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Health information exchanges get down to business


New care models and federal requirements motivate HIE stakeholders

The ability for healthcare stakeholders to exchange information is a necessity among initiatives intended to improve the quality of care and lower costs. Electronic health records (EHRs), accountable care organizations and patient-centered medical homes all rely on it. As such, health information exchanges (HIEs) have received billions of dollars in public and private funding.

The bad news is, the most substantial support for advanced HIEs in 2012 came from federal funding, according to eHealth Initiatives’ 2012 Survey of Health Information Exchange, which identified 222 HIEs. That might raise red flags when it comes to sustainability. In fact, the federal State Health Information Exchange Cooperative Agreement Program (which pumped more than half a billion dollars directly into state HIEs) set to expire next year.

However, many HIEs are bullish on their chances of survival without federal funds. Out of the 161 exchanges surveyed by eHealth Initiatives, 93 said it is highly likely they will be operational in three years and 64 said they will be financially sustainable without federal funds.

Why the optimism? For one thing, one of the biggest hurdles to exchanging information-standardization-is being driven by Centers for Medicare & Medicaid Services’ and the Office of the National Coordinator for Health IT’s (ONC) meaningful use stage 2 rules that hospitals and healthcare providers must meet to qualify for incentives.

“The standards required for data types are significantly more robust in stage 2, which goes into effect Oct. 1, 2013, for hospitals and Jan. 1, 2014, for eligible professionals,” says Janet Marchibroda, director of the Health Innovation Initiative at the Bipartisan Policy Center, a Washington, D.C.-based think tank. “The government endorsed or ‘adopted’ these standards, which in essence makes them the standard.”

Added Value in Data

Knowing what information to share to receive government incentives still doesn’t solve the biggest issue associated with HIEs: operational and financial sustainability. An HIE has to provide services that stakeholders are willing to pay for, and that physicians and hospitals want to use. In short, like any free-market service, HIEs need to provide value.

Part of that value comes from added services that can be provided when data is collected, says Lee Stevens, a program manager at the ONC.

“A good example in how to work toward sustainability can be found in Indiana,” Stevens says. “They’ve done a good job of building a nimble system that allows them to do multiple things. Modular services that people are interested in paying for will be lifeblood of HIEs in the future.”

According to Stevens, those add-on services might include identifying anomalies in a patient population, down to the city block-a task now being done in Maryland-or identifying potential abuse of prescription drugs, which Kentucky is doing with data from its HIE.

Richard Swafford, director of the Inland Empire Health Information Exchange (IEHIE), a collaborative of Riverside, San Bernardino and other California county health plans and healthcare providers, has first-hand knowledge of what it takes to create a sustainable exchange.

“We’re entirely self-sustained, based on a fee structure back to our participants,” Swafford says. “We’re lean and mean in terms of staffing and overhead compared to exchanges that receive federal grants.”

He says IEHIE’s strategy has evolved. The exchange’s business model is still based on stakeholder fees, but it has found added value in providing access to aggregate patient data for public health reporting, business intelligence, and interface reports for labs.

“As we continue to grow and expand, I see increased demand for boutique type products,” Swafford says. “We haven’t even discovered all the benefits yet. Aggregating patient data means I can report across the population, reduce tests, create a patient portal so patients can participate ... We still have a long ways to go in understanding the full value.”

Stevens agrees.

“I think in the future we’re going to see a dramatic uptake in these services by consumers,” he says. “In the near future, a portal may allow New Yorkers to access health information via an app on their phones, for example. That service would be incredible. The value would be amazing.”

National Aspirations

Consumers may be the last piece of the HIE puzzle. Before that, more vendors, providers and payers must buy into an interoperable system. State regulations are making that happen in New York, which has one of the most advanced HIEs in the country.

