Jason Hess

At a Glance

Providers face four obstacles in developing health information exchanges (HIEs):

  • IT governance concerns related to privacy, security, and patient consent  
  • The financial viability and sustainability of HIEs  
  • Data standard confusion  
  • Uncertainty regarding aspects of the American Recovery and Reinvestment Act relating to HIEs  

The development of health information exchanges (HIEs)-IT systems that provide healthcare organizations with access to a patient's health records, no matter where the patient has received care, via an interconnected network-is one of the pillars of the U.S. government's efforts to reform health care. Unlike electronic health records (EHRs), however, the market for commercial technologies that support the creation of HIEs is relatively small, with successful deployments being measured in dozens rather than hundreds.

Although a number of custom-built HIEs have been in operation for years, packaged software applications are relatively new, and despite vendors' claims suggesting long lists of successful implementations, most vendors can point to only two or three live sites. To help provide a reality check on this emerging market, KLAS, a company that evaluates healthcare vendors, products, and services, embarked on a year-long effort to understand, quantify, and evaluate commercially available HIE solutions and the vendors that offer them. The following is a summary of that research.

Defining an HIE

Perhaps one of the most difficult aspects of evaluating the HIE market is defining what constitutes an HIE. According to the eHealth Initiative, a not-for-profit organization that promotes healthcare IT, there are nearly 200 HIEs in various stages of deployment throughout the United States. However, KLAS takes a more narrow view of the market, basing its research on interviews with just under 100 HIE organizations. For an HIE-and the vendor solution it is based upon-to be included in the KLAS research, it had to meet these criteria:

  • At least two provider organizations must be actively sharing patient data that are being used by physicians.
  • The provider organizations must be "non-owned" facilities, meaning the connected sites belong to different healthcare groups or networks. Although exchanging data between two or more hospitals within the same integrated delivery system (IDS) is certainly noteworthy, such a solution does not face many of the political, competitive, and privacy-related challenges encountered by non-owned organizations that determine to share patient information.
  • HIEs must fall into one of two classifications: acute-to-acute deployments, where multiple hospitals exchange patient data, and acute-to-ambulatory deployments, where a hospital shares data with one or more outpatient clinics, laboratories, or other ambulatory entities.
  • The HIE must be built on commercially available technology, rather than custom built.

A second important consideration in understanding HIE solutions is the need to assess the technological approach each software product takes. In general, HIE solutions follow one of three models-aggregated, federated, and hybrid-each of which addresses the issue of connectivity in a different manner.

Aggregated. A system of networks connected by the Internet to a centralized repository where the data are located. The repository is managed at the HIE level by a centralized master patient index (MPI) or record locator service. Providers query the central repository for information such as patient name, date of birth, gender, Social Security number, lab and radiology results, allergies, medications, past medical history, and so on.

Federated. A provider-to-provider network connected via the Internet. Participants maintain their own health information network with no central repository. Providers can search the index to find a patient's medical information as well as the organizations where the patient has been treated. Requests for data can then be made.

Hybrid. A hospital-managed system with no comingling of the data. The data are not stored centrally, but rather are stored by the hospital and maintained on that facility's edge servers. As queries come into the HIE through the MPI or record locator service, the queries are directed to the particular edge server where those data are located.

Finally, the organizational structure of an HIE, including how it is managed and by whom, is an important element in defining an HIE. In general, HIE organizations today tend to fall into one of three broad

Public HIEs. These HIEs may belong to official state agencies or may be semi-independent, with direct and typically temporary government backing. These HIEs demand strong potential scalability and require standards-based technology.

Cooperative HIEs. The development of a cooperative HIE requires that relationships be formed between hospitals that would otherwise be competing with each other, and that the organizations work together to bridge gaps in technology. In a cooperative HIE, competing hospitals work together to form independent HIE organizations, generally with an open invitation to other hospitals, clinics, and physician practices to participate. These HIEs often struggle to establish long-term funding models and look for vendor solutions that offer flexible and affordable cost alternatives while best adapting diverse EHR technologies. The goal is a win/win for all involved.

Private HIEs. In some respects, private HIEs are designed to enhance relationships as well as exchange data. Often, a single hospital or IDS creates an HIE hoping to draw in community physicians while protecting or increasing revenues. Funding is less complicated, and these HIEs are more likely to be satisfied with solutions that best work with their existing technology.

What Are Buyers Seeking?

In a market with so few live HIEs, prospective buyers bring relatively little shopping comparisons to the table. As a result, HIE vendors are unable to boast significant live customer experience on their resumes, leaving technology and cost as the most important considerations during the beginning stages of evaluating HIE solutions (see the exhibit below). Healthcare executives are concerned about data security as well as finding an HIE solution that will tightly integrate with physician workflow, thereby speeding adoption.



The logical result is that among live HIE organizations interviewed by KLAS, vendors deploying portal technologies have won more than 70 percent of contracts due to their relative ease of implementation and the ability to quickly bring results to the physician's fingertips. However, hospitals and physician clinics have indicated the perfect scenario would be to deposit distinct patient data into the EHR so that it becomes actionable. In that model, the physician can directly interact with the data, entering medication orders or updating problem lists rather than just viewing and requesting patient information.

Although key considerations for providers in the initial HIE shopping phase are technology and cost, organizations that have already chosen and come live with their HIE strategy reported an evolving list of criteria. Having a solid, proven solution from an experienced vendor was the No. 1 driver for selecting a particular product and was mentioned by 41 percent of providers that had already gone live. In contrast, vendor experience was mentioned as an important factor by only 10 percent of those still evaluating HIE solutions. Cost-a concern for 23 percent of providers considering HIE products-was mentioned as an important factor by just 3 percent of those that have already made a selection. This pattern of evolving selection criteria between the evaluation and live phases has occurred in multiple market segments in the course of KLAS research activities. It is most common in quickly changing markets, where experience, standards, and off-the-shelf solutions to common problems are in short supply.

