Health Information Exchange (HIE) – Is it the right way?

Increasing dissemination and exchange of health information electronically between multiple care providing bodies has led to the emergence of Health Information Exchanges (HIE). General opinion has been that these HIEs will inevitably enhance the quality of care, but newer studies debate whether this is the right way to encourage information sharing across the healthcare community.

Recent research by experts in the industry questions the ability of Health Information Exchanges to operate fully in compliance with Meaningful Use as required by the HITECH Act. Instead, researchers suggest developing a cloud based Health Record Bank.

THE HRSA website defines a health record bank as an “electronic consumer-controlled warehouse that gathers, stores and disseminates patients’ health records. A patient can, for a fee, establish an account with a health record bank. When the patient has new medical information – such as information relating to an upcoming physician’s appointment – their provider can send it directly to the bank. The patient can also submit their own information as well as determine who can have access to review their personal medical records.”

One of the original researchers for this study shared his idea that since Electronic Health Records are usually banked in communities across the country, it would be prudent for patients to share their information on a single platform. Not only would this give them better accessibility, it would give the government a better chance to monitor and analyze the trend or pattern of population health.

Cloud-based banks would perform functions of data maintenance for patients’ electronic health records in different communities throughout the country with a local or regional provider having a separate copy of the records which the patient will be able to transfer to any other provider, if he or she chooses to.

Researchers believe that current health information systems are faulty and unstructured. The crisis in healthcare and the need for urgency in reforms lead the research team to think about better ways to share large amounts of medical information across the community, connecting all stakeholders related to the industry.

One of the main issues with current health information exchanges is that it Is largely based on an assumption that one can get information about any patient from any provider. This is ineffective because if you go to a doctor for information about a patient, the doctor will have to contact some other doctor and ask for that specific information which the other doctor will have to search for first, and then relay the information back to the doctor you are sitting with.

If all the information related to every patient across the country was kept on a single database, without the need to check with other parties, information sharing would become easier, quick and efficient. The dilemma now is that, considerable amount of money has already been spent on health information exchanges across the country. This leaves little desire to look for alternative ways of information sharing and a lack of capital for more research into health record banks.



One Nation, One EHR –The Direct Project

The essence of Health Information Exchange (HIE) lies in easily accessible health information to improve the quality of care delivered by the healthcare community. Complicated formats intrinsic to many EHR systems are generally counterproductive to this basic nature of HIEs and can prove to be a hindrance against delivering quality care. So the natural question arises, what can be done to remove such blockades in the inherent design of these EHRs to facilitate their intended requisites? A popular solution proposed to answer this query is to develop a holistic system of sharing health information between healthcare providers and other concerned entities on a national level within the healthcare continuum.

With the expected level of complications in developing such a system, a lot of critics would say that the notion of a national EHR system is far-fetched and would dismiss the idea altogether. Their objection would be justified if we considered the amount of time invested into the development and implementation of health information interoperability throughout the nation and still not attaining the desired results. Not even a single developed country so far has managed to go a hundred percent electronic with their clinical documentation. That being said, we have examples of numerous countries that have successfully devised and kicked off a national EHR system including France, Singapore, Sweden and Germany. These systems have been successfully deployed for quite some time now and are functioning with improved efficiency while acquiring a larger database of patients by the day.


When one ponders over the matter, the ideal solution would be to implement such a system in the United States as well. It wouldn’t matter which hospital you visited or if you switched providers, your private health record would be accessible in a secure format no matter where the point of care is located. Reflect on the example where your physician refers you to another specialist. Imagine if the specialist already had your health information upon your arrival instead of you having to remember your previous tests, medications and diagnoses. Wouldn’t that be much more convenient and helpful as compared to the alternative?

