A patient shows up at the emergency room unconscious and unable to give a history. Another patient arrives at his primary care physician’s office 3 days after an emergency room visit, and the primary doctor has received no information. A specialist sees a third patient for a consultation and receives none of the critical records needed to help her make the consultation efficient and effective. These scenarios and many others like them, unfortunately, are all too commonplace. The consequences of incomplete information at the point-of-care can be inconvenience, inefficiency, increased costs, and adverse, even life-threatening outcomes for patients.

The major reasons for lack of sharing health information include the fragmented nature of the United States healthcare system and the fee-for-service business model, a model that does not include financial support for health information exchange. Further, most health information technology (HIT) programs are not interoperable, that is, they do not speak to each other.

Health information exchange (HIE), in its current definition, is the electronic sharing of health-related information between disparate partners, based on nationally recognized standards for interoperability, privacy, and security. Without sharing, silos of information persist, physicians function with incomplete information, and tests are unnecessarily  repeated. Information-sharing is particularly important for care coordination of care for older with complicated conditions; chronic disease management; natural disaster and biosurveillance response; and care for a mobile military, veteran, and civilian patient population.

Recognizing these obstacles to sharing, the federal government has taken an active role in promoting HIE as a key component of healthcare reform. In this article, we will describe the
current landscape of HIE in the United States, how different parties are trying to expand it, current obstacles to the expansion, and the future possibilities.

THE HITECH ACT AND HIE
In 2004, President Bush set the goal of an interoperable electronic health record (EHR) system for all Americans by 2014 and established the office of the national coordinator for HIT (ONC). Initial progress towards the goal was slow until the passage of the American Recovery and Reinvestment Act (ARRA) of 2009, which included the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act funded multiple federal programs to promote the adoption of HIT, particularly EHR systems and HIE at the local, state, and national level.

The basic building block for this national strategy is the EHR, which inputs, processes, and stores digital health information for hospitals and outpatient practices. Health information organizations (HIOs) are the organizations that provide the governance,technology infrastructure, and security to exchange health information. A regional health information organization (RHIO) is simply an HIO that covers a defined geographic area, such as a city, region, state or multi-state area. HIOs have the ability to collect and aggregate health data from multiple organizations and electronically share information with EHRs.

The HITECH Act included a Medicare and Medicaid reimbursement program for eligible professionals who use certified EHRs and demonstrate “meaningful use.” Stage 1 meaningful use included the general objectives of e-prescribing, structured data collection, quality reporting, clinical decision support, patient engagement, security assurance, and HIE. HIE is necessary to provide a hospital discharge summary, electronically exchange key clinical information among providers, report quality measures to Medicare/Medicaid or states, perform medication reconciliation, transmit electronic immunization data to immunization registries, and submit electronic syndromic surveillance data to public health agencies.

Currently, most HIE occurs as part of an existing HIO. HITECH funded a new option for statewide and interstate exchange known as the State Health Information Exchange Cooperative Agreement Program, discussed in a later section.

CONNECTING PRACTICES, HOSPITALS, AND CITIES
Approximately 234 HIOs exist in varying operational stages, according to a 2010 study by eHealth Initiative, a not-for-profit organization that has conducted annual HIO surveys since 2005. Seventy-three HIOs claimed to be operational (exchanging some type of health data), and 18 claimed to be sustainable (no federal funding in the past year, operational status, and receiving revenue equal to or exceeding costs). More than half of the HIOs offered the following core services: clinical messaging (electronic test delivery of lab and radiology results, medication data, outpatient visits, and emergency room visits), EHR connectivity, clinical documentation, and alerts to physicians. Fewer than half of the HIOs survey offered the following newer advanced services: e-prescribing, Web-based EHR-HIE combination, public health reporting, telemedicine, medication reconciliation, emergency room use data, transcription, voice recognition, business analytics/intelligence, value-based reimbursement (pay for performance), credentialing, research, clinical decision support, consumer portal, claims clearing house, care coordination, and picture archiving and communication systems.

HIOs such as HealthBridge, located in Cincinnati, Ohio, and Indiana Health Information Exchange,located in Indianapolis, Indiana, are performing well financially and have the support of the medical community. On the other hand, failures such as the Santa Barbara County Care Data Exchange have dissolved primarily due to lack of perceived value by the healthcare community.

