Health Information Exchange
The world is becoming ever more interconnected thanks to the advent of the internet as well as associated communication technologies. Long gone are the days of writing a letter and waiting for a response or going to the library to do research. Technology has improved various industries and has also broadened the healthcare landscape.
Imagine an 80-year-old patient in the primary care clinic for ongoing atrial fibrillation. Such a patient will have an average of six diagnosable disorders, all managed by different clinicians, and thus will most likely have labs repeated and care not optimized. It goes without saying that there is a need for a synchronization system to give optimal care.
Welcome to the World of HIE (Health Information Exchange).
Health Information Exchange is an electronic "switchboard" enabling different healthcare providers to exchange a patient’s health records electronically. It is the solution for Electronic Health Record (EHR) interoperability. It does not matter how an EHR works intrinsically or how it processes data. As long as it can talk to other EHRs through an HIE, patient data can be easily exchanged and accessed, removing data silos. In the words of the former AHRQ Director, Dr. Carolyn Clancy, "the data follows the patient."
Styles of Health Information Exchanges
There are two main styles:
1. The Federated System:
The most common HIE system is the federated system. The federated HIE system is not a big brother-style database where all the medical information is held. Rather, it helps connect different electronic health record (EHR) systems that different clinicians, hospitals, or other healthcare providers may have to ensure timely, accurate, and high-quality care. It does this by minimizing gaps in patients' medical records and helps achieve the triple aim by minimizing repeated tests. The federated HIE system is designed to replace the manual and arduous process of clinicians calling each other to request records, only to have them mailed or faxed for entry into another digital system.
2. The Centralized System
Unlike in the federalized system, in a centralized system, the data is typically held in a master database and is accessible to appropriate clinicians.
Evolution of Health Information Exchanges
The history of HIEs in the US can be traced back to the early 1990s but sped up after the infamous Institute of Medicine Report, "To Err is Human," clarifying the mortality and morbidity associated with medical errors. As such, the Office of the National Coordinator for Health Information Technology was created with bipartisan support in 2004, and grants were awarded by the Agency for Healthcare Quality and Research (AHRQ) to different states for the creation of HIEs. More recently, the Health Information Technology for Economic and Clinical Health (HITECH) act put the importance of HIEs into focus by increasing the use of EHRs through incentives for clinicians and hospitals.
Types of Health Information Exchanges
1. Directed Exchange
Directed exchange is where providers can directly send electronic health information to each other. That is, the provider can automatically send the data required to another provider as if it were a text message or fax. If a PCP refers a patient to a cardiologist for further testing, he can utilize this directed exchange model to send the patient's specifics directly to the referred clinician. Subsequently, the referred clinician can forward back the findings and all associated data with ease, utilizing the same directed exchange model.
2. Query-Based Exchange
The query-based exchange allows a server to respond to search requests and pull up all the available data. It is akin to a Google search of a patient’s electronic health records. If a patient is brought into the ER following a car crash, his information can be pulled from other providers by utilizing a query-based exchange.
3. Consumer Mediated Exchange:
Consumer mediated exchange puts control of electronic medical records into the patient’s hands. The patient can share their data with providers when/if so desired, and can monitor all associated data and data requests. Basically, in this type of exchange, the patient can utilize their data at their will. The most recent examples are mobile apps demonstrating SARS-CoV-2 testing and vaccination status, pulling data from several different exchanges to comply with local rules and regulations.
Benefits and Advantages
1. Reduction in clinician frustration and enhancement of patient-clinician interaction.
In the era of mass healthcare personnel burn-out, may it be from the SARS-CoV-2 pandemic or short staffing, clinicians spend about 16 minutes per patient encounter on electronic "housekeeping." Imagine if the bulk of that data was automatically generated from other patient encounters and automatically shared with other providers through the HIE. The time savings, as well as the reduction of frustration for front-line health workers, would be immense. This has also been supported by evidence demonstrating that most clinicians reported positive changes in care coordination, communication, as well as "knowing their patients" by HIE use.
2. Health Information Exchanges get us a step closer to Triple Aim.
The triple aim has been the driving force behind US healthcare over the last decade. The three main goals are to:
- Improve the experience of care.
- Improve the health of populations.
- Reduce Per Capita Healthcare Costs
HIEs get us a step closer to achieving all three of these goals.
- Through enhanced clinical information sharing between providers, they help to minimize redundant and unnecessary testing, while eliminating unnecessary paperwork and ever-dreaded repeated questions during and after every doctor’s visit.
- Furthermore, they can put patients in the driver’s seat of their health data. Thus, patients are actively involved in every step, all the while improving their experience.
