Health Information Exchange

Health information Exchange (HIE) implementers confront a number of issues as they convene partners, establish a governance structure, and begin constructing a technical architecture to share data within a diverse consortium. Eighty-two percent of AHRQ's Transforming Healthcare Quality through IT (THQIT) projects cited staffing as a major issue, 63 percent noted unique technical issues relevant to sharing data among organizations, and over half identified issues related to building a consortium and forming a successful governance structure. Funding and sustainability of projects, methods for evaluating HIE initiatives, and policy considerations were also cited by over 40 percent of the HIE implementations as issues they commonly face.

Funding

  • HIE implementation initiatives often include partners with disparate financial resources to invest in purchasing and maintaining hardware and software.  Some projects met this challenge by engaging local endowments, foundations, and private donors who could contribute. 
  • HIE initiatives around the country continue to develop and test models to sustain their initiatives over time.

Staffing

  • Maintaining low staff turnover can help to foster trust and a consistent vision over the course of implementing an HIE effort. 
  • Study practices reported savings due to reduced staff but also loss of productivity during implementation. 
    • Electronic Health Records in Four Community Physician Practices: Impact on Quality and Cost of Care - Dawn Bazarko, United Healthcare

Governance and Consortium

  • Ongoing dialogues with stakeholders are necessary in order to develop the trusting relationships required to enter into legal agreements. 
  • Emerging projects debated whether to establish a separate entity to govern the HIE or whether to house the initiative in one of the partner organizations or providers.

Achieving Buy-in (Provider, Patient, Staff)

  • Constructing and fostering confidence in privacy and security measures for partners and consumers are important in ensuring the success of an HIE initiative. 
  • To obtain buy-in, the system must be built to protect consumers' private health information without scaring participating organizations with liability and business concerns. 
  • Because the governing board is limited in size and probably will not capture all of the needs and issues for all stakeholders, an advisory board is recommended to represent the employers, payers, and healthcare community and report to the governing board. Over time, expect the board to include stakeholders that were previously represented on the advisory board. 
  • RHIOs exchanging administrative data are trying to prove the ROI is worth their members' investment in clinical exchange--some have tried clinical exchange but scaled back due to interoperability costs. 
  • Remember that most of healthcare is delivered by small physician practices. Engage them, and engage them early. 
    • Creating an Environment of Consensus - The challenges of implementing a governance structure to run an HIE - Vicki Estrin, Mid South eHealth Alliance 
    • Connecting to Health: Public - Private Sector Health Information Exchange Efforts - Emily Welebob, eHealth Initiative and Foundation 
    • Regional Health Information Organizations and other Health Information Exchanges: The Value Proposition - Jason S. Lee, National Institute for Health Care Management Foundation

Technical Issues

  • HIE initiatives deal with complex technical considerations to mitigate disparities in technology capacity among information sharing partners in terms of software compatibility and connectivity. 
  • Keeping updated on national standards discussions is helpful to ensure that the standards HIE initiatives select agree with the national trend. 
  • To the extent possible, use existing and emerging standards; open source, non-proprietary software; and an extensible, scaleable platform. 
  • To prevent errors, an order entry system must incorporate decision support functions. 
  • Software should match the mental models of treatment. 
    • Design Elements for Direct Physician Order Entry in Oncology - Anna E. Schorer, Patient Safety Center of Inquiry [PSCI] 
    • The Next Generation of RHIOs: Health Information Exchange Through Common Shared Record - Kate Cauley, Wright State University

Evaluation of Health IT

  • Many HIE initiatives confront the need to develop evaluation metrics that are applicable along the entire continuum of care, not solely for acute care settings. 
  • Although all providers need assistance with readiness planning and implementation, focus is particularly needed on essential community providers (ECPs). 
  • Impact of EHRs on cost of treating chronic conditions is probably delayed by several years, making analysis difficult. 
  • When used as designed, EMR technology with CPOE can improve performance as measured by certain quality and financial measures. Electronic clinical documentation can be designed to improve compliance with required data elements. 
  • Clinical decision support in the form of rules and alerts can be effective, if care is taken to avoid "alert fatigue." 
  • States are providing rules of engagement in places where multiple RHIOs exist. States may have to pick up the pieces in areas where no activity is initiated. 
    • CPOE: Net Benefit Realization One Year After Implementation In an Urban Teaching Hospital - Susan Kraus, Cleveland Clinic Hospitals 
    • Electronic Health Records in Four Community Physician Practices: Impact on Quality and Cost of Care - Dawn Bazarko, United Healthcare 
    • Establishing a Foundation for Medicaid's Role in Supporting the Adoption of Health Information Technology - Shaun T. Alfreds, Center for Health Policy and Research 
    • Regional Health Information Organizations and other Health Information Exchanges: The Value Proposition - Jason S. Lee, National Institute for Health Care Management Foundation

Policy Issues (Legal, Privacy)

  • It is critical for HIE initiatives to research and be aware of relevant State laws and regulations prior to implementation.  For example, some States require specific consent forms for the release of health information that may determine whether the HIE can have an opt-in or opt-out approach to engaging consumers. 
  • Be prepared to address what the law says and what the community wants to do. The Memphis community started with legal advice but felt strongly some of the privacy issues boiled down to ethics not law. 
  • Governors and organizations representing States (NGA, NCSL, etc) have the interest and capacity to lead change at a State level. 
  • For the States that do have more than one RHIO, an overarching State-level RHIO should coordinate RHIOs across the State and set a State-level framework for health information exchange. 
  • RHIOs should follow goals and recommendations from the American Health Information Community as recognized by the Secretary. 
    • Creating an Environment of Consensus - The challenges of implementing a governance structure to run an HIE - Vicki Estrin, Mid South eHealth Alliance 
    • Office of the National Coordinator for Health Information Technology - Kelly Cronin, John Loonsk, Lynn Egan

Administrative, General Timeline, and Scheduling

  • Several projects experienced some unexpected delays in project timeline due to complexities in programming, differences in readiness of sites to go live, or an expansion of evaluation work.