Building HIEs: A Simple Approach Is Best

A lack of solid standards and discrete data stands in the way of a plug-and-play solution from almost any HIE vendor. Vendors building a viable exchange model must overcome a series of complex hurdles:

  • Building and maintaining connectivity with all the parties and solutions involved
  • Structuring the data and messages so that they are easy to receive and view
  • Determining safety measures for HIEs aggregating data to a central repository (This includes establishing long-term maintenance with the surrounding systems and validating the quality and sequence of the patients' information.)
  • Mitigating risks of missing a data element and being held liable
  • Answering legal questions regarding how the original format could be reconstructed to include updates/upgrades created to deal with past issues

Considering these challenges, it is no surprise that organizations that have experienced the best success with HIEs thus far are those with the least complex approaches. In a perfect world, all clinical information needed by healthcare providers would be available at the time of care right at the physician's fingertips. Yet the eclectic way that information is structured, stored, labeled, and shipped makes this perfect scenario virtually impossible to achieve. Custom interfaces, replicated data, and imperfect software gobble up money and are prone to missing a clinical element that is critical for safe care.
These concerns have prompted most vendors to take a more simplistic approach, one that is less concerned with the data elements and focused more on passing packets of data around without taking ownership of the data that are in the packet. This approach creates the need for some manual intervention with almost every transaction, whether clicking on an icon to see the data, going into a portal to review the data, or opening a separate folder on a personal computer to look for the desired information.

The Benefits of HIEs

Nearly 100 HIEs that meet the KLAS criteria are operating throughout the United States. Although the benefits of those deployments have typically been difficult to quantify, providers nonetheless report that they are realizing value from the exchange of patient data. As the exhibit below shows, the benefit most often reported was better, faster clinical decision-making, even though relatively few HIEs expected that particular value at the outset of their deployments.



Obstacles for Providers

Surprisingly, the biggest obstacles providers face in establishing HIEs have relatively little to do with technology. Far more challenging issues relate to the governance of and financial sustainability of HIEs. Specifically, providers pointed to four obstacles as the most significant.

IT governance concerns related to privacy, security, and patient consent. Many participants mentioned they are concerned about the potential risks that use of HIEs may pose in complying with Health Insurance Portability and Accountability Act (HIPAA) regulations. Concerns about how HIEs will affect HIPAA compliance also serve as barriers to physician participation, which reduces the quantity of data available.

The financial viability and sustainability of the HIE. Just over half of the providers interviewed by KLAS (56 percent) are worried about the future funding of their HIEs. Stimulus money from HITECH seems to raise as many questions as it does answers. As stated by one executive, "Sometimes being funded kills us. The funding entity wants a need filled, so it will donate $2 million, but after that, there is no sustainability for the initiative. It is critical for providers to identify long-term payers after the capital from incentives such as those provided through the ARRA [American Recovery and Reinvestment Act] goes away."

Data standard confusion. Several providers cited the lack of standardization regarding how data are to be shared in an HIE as a major problem-something that will likely impede uptake among organizations trying to participate in HIEs. As one provider noted, "The biggest technical barrier is that the EHR vendors have, at best, a rudimentary ability to send results out in a standardized fashion. Even EHRs that are CCHIT certified have a massive amount of variation as to what is released in an electronic file."

Uncertainty created by the ARRA. Although many of those interviewed would agree that the ARRA has given HIEs a strong shot in the arm, others have expressed concern over the uncertainty that the ARRA creates in relation to HIE development. Questions exist around where ARRA money will come from, how it will trickle down from the federal government to the HIE level, how much will be granted, who will control the flow of those dollars, and what constitutes legitimacy among the granting parties. As one HIE executive noted: "I think the stimulus money is a really smart thing to do, but giving the states $4 million to $30 million to plan a state-based network will lead to an absolute disaster. The people the states are inviting to the table don't have enough training to figure out what they should do. It is like the owner of a car dealership trying to design tires. The chairman of the hospital association really doesn't know anything about health information exchanges, so the states are bringing in a lot of high-level officials from associations that each protect the political piece of their territory and don't know enough about the situation."

Bumpy Road Ahead-but with Potential Value

Beyond vague meaningful use requirements and their own individual motives, organizations seeking to develop HIEs have little to guide their efforts in terms of standards or past experience. It can be expected that the HIE organization landscape will see many changes as it evolves over the next 12 to 24 months. Said one concerned buyer: "There is no good sustainable business model for HIEs. Without a vision for HIE development, and without direction, every HIE is headed in a different direction. For a provider, that means we have to throw out a lot of HIEs in which we have no confidence that the HIE will be able to sustain itself. When the HIEs fail, that means providers have to retrench and hook up with somebody else. We are creating a national set of organizations, all of which are fragile and potentially unsustainable."

Still, the HIE model is working and delivering value for a number of providers. That initial value, coupled with government momentum, sets the stage for a rapidly evolving-and in many ways, promising-HIE market. Yet with nearly 40 vendors-including ambitious start-ups, established HIT vendors, and well-known corporations with limited experience in health care-vying for providers' attention using a wide variety of technical approaches and business models, the road toward development of HIEs likely will be a bumpy one for healthcare organizations over the next few years.

Jason Hess is general manager of clinical research, KLAS, Orem, Utah (Jason@klasresearch.com).

Publication Date: Tuesday, February 01, 2011

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