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for any provider to electronically exchange information about the medical
history of any patient may once have seemed like a worthwhile but distant goal.
Today, that capability is almost here.
electronic health records (EHRs) and health information exchange (HIE), is being
used to send data electronically and securely among healthcare organizations. But
availability doesn’t equal acceptance. Barriers persist in the form of
budgetary and time constraints, privacy concerns, and issues with data quality.
there is not even agreement on what interoperability entails. One view holds
that for the industry to truly benefit from interoperability, there needs to be
secure, automatic data exchange not just between providers but between
providers and health plans, providers and patients, and health plans and
patients—and none of that is happening enough.
Tripathi, president and CEO of the Massachusetts eHealth Collaborative, a
nonprofit professional services firm that provides consultation on EHRs and
HIE, says the industry’s interoperability capabilities are maturing.
literally 1 to 1 ½ years away from being able to say we have nationwide
interoperability capability for basic medical records,” Tripathi (pictured at right) says.
vendors are part of collaborations that support common data standards and other
components of a common interoperability framework, Tripathi says. By connecting
disparate networks, such a framework enables data exchange for users of the EHR
systems. Noting that these EHR vendors represent 85 percent of the national market
and are beginning to make the functionality part of their systems (rather than
a custom add-on), Tripathi says most of the market will be able to exchange
healthcare data electronically.
“In a very
real way, that is nationwide interoperability,” he says.
Medical Group (RMG), a multispecialty practice based in Worcester, Mass., has had
interoperability capability since 1993, when it began exchanging data with a
local hospital and area health plan, says Larry Garber, MD, medical director for
informatics and associate director of research. Today, RMG uses its EHR
functionality to exchange patient medical records with organizations in nearly
practice, which has 25 sites and 300,000 patients in central Massachusetts,
also exchanges data through the state HIE, called the Massachusetts Health
are such that when one of our patients shows up in the emergency rooms of any local
hospital, our electronic health record automatically sends a summary document
securely, using direct messaging, to that ER on that patient, telling the
doctors that these are the meds the patient is on, these are the allergies, the
medical problems, recent test results,” Garber (pictured at right) says. “And it all happens within 90
seconds of them registering in the ER.”
EHR vendor’s interoperability platform, the practice can also query other
organizations—with patient consent—for specific patient health data, Garber
also receives claims data from its contracted health plans through secure
interfaces. The data enable RMG physicians to see the treatment that patients
have received from provider facilities to which the practice is not linked
through its EHR or the HIE.
“I think we
really are among the best in the country in terms of interoperability,” Garber
Independence Blue Cross, a Philadelphia-based
health plan, was a founding member of HealthShare Exchange, the HIE
serving southeastern Pennsylvania and the greater Delaware Valley, including
southern New Jersey. HSX has 130 subscribers—including hospitals and
health systems, medical groups, independent physicians, health plans,
accountable care organizations, and behavioral health and post-acute-care
entities—with a clinical data repository that already includes more than 6
million patients (click on the exhibit below for more information).
Over the past year, providers have exchanged more than
300,000 direct secure messages via HSX, mostly between different health
systems, notes Greg Barnowsky, chief enterprise architect for
Independence. Every month, the HIE sends his health plan real-time notifications of thousands of admission, discharge, and transfer (ADT) events for its members that may trigger care management steps, Barnowsky says.
“We have the
ability to recognize that a member has been admitted to an individual hospital
with a tool called an automated care team finder,” he says. The tool also
notifies the patient’s primary care physician of the admission.
very lucky to be [part of] one of the very few plan/provider collaboratives for
sharing electronic health records” data, Barnowsky says.
technical means exist, not all providers are using interoperability
functionality. Several issues pose daunting barriers.
Resources. Certainly, healthcare organizations
are faced with competing priorities that squeeze already limited financial
resources and manpower. Interoperability requires some amount of funding and
internal expertise, depending on the provider’s desired level of functionality.
RMG, for instance, has four clinical FTEs dedicated to healthcare IT work,
to HealthShare Exchange is relatively uncomplicated. Small or solo practices
with limited resources can use standard, secure email messaging to receive
basic patient history data, Barnowsky (pictured at right) of Independence says. However, participants that
want additional functionality, such as the ability to query other EHRs, require
internal technical expertise.
For a health
system, the cost to join the HIE is not considerable, Barnowsky says. Payers
help to cover the cost of operating HealthShare Exchange, and provider funding
for joining HIEs is available from the Centers for Medicare & Medicaid
health systems are directing resources into their EHRs and trying to address
regulatory pressures, such as government mandates relating to meaningful use.
“That’s all competing with the ability to share information,” Barnowsky says.
Health information exchange functionality, such as
Carequality and CommonWell network capability, is increasingly being built into
the core EHR product, meaning there are no up-front costs for development or
implementation. Nor are most vendors charging a separate fee for this
capability, Tripathi says.
