What were we promised?
Health Information Exchanges, Interoperability, Health Information Technology – to say that the health care community was offered quite a bit is an understatement.
Nevertheless, health care professionals have yet to find IT “Shangri La”, and some have given up all hope to find any sort of improvement from the heavily incentivized implementation of IT in hospitals and clinics.
Nowhere is this more evident than in the Health Information Exchange (HIE) area.
HIEs were originally thought to be the perfect vehicle to aggregate clinical information from a variety of areas – labs, imaging centers, hospitals, outpatient clinics, home care agencies, etc.. – and subsequently make such information available to the parties responsible for a patient’s care.
The rationale behind such a line of reasoning is difficult to argue with as these disparate entities often have different record systems, interfacing capabilities, and vendor relationships.
It, therefore, ought to be a significant challenge for them to network amongst each other; however, if they all networked with a specific entity or hub – such as an HIE – that ought to reduce the complexity and provide a neutral medium for users to improve patient care and reduce duplication.
To that end, the Federal Government, in the 2009 Recovery Act, created a grant based funding mechanism to provide seed money to HIEs throughout the country and to bring some information sharing and collaboration together under the auspices of the Office of the National Coordinator (ONC).
The grant funding, however, wasn’t intended to last forever. Rather, the purpose of the funding was to provide HIE organizations with seed money to build up sufficient capacity and organization so that they could subsequently develop sustainable funding mechanism once a strong value proposition could be demonstrated.
The distribution of funding led to a plethora state-level HIEs and, in many states, smaller, regional HIEs or RHIOs. The goal of developing sustainable funding by demonstrating a value proposition didn’t necessarily work out as planners had envisioned.
Many HIEs – especially the public/community HIEs – still struggle for sustainable funding and, indeed, the number of HIEs has decreased. The decrease isn’t – as some have warned – necessarily a negative.
There has been some evidence that some organizations have merged to strengthen their network’s value, to share resources, and to scale effectively.
A good example of such a merger is the creation of Great Lakes Health Connect in Michigan out of a merger of Michigan Health Connect and Great Lakes Health Information Exchange.
Outside of funding sustainability, there have been other issues with HIEs expanding their footprint and increasing their utility to providers.
Fitting HIEs into the workflow of providers and other clinical users has been a persistent issue as most of them run on a web-based platform that is external to the clinical users’ EMRs.
There has been resistance – because of the amount of computer work already necessary for clinical users – to having to remember another set of logins and to go to an external site and access clinical information there.
It has also been difficult to scale HIEs as vendor integration costs still represent a significant barrier – especially for small to midsize providers – to integration.
In the information listed above and in popular conception – when one thinks of HIEs – the idea is of a state, regional, or community-based entity that shares information for a specified geography.
Essentially, individuals are thinking of public utilities that are run by a nonprofit or government and that are available for the benefit of the public by facilitating hopefully lower health care costs and increased quality of care.
The public utility model, however, is not the only way an HIE can be implemented.
There has a been marked growth in what are called private HIEs. These networks are usually designed by the organization using them.
For example, a clinically integrated network or a health system might setup a private exchange – especially if there is a heterogenous EMR environment in the network – to coordinate care and perform the initial data aggregating tasks that are necessary for longitudinal clinical analytics.
These networks likely do use the same vendors – for example Medicity or Orion – as public HIEs.
A big difference between public and private HIEs outside of scale is governance – a private HIE is typically governed by the same bodies formed to govern the network, and its goals are aligned with the overall goals of the network – e.g., risk based contracting or provider alignment with a specific health system.
A public HIE – in contrast – is typically governed by an independent board and charged with a public mission that often involves public health goals and community-based population health goals.
In addition to private HIEs, EMR vendors have been entering the HIE space.
The most notable is Epic with its Care Everywhere product that connects Epic customers with each other’s records to allow for a more seamless exchange of clinical information.
Another EMR vendor, eClinicalWorks has its own eEHX product which although not as comprehensive as Epic’s still provides a strong platform for eCW clients to share data amongst each other.
Adding to private HIEs and vendors, there is a third initiative that, in all fairness, is a hybrid between a public effort and a vendor HIE – Commonwell/Carequality.
The two – formerly separate – initiatives have developed a collaborative agreement to ensure that there will be mutual interoperability.
Often, these two initiatives are implemented through EMRs vendor so that the data is available in the EMR, not in a third-party tool.
Vendors such as Cerner, Athena, eClinicalWorks, and NextGen have implemented this initiative and have it available for their customers.
The Crystal Ball
Nobody knows definitively what is going to happen in Healthcare IT or even just interoperability.
As an industry Healthcare IT combines the disruptive innovation of information technology with the regulatory leviathan that is health care.
There are, however, some trends that can give us a clue as to where HIEs will be in the future and what their role will be.
Private HIEs are likely to continue to grow.
With the increased emphasis on developing aligned provider networks and integrated systems, there will be an increased incentive to implement such networks as a way to align disparate parties into a somewhat unified technology infrastructure.
The main competition to the growth of private HIEs is likely to be the continued work of vendors and Commonwell/Carequality. A common goal during the establishment of integrated networks is technology alignment; for example, as practices are purchased by health systems, they are often migrated to Cerner or Epic.
Even where that doesn’t occur, Commonwell/Carequality may suffice for interoperability needs. This trend towards alignment will also likely hamper – without the development of a unique value proposition – the further growth of public HIEs.
Aligned providers that also have access to Commonwell/Carequality and vendor specific networks have less of a need for public HIEs since an overwhelming majority of their information is likely available to them inside of their EMR.
The wildcard, however, is the growth of application programming interfaces or APIs. If APIs continue to become more available as predicted, and they are well adopted, there is a chance that both interoperability can expand quickly; more importantly, the idea of HIEs could fade as a distinct entity and interoperability could become ubiquitous.
This, however, is contingent on APIs being accessible and affordable to implement and, given the experience that providers have had with interfacing thus far, that is not a foregone conclusion.
The next three to five years will be extremely interesting the HIE/interoperability area as issues such as patient matching, APIs, and privacy will need to be addressed as the push for more data exchange continues.