Electronic Health Records

Health Information Exchanges

SPH 210 - 2010

Overview

• What is an HIE?• Historical perspectives• HIEs today• The value of an HIE• Common challenges• Building a basic HIE• HIEs in California

What is an HIE?

• HIE = Health Information Exchange“HIE is defined as the mobilization of healthcare information electronically across organizations within a region, community, or hospital system” (Wikipedia)

• What is it though?– Is it an organization?– Is it a statewide health IT system?– Is it a process?

Historical Perspectives

• 1990’s – Community Heath Information Networks (CHIN)

• 2001 – National Committee on Vital and Health Statistics called for creation of a National health Information Infrastructure (NHII)

• 2004 – DHHS calls for the creation of a “national health information network”

• Early HIEs– Santa Barbara Data Exchange (closed 2002)– Indiana Network for Patient Care (INPC)– Indiana Health Information Exchange

Ovehage, Evans and Marchibroda. Communities’ readiness for health information exchange: The national landscape in 2004.J Am Med Inform Assoc. 2005;12:107-112

HIE’s today• As of 2009 there were 193 active health information

exchanges in the U.S.• A survey of exchanges in 2004 found that one in four

were no longer functioning (25% failure rate)• 2008 2009 here was an increase of 40% in

operational HIEs• 70% of operational HIEs reported cost savings• Most common services

– results delivery– connectivity with EHRs– alerts for providers

http://medsphere.org/servlet/JiveServlet/download/1286-1302/Ecosystem%20Community%20Call%20-%2020090115.pdf

What providers value in an HIE• Ross and colleagues studied small-to-medium sized family

medicine practices• Goal to identify what small practices value as HIE functionality• 9 practices agreed to participate• Methods: extensive interviews with clinicians, administrators• Existing valued processes

– ordering tests/studies and receiving the results– communicating with hospitals and specialty practices

• Desired HIE functionality in order of priority– #1 – Ability to lookup patient-specific information (test results, clinic

notes, discharge summaries)– #2 – Automated results delivery to the practice– #3 – Electronic prescribing– #4 – Placing non-prescription orders (low priority)– #5 – Creating reports (lowest priority for the group)

Ross, et al. Health information exchange in small-to-medium sized family medicine practices: Motivators, barriers, and potential facilitators of adoption. Int. J. Med Inf. 2010. 79:123-129

HIEs and Physicians• Wright surveyed physicians regarding their

views on HIEs• Surveyed 1,296 physicians in Massachusetts

(2007), with 77% response rate• Results– 70% felt HIEs would reduce costs– 86% felt HIEs would improve quality– 76% said HIEs would save time – only 54% were willing to pay for such a service– up to 32% were willing to pay $150/mo

$150/mo was based on an amount planned by one of the HIE organizations as a charge for providers

Wright, et al. Physician attitudes toward health information exchange: results of a statewide survey. J Am Med Inform Assoc. 2010;17:66-70.

Challenges for an HIE• often must bring together competing

stakeholder groups to collaborate on a common set of goals

• must manage stakeholders with different HIT needs, agendas, and schedules

• must develop data exchange/trust agreements

• must manage competing vendors• must have a viable long-term funding

model that is acceptable and equitable to stakeholders

Public Health and Electronic Health Information Exchange: A Guide to Local Agency LeadershipInstitute for Public Health Informatics and Research. 2009

Important Perspectives on Adoption

• “Information technology is a tool, not a goal”

• “you can’t ‘make’ standards any more than you can ‘make’ friends”

• “Information won’t be shared until there is a compelling reason to share it and until parties that need to share it trust each other”

• “People adopt standards after they have a reason to share”

Diamond and Shirky. Health information technology: A few years of magical thinking. Health Affairs 27(5):w383-w390 2008

A cautionary note on the effects of misaligned incentives in healthcare

• The Portland Metropolitan HIE was shelved when a model forecasted a $10 million drop in revenues for regional hospitals due to elimination of duplicate testing – the hospitals were also being asked to pay $2.5 million/year to support the HIE!

• “Labs may decide it does not make business sense for them to send electronic results to physicians who do not constitute enough business volume”

Jonah Frolich, Oct 2009, Testimony to HIT Standards Implementation Workgroup

Will Ross. Facilitating Network Agility of Health Data. Invited Lecture. UC Davis. Nov 4, 2009.

Typical HIE Stakeholders

• Physician practices• Payers• Hospitals• Pharmacies• Clinical laboratories (regional,

independent)• Radiology practices• HIT vendors• Public health department

Physician Practices

• A challenge because of their relatively slow rate of technology adoption

• The bar is fairly high before practices gain substantially from the efficiencies of computerization– the smaller the practice, the more

difficult the argument for computerization lower volume means longer to recoup

investment smaller practice does not always translate to

lower startup IT costs

Payers

• Have a focus on electronic transactions

• Can gain significantly from an HIE but it must provide efficiency in transactions that matter to the payers

• Payers can gain from HIEs by seeing population based data – this can be counter productive if it leads

the insurance plan to leave that region

Hospitals• Have a major role to play in an HIE

– improve quality– compare with other hospitals

• Hospitals in the same region are competitors– anxiety about making available census and demographic

data– anxiety about ‘report cards’ on quality

• Often are ‘competing’ for physician practices as well

• Need to exchange information with physician practices– follow up– improved communication– allow physicians to have all clinical information relevant

to caring for a patient, whether the physician has privileges in the hospital or not.