In 2010, the State HIE Cooperative Agreement Program funded (via $548 million) 56 states, eligible territories, and qualified state designated entities. The overall goal was to promote standards based statewide and interstate information sharing to meet meaningful use, particularly where none exists currently. Statewide HIE will need to be interoperable with existing HIOs, significant data providers and users (such as Medicaid), and the Nationwide Health Information Network (NHIN).

The NHIN is a collection of standards, protocols, and services that enables the secure exchange of health information over the Internet. Instead of being a specific network, it is actually a “network of networks” connecting disparate healthcare organizations, to include HIOs, federal agencies, and integrated networks. The NHIN primarily will provide a means for large civilian and federal health organizations, to include HIOs, to share information securely. As an example, MedVirginia is sharing information with the Social Security Administration via the NHIN to expedite disability determinations.

WHERE’S THE MONEY?

HIE participation for any given healthcare provider is fundamentally a business decision. The expected net benefit to the provider must be positive so that expected benefits exceed expected costs. These benefits can be monetary in nature, accruing through efficiencies in running a practice or a clinic, or through better use of a reimbursement mechanism. They also can be non-monetary, yielding superior health outcomes through better case management while not affecting the bottom line for the business.

Potential models include monthly or annual pricing on a per physician basis (subscription model), pricing on a per-transaction basis, or some combination of the above (for instance, a monthly fee plus per-record usage cost). Approximately half of the operational HIOs charge physicians a user fee as well as an additional fee to create an electronic interface between an EHR and the HIO. Participants must be willing to collaborate, rather than compete, in data exchange and must be willing to pay operating costs. Organizations must have enough participants to create a “network effect” (enough customers to make it worthwhile) and create subsequent economies of scale to be successful.

One of the more immediate benefits for physicians to participate in information exchange would be to comply with meaningful use objectives as part of the Medicare and Medicaid EHR reimbursement program. Very few HIOs can meet all pertinent meaningful use objectives at this time, however.

Participation in successful HIOs likely will mean access to an increasing number of administrative and clinical tools such as business analytics, telemedicine, clinical decision support, centralized credentialing, research opportunities, and a variety of reports.

According to the latest eHealth Initiative survey, many HIOs report reduced staff time spent handling or filing lab and radiology results and handling prescription issues. Another potential benefit would be creating one EHR-HIO interface to receive results, as opposed to multiple EHR interfaces to outside labs,hospitals, and imaging centers.

NUMEROUS TECHNICAL AND FINANCIAL OBSTACLES
Physicians may object to any change in workflow, user fees, and EHR interface charges to participate in HIE. They may believe that the benefits accrue more to others, such as payers and state and federal governments.

The most commonly reported obstacle for HIE is a long-term sustainable business plan that does not depend on federal funding. HIOs must have the trust of multiple partners that traditionally have been competitors in the market place. HIOs must provide services that have perceived value to a wide audience, such as clinicians, hospital executives, and practice managers. The lack of widely proven return on investment may cause some clinicians to choose faxes and mail over electronic sharing.

HIE also is impeded by a lack of a universal patient identifier that would greatly improve retrieval of the correct patient record. Another administrative obstacle for all HIT initiatives is privacy and security. HIOs will store voluminous data for thousands of patients that can be breached without adequate protection. Further, depending on the state, patients will need to sign an opt-in or opt-out agreement to allow record sharing. HIE participation could raise new legal issues regarding responsibility for reviewing all pertinent information on a patient.

For electronic record-sharing to take place, data standards need to be developed and adopted. The current document standard is known as a continuity of care record or continuity of care document. Both are XML-derived patient summaries that are similar to a problem summary list but are in a format that can be both generated and read by most EHR systems.

ALTERNATIVES ARISE
Although the government approach currently favors HIOs and statewide health exchanges, other models have been proposed. Some favor an approach called health record banking. This approach is consumercentric and particularly appeals to privacy advocates. Each consumer (patient) would directly control who can access his or her account. Patients would authorize their providers to “deposit” and “withdraw” information from their secure online personal health information. It has even been suggested that the consumer would bear the cost of a nominal subscription fee. To date, however, patients have shown little inclination to adopt electronic personal health records, even though several systems are now available for free from organizations such as Google and Microsoft as well as health insurers.

Another proposed option is to use a nationwide electronic messaging system that already exists, such as Surescripts. Surescripts is the primary messaging system between physicians and pharmacies used in this country for the transmission of electronic prescriptions. Surescripts proposes becoming a health information service provider that offers the ability to exchange clinical messages and patient encounters over a standards-based network between providers. The company plans to offer this service in 2011 and support it by a subscription fee.

