Thursday, October 23, 2014
Now that adoption of Electronic Health Records (EHRs) has moved forward, and Health Information Exchanges (HIEs) are following suit, what lies ahead for national healthcare? How does the government leverage its investment in digitizing the healthcare indu

In order to benefit from the stimulus investment made in transforming healthcare, the government will need to support industry by incentivizing the effective use of tools and infrastructure that leverage information to improve care delivery. The groundwork in standards and interoperability laid by the Office of the National Coordinator (ONC) demonstrates that establishing a working infrastructure is challenging, but achievable. In generating implementation guides (IGs) from use cases that address core working processes with standards based approaches, the ONC has started the hard work of implementing tools to facilitate interoperability through standards based processes. However, “Meaningful Use” (MU) requirements precede many of these processes, making it difficult to comply with standards given barriers that exist to accomplish the letter, if not the spirit, of MU. MU1: Stage 1 of Meaningful Use MU2: Stage 2 of Meaningful Use MU1-3: How to Attain Meaningful Use By focusing on tools, infrastructure, and proper incentives to facilitate improved outcomes and efficient use of healthcare resources – for example, by sharing and aggregating information to drive informed and integrated care delivery -- the government, as one of the largest payers for healthcare, can collaborate in the healthcare ecosystem to realize the benefits of its investment in healthcare transformation. This is significant given the government’s position as one of the largest payers for healthcare services. Discussion about the state of HIEs following the widespread adoption of EHRs in the US follows. 1. Who funds, promotes, and uses HIE? The Health Information Technology for Economic and Clinical Health Act (HITECH) provided initial funding (grants) to states and territories (56) to participate in HIE. Below are some links for specifics on success and how these efforts are progressing. As funding shifts from start-up to self-sustainment, many grant-based initiatives are struggling or failing. Those that do persist have several key elements: Stakeholders engaged in success, Trust between organizations and A sustainment model. With federal funds ending, initiatives are emerging to self-organize between states to combine resources in achieving sustainment through broader stakeholder engagement and lower overhead costs. ONC and HIMSS (Health Information Management Systems Society) continue to promote HIE, and use the initial round of funding to expose the benefits/inevitability of HIE as healthcare transforms. Accordingly, stakeholders are embracing HIE as a necessary next step, and finding ways to sustain the work the HITECH grants started. The increased level of HIE reflects a growing use for a competitive advantage across the healthcare enterprise, greater implementation and adoption of HIE by physicians, and a realization that benefits outweigh the costs and effort in this space. HIE Resources State Health Information Exchange Eight Lessons for Successful HIE Implementation Three Traits Shared by Successful HIEs 2. Why is HIE important to small practices? Small practices constitute a plurality, if not majority, of care providers across the country. For small providers who retain their practice populations, a percentage of their patients will inevitably obtain care outside of their practice, for reasons including consultations, care provided while travelling, or hospitalizations. For patient safety, continuity of care, and transitions when patients move, small practices benefit by sending and receiving a comprehensive patient record to enable improved care with decreased cost and a better patient/caregiver experience. A “good citizen” perspective as well as self-interest drives small provider participation. With funding reforms, monetary incentives and penalties will also impact participation. 3. How can small, independent practices benefit from HIE? As they take patients into their system, receiving a comprehensive record will allow practices to provide better care based on documentation of existing conditions and care plans, and less investment will be needed to integrate new patients. Contrastingly, patients who leave a practice can be sent on with a comprehensive record, so that whoever assumes their care will start with information available to provide continuity of care. This trend provides the patient with information about their care as they move through the system. Financial incentives for sharing patient information among providers will follow over the mid to long term. Clinical Value-Add for Health Information Exchange (HIE) Health Information Exchange among Clinical Laboratories Sustaining State Health Information Exchange: A State Toolkit 4. What progress has been made in utilizing HIE? A recent Health Affairs* article notes that while adoption of EHRs has risen to about 78% by 2013, only 14% of those were exchanging information outside of their organizations. The challenge lies in adopting an EHR, which the HITECH Act accelerated, that is interoperable across the healthcare system. Most EHRs do not benefit from information exchanges, and most users are yet knowledgeable enough to focus on that aspect of EHR capability. HIE will follow adoption of EHRs, as the transition from analog to digital technologies equips organizations with a platform on which to start sending and receiving patient records electronically. In addition, the appropriate standards (including C-CDA, HL7 messaging standards, DICOM) need to be operational and in use at the appropriate level to exchange information between organizations. As adoption and use advances, the realization of better care, lower cost, better patient experience and improved health will also advance -- demonstrating the value of an interoperable, and ultimately integrated, ecosystem of care for America. *(Vol 33 No 9, Sept 2014: Despite Substantial Progress In EHR Adoption, Health Information Exchange And Patient Engagement Remain Low In Office Settings) 5. What would first steps be to exchange data? The government can help promote the infrastructure necessary to exchange data, especially an EHR that connects to the internet. This will enable a progression from sending letters with information, to faxing information, to exchanging information electronically at increasing levels of semantic interoperability . The ability to consume information will similarly evolve, ranging from views of a letter, fax, or shared .pdf file, to incorporation of electronic documents into an EHR – enabling the ingest of discrete data that can be arrayed in an EHR graph that, for example, trends Hemoglobin A1C levels. More advanced EHRs allow integration of external information data into their data stores, driving analytics that use data from multiple sources to give a more comprehensive and accurate picture for a given measure of a patient’s health status. For healthcare transformation, the train has left the station. In order to realize the benefit of HITECH and ARRA funding for transformative initiatives, the government will have to shape the environment in ways that enable progress, while maintaining an appropriate level of accountability. Balancing the tension between support and requirements is critical to forge the way ahead in optimizing the digitization of US healthcare. Image courtesy of phasinphoto at