Both EHR interoperability and health information exchange (HIE) will play a major role as the healthcare industry continues to reform and develop more effective patient care strategies. Incentives tied to meeting Meaningful Use (MU) requirements and healthcare reform serve as prime motivators in increasing provider interest and participation in the exchange of health information, according to an NORC at the University of Chicago report presented to the ONC for Health Information Technology. With all of these initiatives, however, comes the issue of rising costs, which promise to continue to present a challenge for providers and HIE adoption.
Sheldon Wolf, North Dakota Health Information technology director, who leads the North Dakota Health Information Network (NDHIN) initiative; Julia Staas, IS director of integration at Virtua Health who in that role also oversees the Virtua Health Information Exchange program; and John Kansky, president and CEO of the Indiana Health Information Exchange (IHIE), weigh in on what it will take to achieve next-generation health data exchange.
Compiled by Amanda Griffith, Contributing Writer
Transforming patient care with data interoperability and trust is a common healthcare industry goal. Three industry experts share their thoughts on how to achieve next-generation health information exchange.
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Both EHR interoperability and health information exchange (HIE) will play a major role as the healthcare industry continues to reform and develop more effective patient care strategies. Incentives tied to meeting Meaningful Use (MU) requirements and healthcare reform serve as prime motivators in increasing provider interest and participation in the exchange of health information, according to an NORC at the University of Chicago report presented to the ONC for Health Information Technology. With all of these initiatives, however, comes the issue of rising costs, which promise to continue to present a challenge for providers and HIE adoption.
Sheldon Wolf, North Dakota Health Information technology director, who leads the North Dakota Health Information Network (NDHIN) initiative; Julia Staas, IS director of integration at Virtua Health who in that role also oversees the Virtua Health Information Exchange program; and John Kansky, president and CEO of the Indiana Health Information Exchange (IHIE), weigh in on what it will take to achieve next-generation health data exchange.
Q: What obstacles are currently impeding the effective exchange and interoperability of information?
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Wolf: Cost and a lack of resources are the main issues. Small critical access hospitals and providers run on slim margins or in the red, so sometimes having money to participate is tough. Small practices do not have enough IT, HR, administrative staff, or lab staff to help with integration and testing. This also drags out implementation because resources are already spread too thin.
Staas: Many practices struggle to obtain the funds necessary to build interfaces with their vendors so they can connect to the HIE, not to mention costs for licensing, implementation, and annual maintenance. While MU has tried to advance this arena by providing incentive dollars to eligible providers, many — such as post-acute care providers — have been left out, creating a gap that needs to be addressed.
Kansky: So many talk about perceived challenges, but I think it boils down to a matter of confusion, of conflicting messages. If you’re deciding whether and how to participate in an HIE or how to achieve data interoperability, your EHR vendor is telling you one thing, the state or local health exchange is telling you something else, and various other entities like CommonWell and the Sequoia Project (formerly HealtheWay) offer still other advice. That’s the greatest impediment because, regardless of standards or the size of the healthcare organization, it’s much easier to keep practicing medicine the way you always have versus trying to cut through all the noise.
Q: What strategies have been successful for implementing, adopting, and sustaining HIE?
Wolf: Building trust with both providers and payors is critical because all sides need to operate with the same goals and vision. In our state, we’ve worked closely with the administration and legislators to secure funding in parallel with the cooperative agreements in place with the ONC. We’ve also funded a revolving loan program that has helped providers access more than $12M to date. It’s also important to work with a reputable and trustworthy HIE vendor. These relationships are critical.
Staas: The best way to achieve buy-in and improve adoption is through transparency and sustainability. Well-structured governance must involve providers who serve as the voices making recommendations on policy-related issues on everything from permitted data use to privacy and security.
Q: How does data exchange support MU and population health management goals?
Wolf: Around MU requirements, we bring in HL7 feeds, like lab feeds from participating providers, and send them to the state’s Department of Health for electronic lab reporting, syndromic surveillance, and the immunization registry. We’ve also used our technology vendor’s direct secure messaging program to help providers exchange information securely and electronically. We can even send emails to patients if they have HealthVault accounts. We have recently begun planning our population health management goals, but are confident data exchange will help in these efforts too.
