What's helping (and hindering) state Health Information Exchanges?

There is no such thing as a cookie cutter approach to healthcare information exchanges. That is a point HIMSS Senior Director of Informatics Pam Matthews can’t emphasize enough. Sure, there may be some common models — network of networks, hub and spoke, peer-to-peer — and each exchange wants to meet Meaningful Use requirements outlined in the HITECH Act. But the exchanges that are progressing well are the ones that go beyond MU and consider the needs of their state or region’s constituency.

One of the most surprising points, Matthews made in a phone interview was this: technology is just one part of making these exchanges work. Sure, the exchange needs to have an IT architectural backbone. But if states can’t successfully engage providers and consumers as stakeholders and make a case for how they can derive value from it, then the public network won’t work. Other factors, particularly politics and the ability to collaborate with the other regional exchanges in a state are critical to pulling it off. So is working collaboratively with health IT companies

The Office of National Coordinator for Health IT commissioned a report on state HIEs by the National Opinion Research Center at University of Chicago and presented at HIMSS earlier this year. It contrasted the different approaches state shave taken and some of the challenges they have faced, overcome and continue to have. Here are four factors that have helped and hindered state HIEs outlined in the report and underscore Matthews points.

Getting consumer stakeholders involved Maine is one of several states that took steps to set up a statewide network years before the HITECH Act. Its health information network made getting the perspective of consumers a priority by assembling a committee of consumer stakeholders and showing how Maine citizens would benefit from electronic clinical information sharing. It led to the creation of an opt-out and opt-in component for sensitive health information. It sounds a bit counter-productive to the goals of HIE, but it has also had the effect of boosting support for the exchange there. Nebraska has also taken this approach. In Texas’ decentralized network of networks, regional health information organizations or RHIOs are connected by one overall network. Each RHIO has its own approach to patient consent and that’s likely to cause problems in the future.

Sustainability: managing HIEs when the grant money runs out Matthews goes back to her point about the importance of stakeholders getting value from the exchange since the grant money used to help set up and develop them will come to an end. If you’re asking stakeholders to help pay for it, then it’s important to communicate and demonstrate its value. Washington state, for example, introduced a tiered subscription model that rewarded early adopters and charged subscription fees based on organization size. Delaware’s network relies heavily on transmitting lab results. Providers pay up to $0.25 per result panel delivered to the community health record. It captures 100 percent of lab results. The reason that it works is that all the state’s hospitals are part of the exchange and major independent labs participate too.

State vs. providers IT system needs Most state systems use Direct, part of the ONCs Direct project, as a way of exchanging data such as lab orders and results, discharge summaries and referrals. Providers exchange the data through a direct connection with each other, point to point. It is considered to be a basic approach to exchanging information compared with, say, a hub.Wisconsin is at something of a crossroads IT-wise, according to the NORC report. It’s facing the problem of having a public HIE that uses Direct while providers in the state are in or affiliated with large hospital systems that have EHRs and need query-based exchange. That is fueling a drive towards private network solutions. This private vs. public HIE issue is one that many states are facing.

Health IT vendor backlog The government’s drive to get so many providers to adopt electronic health records and the scale of that effort has led to delays in getting health information exchanges set up, according to the report. Health IT vendors are so busy getting providers’ systems connected that states see a backlog in getting their exchanges set up. There is also a certain amount of distrust by states of health IT vendors. Despite despite claiming to support the clinical care document standard, the implementation of the standard has varied between different EHR vendors. They don’t see them as being all that interested in interoperability with other health IT systems and has led to states having to use more health IT vendors for more services.