- Finally, they can provide clinicians with the latest evidence-based clinical decision support tools, customized by the patient’s data and lab values. This ensures that value-based, evidence-based, and effective care and treatment methods are employed.
3. They can improve public health.
No other singular event has demonstrated the importance of HIEs on a public health basis than the recent SARS-CoV-2 pandemic. With these information exchanges, the diagnosis of COVID-19 can be transmitted in real-time along with positive test results, as they are designed to source as much information as possible.
From the public health perspective, they are simply invaluable. They make it extremely easy to pull in diagnostic data overlaid with a patient’s risk factors, previous diagnoses, vaccination status, and disease disposition.
The data provided, albeit granular to a patient level, can be generalized within a zip code. Hence, more general inferences can be drawn. And, if necessary thresholds are met, emergency relief (ventilators, auxiliary staff, etc.) can be dispatched to concerned areas quickly. Going forward, HIEs will undoubtedly remain one of the most critical tools, if not the most critical tool, in managing pandemics and mitigating their effects.
Recent Trends in Health Information Exchanges
Interoperability is one of the present challenges of HIEs. In an ideal world, an HIE would not be necessary as all EHRs would be able to "talk" with one another inherently without necessitating the "referee" and "middleman" functions of an HIE. The information would be standardized.
For example, a lab would be able to automatically send results to a physician, and a physician would be able to automatically report a communicable disease to appropriate authorities without an HIE as the facilitator.
In 2015, the ONC revealed its nationwide interoperability roadmap. The long-term goals from the federal regulatory standpoint are to:
- Increase participation in HIEs.
- Send, receive, find, and use electronic health records.
- Have such electronic health records utilized in making medical decisions.
- Have electronic health information available from external sources and make it available to other external sources.
The ultimate goals are:
- Positive outcomes from efficient interoperability,
- Better health,
- Lower cost,
- And improved processes.
The use of value-based payments by the Federal Government is enabled by data sharing through HIEs, and CMS has progressively increased such participation in Medicare and Medicaid over the years. However, this was slowed down by the SARS-CoV-2 pandemic.
2. The "United States" of HIEs
One further goal of ONC is to create a "United States" of HIEs. Currently, HIEs are local, or at most statewide, and cover a handful of states. That is, if a patient is seen in one region, their information is available through HIEs to local providers. However, if that patient relocates or travels across the country, it becomes increasingly difficult to access the data, and the data does not move with the patient. The ONC has contributed to the achievement of this goal through grants and leadership in four major projects:
i. The Direct Project
Launched in 2010, this project specifies a simple, secure, scalable, standards-based way to send authenticated, encrypted health information directly over the internet. Presently, the Direct Project has over 200 participants from over 60 organizations. The ultimate goal is that every EHR or provider can share patient data securely, easily, and without relying on HIEs.
ii. The Nationwide Health Information Network (NwHIN) Exchange
Live in 2011, this project was the first to implement standards and policies to enable secure health information exchange over the internet, as well as work towards achieving the goals of the HITECH Act. Currently, the NwHIN Exchange connects federal agencies as well as private organizations such as the CDC, CMS, DoD, VA, Kaiser Permanente, SSA, and HealthBridge.
iii and iv. Other Two Projects
Also launched in 2010 were two programs aimed at states with the State HIE Cooperative Agreement Program Grants as well as private HIE grants such as the Verizon HIE, enabling enterprises to ensure data accessibility for their employees and insureds. Thus, the 2010s have been successful in ensuring local connectivity, especially from a state perspective.
3. Public Health and Health Information Exchanges
Undoubtedly, ONC will focus on more federal connectivity in meeting the Meaningful Use criteria set by the HITECH Act going forward. The problems with such a lack of connectivity were highlighted during the SARS-CoV-2 pandemic. The goal of these systems was to help public health officials understand the epidemiology of the disease. Instead, there were gaps in reporting, and the officials struggled to ensure accurate test positivity and associated patient data with a hodgepodge of state, federal, and private data.
With that in mind, the ONC accelerated its efforts to bring together the Trusted Exchange Framework and Common Agreement (TEFCA), publishing its first version on January 18, 2022.
The goal of TEFCA is to establish a universal floor of interoperability across the country, enabling users to securely exchange clinical data regardless of their location and the network utilized. TEFCA also puts forward qualified health information networks (QHINs).
The QHINs are entities to be designated by the federal government to create transportation mechanisms to route information among HIEs, with the idea of multiple QHINs connecting all HIEs.
