The creation of the CommonWell Health Alliance announced at HIMSS13 yesterday underlined the fact that the exchange of patient information to improve outcomes and reduce medical errors is entering a new phase. Providers are moving beyond directed exchanges that transmit patient information such as lab results and discharge summaries in secure emails and advancing to query-based exchanges to find and request information on a patient from other providers, especially in sudden hospital admissions.
But the market continues to be fragmented between the providers and health systems that are phasing in query-based exchanges and the ones that are still implementing direct exchanges. There are also the hundreds of electronic medial record vendors to consider. Micky Tripathi, the CEO of the Massachusetts eHealth Collaborative, acknowledged that HIE implementation is working out a bit differently in practice than what was envisioned on paper. It’s pretty messy, actually.
As of July last year there were more than 600 electronic medical record vendors, so many that a consulting company created a database to help providers compare them.
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Having loads of different options for providers is a good thing because it means they can be tailored to the needs of each healthcare facility. The idea that every hospital could share patient information at the same level of the leading providers, for example, just isn’t practical. “We have always had this presumption that any [provider] could connect with anyone in the same way,” Tripathi said. “Just because CMS says we can doesn’t mean we can do it.”
What’s the biggest obstacle? For one, Tripathi says: “There are no national requirements for cross-system queries.
There are no national technical standards for these automated queries — how [they] get created and deployed in market.”
And then there are the legal implications. How can we determine who the users are and if they’re authorized to see those medical records?
Although most hospitals operate on the honor system with respect to security and privacy protection, and agree that only authorized professionals can look at them, the reality is there’s no way to confirm that. So, some providers are having to set up security systems like firewalls. And that is perhaps the most galling thing about electronic medical records. By making patient records digital, they can be seen by more people. And while that’s generally agreed that’s a very good thing, it also can make it more vulnerable to data breaches.
“Hospitals are having to figure out how to connect the dots on those issues,” Tripathi said.
And yet, as Tripathi observes, progress is being made. “It’s been along time since I ran across a hospital that doesn’t have some sort of program for a health information exchange.” Public health information exchanges facilitated through the federally funded Direct Project has gone a long way in helping these providers achieve the equivalent of stage 2 of the meaningful use requirements stipulated in the HITECH Act. The project offered grants to states to fund the cost of implementing direct exchange through secure emails for smaller providers has been critical to achieving that.
Tripathi is also the chair of the information exchange work group tasked with making recommendations to the ONC’s HIT Policy Committee. In a presentation to the ONC’s Health IT Policy Committee and the Health IT Standards Committee’s joint hearing on health information exchanges earlier this year, Tripathi noted that there’s been progress with what he called visual integration and document integration — particularly exporting and importing clinical documents and attaching them to patient records. Data integration has lagged behind except for e-prescriptions and digital transmission of lab test results.
There has also been some progress on communication systems called patient portals developed by electronic medical record vendors in which patients can send and receive messages from providers. eClinical Works and Epic dominate the market — eClinical Works has more than 8 million patients using its portals.
And yet, meaningful use stage 3 looms large, so much so that with the public discussions on the subject, Tripathi thinks maybe a better approach would be to phase it in more gradually by dividing it into three stages. Several providers and health systems have led the way toward developing data sharing as well as implementing ways to reduce readmissions such as Geisinger Health System, which is also part of the Care Connectivity Consortium. Some accountable care organizations are also helping guide implementation.
But as a way to help other providers comply with meaningful use, reduce healthcare costs and avoidable readmissions, Geisinger has launched a startup called xG Health Solutions. Tripathi, though, doesn’t see that as being a common business model going forward. Geisinger’s designation as a Beacon community helped it implement reform initiatives ahead of many other providers. “Hospitals are not professional consulting companies. … I think that would be a bit of a challenge.”
