Health Information Exchange: A Progress Report

At its simplest, a health information exchange (HIE) "allows doctors, nurses … and patients to appropriately access and securely share a patient's vital medical information electronically; improving the speed, quality, safety, and cost of patient care," according to the Office of the National Coordinator for Health Information Technology (ONC).

Created under the HITECH Act, HIE delivery models can take the form of a single statewide exchange; local information exchanges; or technology available through commercial vendors.

But since their inception, HIEs have experienced a sometimes rocky and inconsistent roll out. What is happening in one state very often is quite different from another. And now that original federal funding has been exhausted, financial sustainability has become an issue as well. But that doesn't mean the dream of information exchange is defunct.

Laura McCrary is the executive director for the Kansas Health Information Network (KHIN), offering information exchange services to providers and healthcare facilities in Kansas. KHIN's members include over 800 healthcare providers and 100 hospitals throughout the state.

McCrary attributes strong participation to the quality of services that KHIN provides. "We have a highly robust health information exchange that … provides very good services to our members to help them meet their meaningful use requirements … improve patient care, and reduce costs for our patients in Kansas," she says.

If you believe that information exchange can benefit your practice and patients, here are the key factors to consider.

WHAT ARE THE CHALLENGES?

Physician Kenneth Salzman, a member of the Healthcare Information and Management Systems Society (HIMSS) Innovation Committee, says that adoption of EHRs rose to 78 percent in 2013, according to the ONC, yet only 14 percent of users were "exchanging information outside their organizations."

Furthermore, Physicians Practice's 2014 Technology Survey, Sponsored by Kareo, indicated that only 18 percent of more than 1,400 physician practices nationwide are part of a state-run or proprietary HIE.

There are a number of challenges to successfully exchanging information, not the least of which is cost. Independent medical practices that participate in HIEs often exchange patient data through a state or regional health information network, but in many cases they need to pay for technology upgrades and interfaces themselves, unless state funding is available. And there are usually fees to participate in an information exchange. KHIN charges a per provider annual fee and a one-time implementation fee, which pays for the cost of the interface itself and the connection to that interface.

According to a joint report by the Robert Wood Johnson Foundation, Harvard School of Public Health, and Mathmatica Policy Research, physicians are less enamored with information exchange when they are expected to pay for participation and do not see a clear and immediate benefit to themselves and their patients. That is partially the case for Mark Nunlist. Nunlist is a semi-retired primary-care physician based in White River Junction, Vt., who serves as a consultant for his former practice, White River Family Practice.

"Vermont … [has] a developing health information exchange and they have been very proactive in trying to get practices in the state to use health IT effectively," says Nunlist. But, he says the state government is considering passing the cost on to providers. "[My] sense is [they reason] we'll charge you $50 per provider per month to access [the exchange]. That doesn't sound like much when you are sitting at the state capitol, but when you have nine providers, that's $450 a month …."

If you stand on the roof of Nunlist's practice you can see the Dartmouth-Hitchcock Medical Center just across the Connecticut River in New Hampshire. With one half of White River's patients residing in New Hampshire and the other half in Vermont, that poses some unique challenges for the practice; especially when it comes to information exchange.

It is difficult for the practice to engage in full data exchange with Dartmouth-Hitchcock.  Nunlist says the practice can access patient information through the hospital's EHR, but "the hospital cannot see the outpatient record, so it is a one-way street because there are different systems, and they are in different states, and there is not enough interconnectivity between health systems."

And while Nunlist sees the value in exchanging health information, he thinks the utility for independent medical practices is not there yet. "I don't think I see my partners logging on to a system in the middle of care to access information in the HIE until it's quite more sophisticated than I think it is [now]," he says.

WHY IS IT IMPORTANT?

Salzman, also chief medical officer for IBM's Global Business Services, says that despite significant barriers to information exchange, "There are initiatives to self-organize between states to combine resources and effort to achieve sustainment by broadening the stakeholder community and reduce overhead costs." He also says that because providers understand the future benefits to their practices they are "… embracing HIE as a necessary next step and finding ways to sustain the work the HITECH grants started."

That's an ethos felt by family physician Jennifer Brull. She is a solo practitioner in rural Plainville, Kan., a community of fewer than 5,000 people. Her practice, Prairie Star Family Medicine, is part of an organized healthcare arrangement, a relationship recognized by HIPAA laws that allows two or more providers to share protected health information. The reason? Brull and her colleagues know there's power in numbers: Each of the five practices that collectively form Post Rock Family Medicine retains its independence, but benefits from shared resources like EHR, physical office space, and some staff members. And, Brull says, they signed up for the Kansas HIE as a group.

Post Rock was one of the very early, small independent practices to join KHIN. Brull says their motivation was an extension of their practice culture: work collaboratively. "That's our philosophy, 'Somebody has to go first,' so go first and eventually it will pay off down the road," she says. Another motivation for Brull's group was to receive full integration with the state's vaccination registry. That hasn't happened yet, but Post Rock is waiting "in line" for the interface, and that is enough to be able to attest to that metric under the Stage 2 rules of meaningful use.

Exchanging health information is necessary, and required by law, for the first three stages of meaningful use, and gradually increases in importance for successive achievement of core elements. For instance, two information-exchange-related Stage 1 criteria are the capability to electronically exchange key clinical information and the ability to provide a summary of care record to providers.

Detailed data retrieval and reporting are also necessary to participate in a number of other programs such as fee-for-performance reimbursement models, accountable care organizations, Patient-Centered Medical Homes, and population health management. Post Rock received grant money from the state of Kansas to build a data connection (separate from KHIN) to participate in a state chronic-disease management program. It also took advantage of money from an insurance company to build a patient registry. In return, Post Rock shares patient data with the payer, which gives a much better picture of overall patient health than claims data. "[The payer] can identify high-risk patients in their panels … and [we can] connect them with the care managers," says Brull.

WHERE IS IT HEADED?

Medical coding and compliance audit consultant Betsy Nicoletti says that when it comes to sharing data, the physicians she talks to are frustrated. "[Physicians] tell me that the data doesn't import into their EHR and they have to go look for it and add it [in the patient record]. Or even if they want to get results from lab tests or X-rays, they don't always have an interface in their EHR," she says. 

Nicoletti thinks that problems with interoperability are especially troublesome for small hospitals and practices, compared to large integrated health systems like, for example, Pennsylvania-based Geisinger Health System, which is nationally recognized for its cutting-edge use of EHR.

If your state has an active HIE there are many good reasons to join; the benefits to your practice may help outweigh the cost to participate. For instance in Kansas, McCrary says that KHIN helps members meet their transitions of care for meaningful use; provides a state-wide personal health record that is free to all patients; and "provides the transport layer for all public health registries that our providers are required to send data to" for meaningful use. She says KHIN looks for ways to assist smaller practices in finding resources to pay for the interface costs and implementation fees.

Nunlist believes that in order for small, independent medical practices to realize the benefit of information exchange it would need to be "seamless and affordable."

"It would be sweet to know all the care that had been provided to the patient that I'm about to see … And it would be good for the patient to be able to travel around and know that the [record of] care provided at my office would be available … someplace else in the state," he says.

IN SUMMARY

Done well, exchanging health information can help practices and patients in many ways. Some of the greatest benefits are:

• Meeting meaningful use metrics related to data exchange

• Improving the quality of patient care

• Reducing operating costs

• Participating in population health initiatives

• Facilitating continuity of care

Erica Sprey is associate editor for Physicians Practice. She can be reached at erica.sprey@ubm.com.

This article originally appeared in the January 2015 issue of Physicians Practice.