Staas: We have 54 participants in our HIE, 25 of whom fall into the long-term post-acute care category, so data exchange supporting transitions of care is one of the ways our HIE supports MU. We also host the personal health records of Virtua’s own patients and data on the same platform, so we’re well equipped to report aggregated data. Population health is also a growing field for us as we explore high-level paths around real-time notifications. Being able to monitor the data flowing into the HIE and notify care coordinators and care providers if any patient data falls out of range provides tremendous value.
Kansky: Data exchange can absolutely support MU and population health goals, but it depends on two very different paths. Not all HIEs deposit data in a repository, so it’s hard for them to support population health efforts because they don’t accumulate or have access to needed data. In the case of MU, we handle 120,000 transitions of care exchanges each month. It is one of the trickier goals to meet, particularly with MU Stage 3, but it’s the most helpful thing we do, particularly in regard to bio-surveillance, immunization data, and lab results. I like to say that the HIE can help you learn everything you don’t know about your patients.
Q: How can clinical and claims data be combined to derive insight?
Staas: We know that ACOs, bundled payments, and quality programs all have one common goal: to improve quality while reducing costs. You need access to the clinical data to work on quality, but you can’t reduce costs if you don’t know what they are. Unless you can put those two data sets together, it’s hard to do anything. We view HIEs as a great way to facilitate that process.
Kansky: Taken alone, clinical and claims data can be used to gather great results, but they work better together. Case in point we recently executed a program that identified gaps in care, for patients with diabetes, monitoring everything from annual retinal eye exams and foot exams to blood work, and found we could use both sets of data not only to identify any gaps in care but also to then inform the PCP of that patient when a gap existed. We discovered that combining claims and clinical data was necessary to do both of those things and to do them well.
Q: How is interoperability transforming care?
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Wolf: For one thing, image-enabling NDHIN equips our providers with the tools they need to conduct real-time image consultations with other caregivers for a faster and more complete diagnosis and treatment. The integration enables providers to share medical images via the statewide HIE so users can access, view, compare, and transfer images from X-ray, computed tomography, magnetic resonance imaging, and ultrasound studies. Because our providers can now access images from any external connected facility without installing additional software, we’re delivering better care to our patients and minimizing duplicate services provided. It’s particularly helpful for those patients who travel 60 to 70 miles to appointments, sometimes in the middle of winter. For them, saving a trip means a great deal.
Staas: Patients are becoming much more engaged in their own care because of the technology now available to facilitate this knowledge exchange. We’ve just begun to scratch the surface in terms of what we will see in the mobile space, which we feel will further transform healthcare. From a technical, standards side, the industry sees it coming and is preparing for the future, with initiatives like HL7’s FHIR, which can be extended and adapted to provide a more manageable solution to the healthcare demand for optionality and customization. Being able to develop mobile apps and standards that everyone can view and share will continue to support even greater two-way interaction between patients and providers.
Kansky: In Indiana, if a patient walks into the ER, they see a physician they have never seen before and probably won’t see again. That physician is limited to the data the enterprise knows about that patient. On the other hand, if you can collect clinically relevant information and present it in a way that fits into the existing workflow, you can transform care. With our HIE, a patient can register in an emergency department and, without a human having to make a query, we can use the registration event to match the patient with existing data and provide the triage nurse and anyone else treating the patient with contextual information from everyone participating in the repository system, including drug allergies, med lists, recent labs, problems list, and even recent treatments.
Q: What needs to happen to take HIE to the next level — which is true data interoperability?
Wolf: Having a patient identifier would help make it easier to share and match patient information. The challenge is to work with vendors who can address the technical challenges that stand in the way of sharing information efficiently, quickly, and economically. Everyone has to get to the minimum ONC standard, but as you get in and share information, you need to have better and better standards all the time. It takes time and needs to evolve.
