mechanisms that are not standards-based as a way of locking users into their products. It might be argued that it’s better to be able to exchange information within an RHIO or group of RHIOs regardless of their adherence to standards than to be standards-based but make it more difficult to exchange information. This outlook is self-defeating in the long term as more and more vendors base their products on standards and HHS and other funding bodies require standards-based software in order to qualify for grants, incentives and other funding.

Finally, large-scale sharing of information among geographically distributed organizations is a complicated problem with complex solutions. Exchange of each different type of information may have to be based on different standards with different mechanisms for transporting and displaying that information. Other industries, such as financial services and manufacturing, have developed solutions for this type of sharing, and much of the mechanism available in health care is based on this previous work (with many of the same vendors). So it is possible. It just takes time to work out all the details.

I wrote in my last column about the non-technical issues that impede information exchange. These include the lack of a viable business model, the time it takes to implement an exchange, as well as organizational issues such as the lack of incentive to participate in an exchange. Add to these the issues presented here, including mitigating the gap between policy and current exchange practice and the problems with standards.

These technical and non-technical issues aside, health centers have some important reasons for seriously moving toward HIE. First and foremost is the emphasis in the federal stimulus package (ARRA) for the use of EHR and participation in exchanges. The possibility of funding for acquisition of an EHR and incremental reimbursement for its ‘meaningful use’ cannot be ignored by health centers. It also seems clear that the definition of meaningful use will include HIE, and because of the timeframes involved for adoption and use of EHR, not to mention HIE, getting started on this now wouldn’t be too soon. The immediate advantages will be eligibility for additional funding and reimbursement. The eventual advantages will be the improvement of operational efficiency and the improvement of patient outcomes.

More details:
From a technical point of view, the integration engine connects separate software applications so that they can exchange information, such as medication lists, with an end-user application. A directory provides data about where the information is located in the exchange and associates this information with known patients. It will also have a list of providers and other people who may have access to information. These exchange systems range from very expensive ‘turn-key’ systems that provide everything needed for an exchange to operate technically to ‘construction kits’ that require considerable programming to set up and operate. The design and implementation of these systems vary from contemporary to decade- old technology, while the features of the exchange depend on the vendor, or more commonly vendors, who are selected.

Standards are an important element of the design of exchanges, whether they are RHIOs, HCCNs or some other form. Many software standards are relevant to interoperability and healthcare information exchange. The Healthcare Information Technology Standards Panel (HITSP, www.hitsp.org/) and Integrating the Healthcare Enterprise (IHE, www.ihe.net/) are two of the standards bodies working in health care information. Between the two of them, they have over 50 recommended standards for HIE.