The fact of the matter is that the government is not oblivious to the huge potential which lies in developing such an interface on a national scale. Significant efforts have been made towards achieving such a system. The government’s endeavors came to fruition in March of 2010 when the Direct Project was launched and furthered the struggle to form a robust nationwide health information network. The Direct Project was developed in order to create a secure, simple and scale able platform which is standardized to send/receive authenticated health information to trusted entities over the internet. More than fifty different organizations and 200 participants are currently employing the Direct Project to their benefit. These participants consist of PHR and EHR vendors, system integrators, medical organizations, federal organizations, health IT consultants and many more. We will try to illustrate some implemented instances pertaining to the Direct Project with some examples in this extract.



The Newborn Hearing Screening Program (NBS) in Florida mandates the state’s hospitals to monitor all newborn babies to check for any potential hearing impairment which the infants might be experiencing. This process is carried out in order to make instant interventions in case a problem is detected so that any undesirable effects of hearing loss may be countered. Conventionally, the NBS processing was largely accomplished through fax. This meant that hospitals were required to present screening results to the state and NBS had to provide a compilation of results which were accumulated back to the hospitals through fax. One can imagine the inefficiencies as a consequence of using such an outdated medium. Right now, Florida is employing the Direct Project to make electronic transmissions for NBS and the results have spoken in volumes. The cost incurred for paper during processing has virtually been eliminated along with the hassle of using paper which accompanies it. Furthermore, it has created a sizeable increase in the efficiency of workflows for audiologists and various other professionals conducting the screenings.


The St. Joseph Health System and Redwood MedNet in California are collaborating to implement the Direct Project to enhance care delivery for newborns. Maternity wards inside different facilities will make use of the Direct Project to deliver newborns’ health information to their concerned pediatricians. Moreover, this health information will be transmitted to the patients’ HealthVault accounts as well which will enable parents to view their babies’ health data even prior to their discharge from the hospital. Redwood MedNet takes this even a step further; using the leverage of the Direct Project Redwood MedNet is providing hospitals the capacity to share clinical summaries once patients are discharged from the hospital. This gives hospitals the capability to demonstrate proposed Meaningful Use requirements which direct providers to electronically share care summaries during a patient’s transition from one clinical setting to another.


Guam HIE is tackling several distinct aspects in their implementation of the Direct Project for the Department of Defense (DoD) and the Department of Veterans Affairs (VA). VA and Guam HIE are at present referring VA patients in Guam for mammography by means of the Direct Project. They are looking towards using the resourcefulness of the Direct Project in making all future referrals for VA patients, providing a simple mechanism to expedite test results and imaging results alike. Guam HIE is also planning to employ the Direct Project to exchange military patient information with the Department of Defense as well.

Approximately 30 states across the country have gone live with the Direct Project with numerous others to follow. Providers may now share confidential patient health information electronically to ensure informed referrals and safer care transitions to other care delivery organizations via the Direct Project services presented by the ONC. Unnecessarily spending money on duplicated results is abolished once this innovation is adopted. The Direct Project will undoubtedly prove to be an innovative tool to enhance patient care and become a time saver for both doctors and patients.


EMR Adoption and Health Information Exchange

The last few years have been monumental for health. Electronic medical records have flooded into the mainstream with a recent report from Center for Disease Control (CDC) suggesting that nearly 55% of physicians in the US are at some stage of adoption. The survey also indicated that most respondents felt that EMRs had improved the overall quality of care. Industry analysts view this as a huge achievement for the healthcare industry and a giant leap towards the reformation process. One industry expert says, “The EMR has the numbers now. With more than half of the physician populous already using electronic medical records, physicians still using paper will have to join in or risk becoming obsolete.”

The U.S has been quick to utilize emerging technology in healthcare and with EMR adoption on the rise, physicians are likely to respond positively to innovation. “Our objective is connecting care and to reach this goal, we require an electronic health information exchange platform. EMRs provide just that”, says a hospital administrator.