Staas: In my mind, true data interoperability occurs when you can apply the same standards and integration and have every system it’s supplied to come out with the same result. That doesn’t always happen. Part of our HIE includes a health information portal for direct, secure messaging. As we’ve begun to install and implement this technology, we’re finding different vendors interpret the standards in various ways and only allow for certain use cases. For instance, Vendor A may allow me to attach a Continuity of Care document and include a free text message. I then send it to Provider B, but Dr. Smith may not be able to view the free text because his vendor may only support the display of the Continuity of Care document. We need to remove the disparities in technology.
Kansky: Technical challenges won’t stop HIEs from being successful because there’s no such thing as true data interoperability. In fact, if you ask me to define interoperability, I would tell you I will know it when I see it. It’s misleading to say true interoperability occurs when “X” happens. The reality is we’re trying to do at least two things with our healthcare system: provide safe, high-quality, efficient healthcare and make people healthier even when not in the healthcare system. Right now clinicians have information systems coming out of their ears, whether they be hospitals, doctors, labs, or HIEs — public or private. There’s so much information and data moving back and forth that there needs to be a way to leverage those information systems so that people are healthier and healthcare improves. IHIE has been doing this for 20 years. Now, we’re just trying to do it cheaper, better, and more often.
Q: What advice would you share with other providers on how to optimize their HIE efforts today?
Wolf: If you don’t have trust, all the technology in the background doesn’t matter. To share information between stakeholders, it’s critical to build trust so both sides find ways to make all the technology work together efficiently and effectively. We’re at the point where we’re building an infrastructure, like working on the foundation of a building. As time changes and things happen, we can build upon the foundation, but only if we have the right vendors to partner with.
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Staas: Be transparent with policies, procedures, and data use. Sometimes, the people issues are harder than the technology issues. Use your HIE to close gaps in technology for providers and make sure your HIE vendors meet interoperability standards. Finally, be involved; don’t be a passive recipient. With a plethora of technology and standards bodies out there, align with quality-focused workgroups that are contributing toward a movement of bettering interoperability. Be on the forefront of being involved in changes and workgroup efforts.
Kansky: There’s enough value in interoperability and HIE that you should make sure you have a smart person or people dedicated to maximizing that value. Even within organizations that have CMIOs, that person barely has enough time and resources to take the time to learn and understand the capabilities of what we could be doing to maximize the full potential of the information we have. Find the right person who understands your questions and speaks your language, and stay on them to steer, cajole, and coerce information from the HIE.
Both EHR interoperability and health information exchange (HIE) will play a major role as the healthcare industry continues to reform and develop more effective patient care strategies. Incentives tied to meeting Meaningful Use (MU) requirements and healthcare reform serve as prime motivators in increasing provider interest and participation in the exchange of health information, according to an NORC at the University of Chicago report presented to the ONC for Health Information Technology. With all of these initiatives, however, comes the issue of rising costs, which promise to continue to present a challenge for providers and HIE adoption.
Wolf: Cost and a lack of resources are the main issues. Small critical access hospitals and providers run on slim margins or in the red, so sometimes having money to participate is tough. Small practices do not have enough IT, HR, administrative staff, or lab staff to help with integration and testing. This also drags out implementation because resources are already spread too thin.
Wolf: For one thing, image-enabling NDHIN equips our providers with the tools they need to conduct real-time image consultations with other caregivers for a faster and more complete diagnosis and treatment. The integration enables providers to share medical images via the statewide HIE so users can access, view, compare, and transfer images from X-ray, computed tomography, magnetic resonance imaging, and ultrasound studies. Because our providers can now access images from any external connected facility without installing additional software, we’re delivering better care to our patients and minimizing duplicate services provided. It’s particularly helpful for those patients who travel 60 to 70 miles to appointments, sometimes in the middle of winter. For them, saving a trip means a great deal.
Staas: Be transparent with policies, procedures, and data use. Sometimes, the people issues are harder than the technology issues. Use your HIE to close gaps in technology for providers and make sure your HIE vendors meet interoperability standards. Finally, be involved; don’t be a passive recipient. With a plethora of technology and standards bodies out there, align with quality-focused workgroups that are contributing toward a movement of bettering interoperability. Be on the forefront of being involved in changes and workgroup efforts.