Pharmacies• E-prescribing improves efficiency for

physicians and pharmacists– improved prescription accuracy– reduced number of calls

• E-prescribing improves safety– improved legibility– ability to introduce some form of decision

support in the e-prescribing modules for EHRs

• HIE could send a pharmacist relevant and important segments of the medical record– drug allergies, food allergies, co-morbidities– health plan and formulary information

HIT Vendors

• There is a large number of HIT vendors

• Increasing number of HIE ‘services’• Ability to consume HIE services and

furnish information through an HIE will be critical

• HIT vendors are key in enabling that functionality for their customer base

• But lack of well-established standards for HIE exchange makes this very difficult

Building an HIE – building blocks• EHR/EMR systems in the community

– how ready is the community? only 15-20% of providers have EHRs in some

form• A Health Information “Exchange” system

– what interfaces?– what connectivity?– repository for result viewing vs sending results

A survey of HIEs by Overhage in 2004 showed 3% were federated, 54% centralized databases, 20% used peer-to-peer connections, 18% had not yet selected an standard architecture

• NHIN Gateway– allows exchange across HIEs (across regional

boundaries)http://medsphere.org/servlet/JiveServlet/download/1286-1302/Ecosystem%20Community%20Call%20-%2020090115.pdf

HIE Technical Components

• End user applications– Ambulatory EHRs– Hospital EHRs– Laboratory information systems– Pharmacy Systems, – Remote clinical viewer for providers

• Infrastructure (HIE) Services– Provider Registry– Enterprise Master Patient Index Services– Data Repository– Messaging Hub (document hub)

which supports granular and patient-centric privacy which is efficient, scalable, secure

http://medsphere.org/servlet/JiveServlet/download/1286-1302/Ecosystem%20Community%20Call%20-%2020090115.pdf

MIRTH Results – Redwood MedNet

courtesy of Will Ross, Redwood MedNet. used with permission

MIRTH Results – Redwood MedNet

courtesy of Will Ross, Redwood MedNet. used with permission

Prototypical HIE Services

• Patient identification and patient query

• Patient Record Locator• Clinician Authorization• Storage of Clinical Data• Privacy and Security • Consent management• Secure messaging (provider to

provider, provider to hospital, patient to provider?)

HIE Architectural Models

• Repository Model– centralized data storage– participant data may be segmented but physically

stored in one database– the more complex the healthcare community, the harder

it is to use a repository model

• Federated Model– each provider retains control over their own data– places a premium on harmonizing/standardizing data

elements– NHIN and CDC’s proposed models are federated

• Hybrid – repository and federated combined

Ref: Public health and electronic health information exchange: A guide to local agency leadership. The Institute for Public Health Informatics and Research

Vendor based HIE’s

• Vendors are moving to interconnect customers – sold as an advantage to customers in

aggregating their data– regionally close customers can

exchange data about patients they might be co-managing

• Disadvantages– continues to fragment and silo data in

healthcare – particularly in within a region

– ignores the benefits of having a regional HIE

California HIE’s

• 12 operational health information exchanges in California (2010)

• Examples– Redwood MedNet– Long Beach Network for Health– Santa Cruz information exchange– East Kern County integrated technology

association

California HIEs – early 2010

courtesy of Will Ross, Redwood MedNet. Reproduced with permission

Santa Cruz HIE

• Has been exchanging data since 1996

• Connects 350+ providers, 650 other users, 7 EHRs

• Users include hospitals, doctors, labs, imaging centers, surgery centers

• Exchanging hospital reports, referrals, encounter data, lab results, radiology reports, allergies, and medication prescriptions

Redwood MedNet• Originally founded by Carl Henning and five

others including other Mendocino healthcare providers non-physician members of the Mendocino healthcare community

• Incorporated as a 501(c)(3) non-profit in December 2005.

• Connects 6 regional laboratories, 2 regional medical centers, and 5 provider practices

• Exchanging demographics, lab results, radiology results today – e-prescribing planned for 2010

• Feb 2010 – Used NHIN Connect gateway to demonstrate an exchange with Thayer County Health Services in Nebraska

Long Beach Network for Health (LBNH)

• Established by Long Beach Public Health Department in 2003

• Incorporated as a non-profit 501(c)(3) in 2007

• Connects 4 hospitals, 35 community clinics, Quest diagnostics, and Wellpoint

• Exchanging demographics, encounter data, lab results, dictated notes, allergies, and prescribed medications

EKCITA

• East Kern County Integrated Technology Association

• Established in rural California, Tehachapi in Kern County

• Incorporated as a non-profit 501(c)(3) in 2006

• Connects 22 providers including 1 hospital, a medical group, 3 regional health centers and 5 provider practices

California and HIE funding

• In February 2009 California received $32 million from ONC to build a statewide health information exchange

• HIMSS 2010 Interoperability demonstration– Santa Cruz Information Exchange– Long Beach Network for Health– East Kern County Integrated Technology

Association

http://www.healthcareitnews.com/news/california-build-hie-nearly-40-million