John Lynn from shared a similar opinion in his blog. He believes that most of the healthcare community is aware of the benefits of Health Information Exchange (HIE). John argues that while standardization and development costs are two main barriers, the scale of EMR adoption in the country may be the biggest impediment to growth in the sector, he writes, “We want HIE’s to be successful, but can an HIE be really successful for doctors and hospitals that don’t have an EHR? The lack of EHR adoption might be the biggest impediment to HIE.”

The transformation of the healthcare system hinges on the success of electronic medical records. Having realized the importance of EMR adoption, the government extended its support through Regional Extension Centers and other educational communities in various states. The ONC highlighted the need for outreach programs targeting the rural and underdeveloped areas. While cost is a major deterrent here, education and exposure are the other key constraints.

The CDC survey also listed solo providers as the laggards in the adoption cycle, with only 30% reporting for adoption. However, the outlook is not so bleak. An industry expert highlighted that it’s common for independent businesses to lag behind in industrial changes, saying, “The adoption may be slower for independent doctor offices but it would change in the long run. Physicians are likely to follow large health corporations and hospitals in adoption. In fact there is an increasing trend of independent doctors adopting EMR systems with an HIE interface with their local hospital.”

HIEs are a step in the right direction and should help reduce cost in the long run. The communication process will simplify and health organizations will be able improve the patient care process through coordination. EMR adoption will continue to be the top priority and the government remains optimistic as it aims to shift America to electronic medical records by the end of 2014.

Read more: Data migration: Why is it important in Healthcare?


The Healthcare Reform – Are We There Yet?

The progression in health IT is introducing a new culture of care across the US. Developments in the world of technology have paved the way for a fluid and pro-active healthcare system.  “The pace of technological advancement in health IT has been incredible. We have witnessed a significant change over the course of a few years.”, says Josh Andrews a health IT analyst. Josh elaborates that the transformation of the healthcare industry within the US has come about rapidly saying, “While the health IT phenomena is worldwide, the growth rate across the US has been unprecedented. Our EMR adoption rate is extraordinary, having doubled from 2009 to 2011 and this is likely to increase in the coming months.”

However, this exponential growth presents new challenges for providers and regulatory bodies alike. Mark Kadrich, a security expert and the author of Endpoint Security explains that, the shortening of the testing phase to push technology is likely to give rise to multiple threats in the long run. 2011 was a huge year for mobile health with a lot of tablets and alternative devices being launched one after the other leaving the EMR industry to follow suit. Majority of the EMR vendors created non-native, remote desktop interfaces to grab a quick market share. However, in most cases these solutions were not practical and lacked maturity as Kadrich explains, “Mobile applications linking medical workflow between clinician and patient aren’t quite there, yet. There are some, but they’re rife with flaws.”

The healthcare system requires sustainable technology to grow and poorly developed systems will only hamper progression while compromising patient safety. There is a clear gap between the actual and expected capabilities of EMRs, in terms of interoperability. This is the reason that most medical professional were aghast upon learning the proposed requirements of the meaningful stage 2. “Our systems are incapable of connecting with hospitals and we still have issues with lab integration and e-prescribing.”, says a new EMR user.

The Health Information Exchange initiative (HIE) has shown remarkable growth and potential but the HIE industry itself is still in its adolescent stage. Only a handful of HIEs have been able to resolve technical issues. Exchange of medical information will pose significant risks that need to be addressed before commercial use. However, there is much optimism surrounding the development of HIEs.

Security is a huge concern for the health IT industry. With countless mobile and connected medical devices coming out, developers cannot ignore the need for improved security measures and better system design. The reason we are seeing an increased activity on the part of the federal government for system abuse is because our current healthcare system is arguably immature. Fraud and abuse are huge concerns for CMS as bugs in the systems are likely to be exploited. According to Kadrich, traditional methods will no longer be adequate, “We need to get beyond the traditional throw it behind the firewall’ mentality and take a good hard look at some new and innovative ways to fix things.”