From a public health perspective, the Strengthening the Technical Advancement & Readiness of Public Health via Health Information Exchange Program (Star HIE Program) was founded in 2020 to ensure that immunization and other similar data flow to the public health agencies. This ensures that the gaps highlighted by the SARS-CoV-2 pandemic are appropriately resolved and HIE services are improved to support those disproportionately impacted by COVID-19.
4. Use of HIEs as Utilities
There is no doubt that HIEs are here to stay and ever expand. If anything, the COVID-19 Pandemic and the utility of HIEs in monitoring epidemiology, and vaccine uptake, have given regulators more reasons to possibly treat HIEs as "utilities". From a state regulatory as well as emergency management perspective, HIEs have proven invaluable during the pandemic in merging both COVID-19 cases and associated patient data to ensure appropriate risk stratification and rational distribution of resources.
Following the loss of funding in the mid-2010s and the shuttering of several HIEs, there is no doubt that regulators will prioritize HIEs going forward and treat them akin to a utility, ensuring funding and advancements for years to come, particularly in light of the simplified business model that is a commodity exchange. Of note, though, programs like TEFCA will no doubt ensure that EHR providers have their on-ramp into the HIE ecosystem, and, for more individual providers, the HIEs will be the merging lane.
What Can Small Practices do so They Don’t Get Left Out?
1. Ensure interconnectivity
The current landscape of HIEs is akin to a pyramid, with smaller fish connecting to even bigger ones. From a small practice perspective, the time is now to ensure you’re aligned with a particular HIE provider as well as switched over to an appropriate EHR system.
As a small practice, you should be on the bus to Abilene, and not get off until the destination is reached. This will ensure you’re aligned with the bigger picture and you ace any regulatory requirements that will ultimately tie to your bottom line in the context of value-based medicine, for example via MIPS scores.
2. Costs, costs, costs
Participation in an EHR will ultimately necessitate upfront costs. However, these are likely to come back to you in the future as increased billing opportunities. Furthermore, you can also look for appropriate grants or associated state-level funding to help achieve these goals.
When you’re in an HIE and have access to the patient’s complete picture, it becomes easier to provide value-based medicine. You can even consider capitation and at-risk contracts in the future, as you’ll have better access to the full risks and disease status of the population at risk.
Moreover, you’ll be able to provide more efficient care, instead of spending ever-increasing amounts of time on paperwork. Thus, you can bill more effectively and spend your time on direct healthcare instead of administrative paperwork.
3. Use caution when selecting HIEs.
Not all HIEs are created equal. How one HIE succeeds where others fail depends on their services, as well as their vision and mission. You should be aware of:
- Economics and sustainability of the HIE
- Internal requirements of participating in the HIE
- Technology behind the HIE and which forms of exchange the HIE supports
- Non-economic benefits of the HIE (in-direct return on investment)
- Risks and liabilities involved with joining the HIE
Furthermore, you should be well aware of the HIEs' data analytics. Be sure to know whether your care will be compared to other similar providers' and whether you’ll be benchmarked, as this can come up during negotiations with payers.
Finally, you should pay careful attention to which HIE the local bigger fish (such as your local hospital system) uses and plan to have access to most of the data generated by your patient population, which will be in the local healthcare systems.
Future of Health Information Exchanges
The size of an HIE also influences its chance of success. The larger the HIE, the more data visualization they’ll have, including social/emergency services, LTPAC, payers on a local level, and the Federal Government/CDC/Public Health officials on a nationwide level. Thus, there will most likely be two separate but ever interconnected services provided by HIEs, local and nationwide.
Locally, it is also likely for HIEs to provide semantic analysis, as well as data housekeeping and longitudinal record keeping, to ensure state governments are engaged, building strong local relationships.
Conclusively, there is no doubt that the goal of achieving a healthier US and meeting the HITECH Act and the Triple Aim objectives will all go through more and more integrated HIEs, hopefully on a federal level within the next decade.
HIEs are an important part of the US health care system and are actively encouraged by both state governments and the federal government, particularly in light of the SARS-CoV-2 pandemic. Going forward, the challenges will be differentiating the HIEs by services and scaling these up as necessitated by the market requirements, hopefully under nationwide operability.
Ultimately, HIEs are here to stay and will become progressively more important the closer and tighter the global interconnectedness becomes. The time is now to join an HIE and start reaping the benefits of data sharing and data analytics. The days of data silos and faxes are long gone, and those left behind by HIEs will have a progressively harder time catching up with the bus of 21st century US healthcare, driven by triple aim and value-based purchasing.
Tortolero GA, Brown MR, Sharma SV, et al. Leveraging a health information exchange for analyses of COVID-19 outcomes, including an example application using smoking history and mortality, PLOS ONE, 16(6), e0247235, 2021.