Additionally, the government recently has proposed a simpler alternative to HIOs called the DIRECT Project. In this option, which could be available as early as 2011, physicians will be able to push encrypted clinical messages between healthcare partners. Pilot tests will be under way in early 2011, and further details are forthcoming.

THE FUTURE OF HIE

Some see the role of the HIO as an “infomediary” or information-hosting organization that reuses data for more than clinical medicine, such as public health and research purposes. Several HIE vendors are planning to add Web-based EHRs, practice management systems, and business analytics to allow for fully integrated clinical and financial functions. A few HIOs are offering services such as transcription, credentialing, reporting (public health, quality and pay for performance), and patient access to health data through a portal and personal health records. In spite of approximately a dozen successful HIOs, HIOs remain expensive and complex.

Further, the viability of the new State HIE Cooperative Agreement Program is uncertain. States will be required to charge for HIE use, and it is unknown how this requirement will be viewed by data providers and users.

If you haven’t already done so, you will need to make a business decision whether to purchase a certified EHR to receive federal government reimbursement. As part of that decision and as an aid to achieving meaningful use, you also should determine how you will share medical information in the future. Ascertain whether you can use an existing HIO, a new statewide HIE, or a simpler solution such as the DIRECT project or the SureScripts network.

The degree of uncertainty regarding both EHRs and HIE is substantial, but so are the potential benefits to you and your patients. Mature and successful HIE is a rarity today but likely will be standard operating procedure in the foreseeable future.

2010 Advanstar Communications Inc..

Source:  Modern Medicine.com
View Full Article: http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=700603&pageID=1&sk=&date=

Education session 20, “HIE Connectivity Using the NHIN: Lessons from the SSA, C-HIEP and NHIN Projects,” Thursday at 11:30 AM-12:30 PM CST highlights real-world interoperability projects that have successfully enabled entities to exchange patient data.

Todd Rowland, MD, executive director of HealthLINC, and Rodney Cain, chief technology architect of HealthBridge, will discuss their respective HIE projects, which include collaborating with the Social Security Administration and the Centers for Medicare & Medicaid Services, among other federal and private-sector partners.

The projects range from the NHIN Prototype Architecture, CMS’ CARE Health Information Exchange Project (C-HIEP) and SSA’s electronic disability determination.

Leaders of HealthLINC, a community-based organization serving South Central Indiana, applied for NHIN grants in 2008 as a way to achieve enhanced interoperability, according to Rowland. HealthLINC partnered with HealthBridge on each phase of the NHIN work it participated in, he said.

“The ongoing work with NHIN and other interconnecting projects clearly demonstrates the power of interoperability,” Rowland said. He pointed out that enhanced interoperability will enable providers to integrate and reuse clinical information.

In addition, technology companies can contribute to significantly improving patient safety by developing applications and services that deliver enhanced interoperability.

“NHIN has become an essential method for federal agencies like CMS, SSA, DOD (Department of Defense) and VA (Veterans Affairs) to connect to each other and with the private sector,” he said. “We are likely to see a significant growth in reporting requirements with federal agencies as healthcare reform unfolds, so all providers will need to have this capacity.”

November 03, 2010 | Patty Enrado, Special Projects Editor

Source:  Healthcare ITNews

Two Indiana physicians made a trip to Washington, D.C., to showcase our state’s ability to exchange health information electronically. Now you can see and learn from their testimony.

Todd Rowland, M.D., executive director of Bloomington’s HealthLINC, and J. Marc Overhage, M.D., president and CEO of the Indiana Health Information Exchange in Indianapolis, demonstrated at a meeting of the American Health Information Community (AHIC) showing how geographically separate health information exchanges using different systems can trade critical patient information in an emergency.

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Collaborative Partnership Using Axolotl’s Technology to Further the Nation’s Goal to Interconnect Healthcare

Cincinnati, OH; Bloomington, IN, September 24, 2008 – HealthBridge, the nation’s largest health information exchange (HIE) operating in greater Cincinnati and northern Kentucky, and HealthLINC in Bloomington, Indiana participated today in a federally-funded demonstration of the Nationwide Health Information Network (NHIN).

As we increase the number of physicians and breadth/depth of HealthLINC HIE services we are meeting basic communication needs for providers such as receiving diagnostic information in a timely and reliable manner.

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