The Incremental Approach Towards HIEs

Connected healthcare is a maze of landmines to be trodden lightly. Micky Tripathi CEO of the Massachusetts eHealth Collaborative points out in his recent article, the dangers of overbuilding HIEs. Although, this is not the first attempt at healthcare information exchange (HIE) as Micky has referred to the publicized failure of Santa Barbara Care Data Exchange and the ill fate of Community Health Information Networks in the 1990s. “I’m delighted that we’re moving rapidly in this direction, but one concern keeps nagging away at the back of my mind, and that is the propensity to pursue over-architected HIE solutions”, he says.

The problem lies with the ideology of constructing a comprehensive solution that is capable of handling inter-industry information exchange, along with providing electronic support to remote clinical sites which themselves are a mere concept for now. What the government must understand is that the process cannot be sped up to reflect drastic changes and thus must follow a natural course. Incremental changes will allow the industry to respond appropriately while developing sustainable solutions that can be built from the ground up. Forcing instant change will not yield the benefits attributed to a HIE.

EMRs have been a prime example of why there is no single pill solution. Despite the rapid development in the industry, EMRs have not attained a form that could be considered complete in any regard. The world of technology is ever developing and nothing can truly be a final form. Changes are likely to occur as usability increases. While we may have a general idea of the risks associated with information sharing and health networks, actual usage will be more likely to shape a sustainable design.

The HIE infrastructure is still in its infancy whilst most practices lack the resources or adequate training to support the transition. However, it is expected for the industry to develop substantially over the next few years, with the private sector likely to lead the charge. A recent report by Chilmark Research highlighted the phenomenal growth in HIE(s) during 2011, increasing to a colossal 40% per annum.

HIEs can change the landscape of healthcare and while Accountable Care Organizations may be the initial goal; HIEs will inevitably shape a new world of care delivery.


HIE Integration – Why is it Necessary?

The goal of health information technology (HIT) is to improve the availability of information to clinicians at the point of care. The two most significant components in the HIT infrastructure are electronic medical records (EMR) and health information exchange (HIE). Together, these technologies will be the major disrupts in the health care industry over the next five years. Most health care providers are already aware that they must have an EMR with HIE integration in order to achieve meaningful use, start an Accountable Care Organization, or participate in a medical home model; however, adoption remains low while resistance remains high.
Information Availability with EMR

While healthcare IT executives applaud the benefits that HIE can provide, such as improving the quality of clinical reporting and the coordination of care among physicians, the high costs of participating in an HIE is still an impediment. A recent study found that 41% of physicians consider high start-up costs and insufficient capital to support HIE as their major concerns. Additionally, 38% said they have annual budgets for HIE development of less than $1 million, while 21% have no budget at all.

There are several implementation issues with HIE integration as well. Currently, because there is not one single set of standards consistently implemented, a custom connection has to be developed from each EMR to each HIE. The development of the interface represents a significant expenditure of cost and time for all stakeholders, including physicians and vendors, which has been limiting both adoption of EMR and the usage of HIE services.

Regardless of the foregoing problems, we cannot deny the substantial albeit unforeseeable benefits on the EMR/HIE horizon, especially if we look at precedent-setting examples. HIE is the most significant transformational tool healthcare has seen since advanced imaging, and the benefits will lead to tremendous improvements in treatments and outcomes. Stakeholders will soon face a much bigger stick than competing in the market to answer the health care equivalent. Patients and physicians will demand more efficient information exchange through a multifaceted approach that will create unprecedented resource disruption and, ultimately, higher costs to the stakeholders that continue to lag behind.

At present, 90% of patient health information resides in private practices within any given community. This is a staggering number considering the fact that there is no efficient way to transition and coordinate care between health care providers. The gradual but steady adoption of EMRs is a step in the right direction for improved workflow and quality of patient care. The next step is for physicians to realize the value of being able to efficiently transition care and the information that is associated with this process. The idea of a fully functioning national HIE may seem farfetched, but then again, there are substantial grounds to continue its development.