“In New York, the situation is kind of unique,” says Anuj Desai, director of business development for the New York eHealth Collaborative. The Collaborative also leads the EHR | HIE Interoperability Workgroup, a coalition of 15 states that Desai says represents close to 50% of the U.S. population, 19 EHR vendors, and 18 HIE vendors. “There is a lot invested-$943 million-in the HIE,” he says. “The Department of Health is going strong in terms of requiring providers be part of the HIE. The challenge is getting small practices attached to the HIE.”

One way to assure small practices that their HIE investment is sound is through certification. The EHR | HIE Interoperability Workgroup launched an HIE compliance testing program at the Healthcare Information Management Systems Society (HIMSS) 2013 Annual Conference and Exhibition, together with Healtheway, the public-private partnership of the eHealth Exchange. The Certification Commission for Health Information Technology (CCHIT) was selected as the compliance testing body by the partnership.

Certification is intended to give providers and purchasers of EHRs and HIE a way of ensuring a system has all the capabilities required for plug-and-play interoperability via a seal that shows whether the products are in compliance. In New York, vendors will be required to pass a compliance testing program to connect to the SHIN-NY (the Statewide Health Information of New York).

But that wasn’t the only HIE-related announcement at HIMSS. Cerner, McKesson, Allscripts, athenahealth, Greenway Medical Technologies and RelayHealth launched the CommonWell Health Alliance. The Alliance will be an independent not-for-profit organization that will support universal access to healthcare data through seamless interoperability, according to the press announcement. Goals for the Alliance include defining, promoting and certifying a national infrastructure with common platforms and policies. It will also ensure that products displaying the Alliance seal are certified to work on the national infrastructure.

Verizon Communications also made an HIE-related announcement at HIMSS. The country’s second-biggest U.S. telephone company introduced what it says is the first national service enabling doctors to securely exchange medical records no matter what computer system they use. It will allow direct exchange of healthcare data, texts and e-mails while still meeting U.S. privacy standards.

For Marchibroda, these initiatives and others by large organizations signify a shift in the HIE landscape.

“For the first time, we have an emerging business case for exchange,” she says. “That is the primary barrier. It always comes down to the business case.”

These national initiatives appear to be the next stage of HIE implementation, but Marchibroda doesn’t expect them to uproot regional efforts.

“I think they’ll operate in parallel,” she says. “My hope is that this will shake out in next year or two and we’ll get there. At end of the day, physicians and hospitals will pick the thing that works best for them. Payers are going to say: ‘Dr. Smith, I expect you to coordinate care and get to better outcomes.’”

Plans Becoming Reality

The business case for HIEs becomes less theoretical as more exchanges transition from the planning to the implementation stage, Stevens says. 

“I really believe we crossed a threshold about 18 months ago. We reached a point where everybody really understood what we needed to do to enable exchange,” he says. “We had, for the first time, a set path with clear milestones laid out - the first being implementation of direct messaging services. With that achievement, and the ability to make it available, we suddenly realized how much the world had changed.”

IEHIE’s Swafford says he feels the same way, up to a point.

“I’m more confident now,” he says. “You can’t look at the EHR penetration rates and not be confident about HIE.”

But he says the HIEs have much more untapped potential.

“I don’t think we’ve landed on 50% of the value that HIEs are bringing,” he says. “We have so much further to go to find a strong value proposition for HIE. I don’t think we have an inkling in terms of how this is going to change healthcare and how much it will benefit patients.”

Marchibroda doesn’t guard her optimism quite as much.

“If these initiatives, these collaborative efforts, pan out the way we hope they will - for the first time we will have a solid foundation to coordinate care, create more patient-centered care, and more accountable care,” she says. “We’re moving now. I think 2013 is year of interoperability and exchange. MHE


Types of data exchanged



  • Discharge list

  • Problem list

  • Inpatient medication list

  • Physician notes



  • Clinical summaries

  • Problem list

  • Ambulatory medication list

  • Physician notes

  • Referrals


Patient summary care record


Public health reports


Source: eHealth Initiative

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