Liability. Providers are concerned over how to
manage the potential legal consequences if data is used inappropriately, Barnowsky
“One of the
biggest challenges we’ve had is the understanding of where you are from a
liability standpoint if your individual electronic health record is lost or
used in the wrong way,” Barnowsky says.
Some EHR systems are coming out with functionality that
enables providers to self-enroll in data-sharing networks by clicking on a link
to a contract and agreeing to terms. These are standard contracts that define
the “rules of the road” of the network and essentially state that providers are
responsible for what they do on the network, including getting appropriate
permissions from patients, Tripathi says.
challenge is the incongruency of state privacy laws that govern patient data.
Again, Tripathi says this is a manageable issue. The potential solution is
similar to the approach used by Amazon in dealing with varying state tax laws that
relate to online sales. “Computers are very good at managing [variation],”
Tripathi says, and the greater penetration of networks such as Carequality and
CommonWell will pressure states to align policies with nationwide standards.
On the other
hand, a federal law preventing federally funded substance abuse clinics from
releasing data on patients without separate consent is a more challenging
barrier, Tripathi says.
Data quality. Continuity-of-care documents—the
electronic vehicle for exchanging bulk data—are standardized to an extent but
still allow for local customization that clinicians find frustrating
of those is just really bad. They’re really bloated. They have way too much
information in them. They’re inconsistent,” Tripathi says.
determining whether a patient is allergic to penicillin may require sifting through
a large electronic document, making it easier to telephone for the answer,
lies in increasing the number of users and the amount of data being exchanged.
If users, rather than software engineers, specify what does and does not work in
interoperability functionality, vendors will respond over time and make
have to be motivated to exchange data, and that may present the greatest
obstacle to date.
Incentives. RMG has such strong interoperability
capability, Garber says, in part because it engages in risk-based contracting,
which offers incentives for lower-cost, high-quality care. But many physicians
still practice under the fee-for-service model, which incents volume.
claims data for clinical analytics to better predict and manage patient health,
and for business analytics to assess the acuity level of their patients when
determining financial risk.
if other physicians were similarly incentivized, they, too, would improve their
the technology that holds you back,” Garber says. “It’s the individual
organizations and whether they’re motivated to turn on the [interoperability]
functionality to make it happen.”
barriers are overcome and EHR vendors make interoperability for basic medical
information more readily available, provider-to-provider data exchange by
itself may be insufficient.
argue that without plans and patients and providers all working cohesively—all
engaged—you will not have a successful system,” Barnowsky says.
can incent physicians to provide better care by linking payment to care and can
motivate members to engage in wellness programs in return for lower premiums.
All of this is what drives down overall costs and improves quality, Barnowsky
says. This approach requires not simply data but the ability for data exchange
among all three groups of stakeholders.
from personal health-tracking devices to individual patient care plans can help
with population health management initiatives. In a program at RMG, for
example, several hundred patients with both diabetes and hypertension have home
blood pressure monitors that can download readings to the practice’s EHR, which
analyzes the data and issues alerts when problems arise, Garber says. “The
computer lets us know when there’s something significant to see,” he says.
discount the patient or plan out of that model, providers may still have ways
to exchange information, but you may not be able to get the results or sustainability
needed to improve population health,” Barnowsky says.
EHRs, which are used by providers only, nor HIEs, which some experts say lack scalability
for national reach, appear to be a true solution for such three-way data
solution is Fast Healthcare Interoperability Resources (FHIR), a new standard
for health data exchange that is said to be more flexible and simple to use
across disparate organizations.
Blue Cross adopted the FHIR standard as part of its member health and wellness
portal, allowing member information to be more easily exchanged with vendors of
health and wellness programs.
has real-time data exchange capabilities, Barnowsky says, unlike the typical
file transfer method, which requires several hours. “That will drive a whole
new ecosystem of health and wellness in the future,” he says.
agrees that three-way data exchange is necessary and that FHIR may provide a
viable answer. Despite existing barriers, he believes that the quality of clinical
care documents will improve, and he is optimistic about where healthcare interoperability
“I would say
that we are on the cusp of having the version 1.0 of real nationwide
interoperability, which is a significant milestone for the industry,” he says.
“And it’s just going to get better and better over time.”
Karen Wagner is a freelance healthcare writer based in Forest Lake,
Ill., and a frequent contributor to HFMA publications.
Interviewed for this article: Greg
chief enterprise architect, Independence Blue Cross, Philadelphia; Lawrence Garber, MD, medical director for informatics and
associate director of research, Reliant Medical Group, Worcester, Mass.; Micky
president and CEO, Massachusetts eHealth Collaborative, Waltham, Mass.
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Yuma Regional Medical Center case study
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