In this first of our series, Donna Fedor, Managing Director for Digital Health at Mavericks Capital, interviews three industry-leading healthcare data and information experts and provides some basics and history about Health Information Exchanges (HIEs).
It is astonishing that ten years have passed since the United States federal government started to facilitate healthcare information sharing with the establishment of the first Office of the National Coordinator (ONC) for Healthcare IT. Soon after, the first Regional Health Information Organizations (RHIOs) started popping up across the country.
After a decade, most people, however, are still in a state of confusion about shared health data or specifically, Health Information Exchanges (HIEs). If you are still one of ‘the confused’, welcome to the club! Google the terms “HIE” and “confusion” and you might be surprised at the number of articles that pop up.
This series intends to shed a bit of light on healthcare information sharing to help both the healthcare novice as well as those that reside inside the healthcare value chain but have largely ignored the decade-long muddled evolution of HIEs.
Three healthcare information experts have generously shared their thoughts about the progress of health data exchange in the United States. Enrique Estrada is Solutions Architect at Sandlot Solutions, a fourth generation health information exchange (HIE), Bob Yencha is the President of RTY, LLC, a consultancy focused on information standards development and data sharing programs, and Bill Beighe holds CIO positions at Santa Cruz Health Information Exchange (HIE) and Physicians Medical Group of Santa Cruz.
HIE stands for Healthcare Information Exchange. Estrada suggests,
“You can think about HIE as both a verb, the act of sharing data as well as a noun, the actual entity, industry or government consortium that implements policy, governs and collaborates to provide a successful structure or framework for facilitating movement of the data.”
Typically, HIEs are entities that securely house or facilitate the exchange of patient data for the main purpose of collective accessibility by their entire team of care providers. Sharing data between disparate organizations via an HIE can facilitate the synchronization of care across multiple providers, even if they are in different systems or even in different states.
Beighe adds “patients and doctors often do not realize that these different electronic systems do not easily share data; this is where the HIE comes in, to make the safe, secure exchange of data possible so that all providers have the information they need to provide better care.”
The History of HIEs
The reason behind the advent of HIEs is simple. Healthcare costs are predicted to be almost 20% of the US GDP in 2020. Costs are becoming unmanageable as we age, live longer, and lead more sedentary and unhealthy lifestyles. Beighe observes, “It makes sense that patients will receive better care at lower costs if their providers have access to all relevant patient data.”
To help stem the rise in costs, the US federal government passed legislation to drive the healthcare industry towards a Pay for Value reimbursement system, placing significantly more emphasis on paying for patient outcomes. Today’s reimbursement system incentivizes a Fee for Service system, where payment is made for a specific healthcare activity or transaction, somewhat regardless of patient outcome.
HIEs have been around since the early 1990’s and by 1995 there were about a dozen multi-stakeholder HIEs in existence. Steady growth occurred throughout the 2000’s and HIEs started to sprout up across the country when the federal government passed the American Recovery and Reinvestment Act (ARRA) of 2009, which included the HITECH Act (or Health Information Technology for Economic and Clinical Health). This funded the states to the tune of $600M to build entities that aimed to convert redundant silos of clinical healthcare data into a shared database that coordinated care and allow patient data to follow patients across different settings.
Bill Beighe submits that there were two main approaches that the states took to create HIEs with their chunk of the federal HITECH money.
One approach was to encourage the formation of and orchestrate the operation of regional HIE organizations, and the other approach was to set up their own state-operated HIE organization. As an example, he summarized the official HIE roll out in the State of California.
“California Health and Human Services (CHHS) used their $38M share of the HITECH act to ambitiously fuel, encourage and support existing and new HIE organizations across the state through the launch of CalConnect in 2010” (where Beighe was a board member).
California wisely chose not to try to build and run a state-wide exchange, asserts Beighe, “California is too big, too diverse and 38 million dollars is a drop in the bucket compared to what it would cost to build and run a state-wide HIE.”
“One HIE already in existence was Santa Cruz HIE, which was formed in 1995 and began exchanging data in 1996 with the goal of facilitating treatment of patients and enabling better transitions of care. Because Santa Cruz was a system of many smaller, disparate physician offices operating with different systems, one of the critical early goals was to reduce costly redundant testing when patients were referred from one doctor to another.”
Part of the HITECH Act also established specific objectives called Meaningful Use (MU), which introduced the concept of using national standards so that the users and systems could meaningfully exchange data.
MU aimed to monetarily incentivize (and also penalize) the healthcare industry to implement healthcare IT programs in a defined and more “meaningful way,” eventually giving the industry the ability to implement a Pay for Value system focused on outcomes versus single transactions.
Meaningful Use is being implemented in a three-phased approach, MU1, MU2 and MU3. Broadly, MU1 involves digitizing healthcare and medical data via Electronic Health Records (EHRs), which, according to an 2014 article on the Health and Human Services website, “about 75 percent of eligible professionals and over 90 percent of hospitals have adopted or demonstrated Stage 1 Meaningful Use of certified EHRs.”
MU2 introduced the concept of interoperability, which defined by Beighe is “the ability of two systems to understand and act on data that is sent and received.” MU2 objectives focus on communication of the data between entities including e-prescribing, lab results reporting, and sharing of patient care summaries between other care providers, as well as with patients.
Interoperability through HIEs will be a critical part of MU2. MU3 focuses on implementing quality measures and moving to reporting and managing patient outcomes. There has been some industry difficulty with both specification of standards and adoption of MU 1 and 2, which has resulted in extended timeframes for implementation.
The 2010 Patient Protection and Affordable Care Act (PPACA, or more commonly known as Obamacare) included the concept of bundling a single payment for the entire care team for a specific patient episode or treatment, in order to help achieve the final phase of Meaningful Use, or a Pay for Value environment.
New entities called ACOs, or Accountable Care Organizations, will have the responsibility for reporting on numerous quality metrics and patient outcomes as well as managing the payouts from these bundled payments to the multiple healthcare service providers that affected the patient’s care.
Shared data provided by healthcare providers and hospital systems to the HIE organizations will be a critical part in an ACOs ability to coordinate and plan for more targeted and effective outcomes definitions, quality measures and payments. ACOs will be covered in more depth later in this article series.
HIEs will also greatly affect the creation of higher-level, public health statistics, through which critical health trends can be tracked and measured. Public funds can be routed to where they can make the most significant impact.
Stay tuned for the next segment in our series, where we'll examine why HIEs are still causing so much confusion.
The nuviun industry network is intended to contribute to discussion and stimulate debate on important issues in global digital health. The views are solely those of the author.