5 Considerations on Health Information Exchanges: What Your Hospital or Health System Needs to Know

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Hospitals and health systems are scrambling to become meaningful users of certified electronic health record technology within their own entities, but what's the next step to share health information after that step? The answer for many organizations will be health information exchanges.

HIEs mobilize patient healthcare information electronically across multiple member organizations, hospitals and other stakeholders. In many ways, it's like an EHR for an entire geographical region or, on a smaller scale, a health system that gives physicians and other healthcare professionals secure access to patient data when it might be needed in critical moments. The following five considerations can give hospitals and health systems more insight on what a HIE is and what the benefits and drawbacks of joining or creating one are.

1. Nuts and bolts.
For a HIE to work, hospitals and health systems must first have functioning EHR systems, preferably ones that satisfy the Office of the National Coordinator for Health Information Technology's requirements for meaningful use. Federal grants through the HITECH Act are helping hospitals and health systems adopt EHRs, and the ONC has been funding states to implement HIEs. The State HIE Cooperative Agreement Program has awarded more than $547 million to 56 states, eligible territories and qualified state designated entities, according to the ONC website. Providers wanting to join a HIE look for a basic starting point: where is there a HIE geographically closest? Health systems wanting to create their own must decide if it is financially and logistically feasible to interlink member hospitals.

With EHRs in place, the HIE organization can recruit different providers, hospitals and health systems to join the exchange in order to share patient information. For example, Tom Penno, chief operating officer of the Indiana Health Information Exchange, says patients can go to a physician, have blood work completed and that information can be uploaded if they see other physicians or specialists within the HIE. This gives the provider a new way to obtain patient information quickly and securely at crucial points of care, he says. Joy Grosser, vice president and chief information officer of Iowa Health System, says HIEs make it possible for clinicians and physicians to have all the information they need to give the best possible care to patients, be it in a clinical, ambulatory or hospital setting.

"HIEs are really an infrastructure necessity to change the way we're doing healthcare across regions, states and the nation," Ms. Grosser says. "Most people don't spend their entire life at one hospital or one physician. It's integral to help manage the healthcare of a population to be able to share this info. We're on the first step of a stairway through this process."

2. Implications of health IT vendors. According to a recent eHealth Initiative survey, HIE initiatives are up nine percent from last year, so there is a demand when it comes to HIEs and vendors to build their infrastructures. Consequently, hospitals wanting to join a HIE or build their own are at a time of both early adoption but, as the survey shows, a growing demand. There are dozens of HIE vendors, many of which are similar to a hospital's EHR vendor, but John Hendricks, IT director for interoperability and web programming for Iowa Health System, says knowing the right certified system within the HIE is key. The HL7 Clinical Document Architecture is a standard that all lays out the specific structures and meanings for clinical documents to be exchanged. The Continuity of Care Document is the main document within the HIE and EHR systems, and some include different subject areas of patient health, such as allergies, family history, results, vital signs, payor details and others. Hospitals entering or creating HIEs must be cognizant of the information that is actually being shared and how a vendor handles the sensitivity of the information. Mr. Hendricks notes that not all vendors support the different subject areas and CCDs, and there is not complete interoperability among all different hospital EHR systems.

Ms. Grosser adds that choosing vendors and implementing HIEs is still very new and proprietary for each organization's core IT systems. However, putting certified systems and coding in place is one of the best practices an organization can do, she says. Standardizing those systems with certified nomenclature will lead to less overall confusion between participating providers while sharing information.

3. Main incentives.
With the industry emphasis turning to both quality and access, Ms. Grosser says HIEs give health systems, hospitals, patients and all involved in healthcare a more efficient and easier way to administer quality healthcare. "At the point of care, it provides a broader picture for them to take care of the patient," Ms. Grosser says. "Health information exchanges are about caring for the patient." She adds that tests might not have to be done twice, and allergies can be caught earlier if providers have patients' medical histories at their fingertips, regardless of what provider they've been to before.

Mr. Penno has been at the IHIE since it started in 2004, and it is currently the nation's largest self-sustaining HIE, covering the entire nine-county area around Indianapolis as well as numerous communities throughout Indiana. He says he has seen the benefits of an HIE for hospitals and other providers as the IHIE has grown, and one of the biggest incentives he's witnessed is the ability to manage a population better. HIEs allow for better health decisions to be made at the point of contact, and it could lead to providers automatically helping people with chronic diseases such as diabetes or cancer to stay up-to-date on appointments and checkups. "If you give physicians patient-specific alerts and reminders — this lady hasn't had a mammogram, this guy hasn't had a colonoscopy — you become much more proactive in managing their healthcare," Mr. Penno says.

4. Financial and political challenges. Politics and finances go hand-in-hand for many big operations, and Mr. Penno says that's no different for hospitals, health systems and HIEs. Before ARRA and the HITECH Act, he says it was a challenge for hospital leaders to prioritize a HIE in their plans, but now with meaningful use incentives from the government in the future, some of which are still being ironed out for HIEs, it has become easier to attract participants. "It was a challenge to get CEOs and CIOs to return your phone call, but as HIEs came onto the horizon, suddenly they had a vested interest," Mr. Penno says. "They knew that was going to be an important part to achieve meaningful use and incentives."

Still, Ms. Grosser says large regional or statewide HIEs can cost upwards of tens of millions of dollars, and they are more expensive than an internal exchange within a hospital or other healthcare organization. HIEs are still in their infancy, so it will naturally cost more initially, but government-provided grants and meaningful use incentives are the big financial stimulants for both sides, she says.

5. Opt-in versus opt-out. A key for any HIE is to have patient data to share in the first place. There are two approaches a HIE can employ to obtain patient data for its exchange: opt-in or opt-out.

The opt-out approach puts the onus on patients to have their information removed from the exchange. HIEs would have a privacy consent form stating the patients' information might be used for healthcare purposes, but the patient is put into the system as a default. Mr. Penno says the IHIE utilizes the opt-out approach in order to obtain as much patient data as possible, but some sensitive data such as HIV results and behavioral health results would not be included. "You're going to get more people contributing their information," Mr. Penno says. "It could be more important when they're on a gurney in the emergency room, or maybe they are allergic to something."

The opt-in approach, however, puts the onus on the hospital or health system to obtain permission from each patient stating they are opting in to the HIE. While this type of data exchange might not be as robust initially, growing more slowly, Mr. Hendricks says the patient may prefer the opt-in default approach because the patient would have full control of his or her information. "The opt-in default approach establishes transparency between the exchange and the patient," Mr. Hendricks says. "In either case, patient education is a must for health information exchange."

"But the key driver going forward is going to be the patient," Mr. Hendricks adds. "As patient awareness grows, hopefully they will drive the adoption of health information exchanges."

Related Articles on Health Information Exchanges:

University of Maryland Researchers Develop Framework to Assess HIEs
ONC Looks Into Researching Patient E-Consent for HIEs
eHI Survey Shows 9% Increase of HIE Initiatives

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