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Interoperability remains a challenge for EHRs


The goal of expanding health information exchange networks was to help providers exchange patient data safely, but not all networks are created equally.

Most adults can access their cash anywhere, and few banking customers would tolerate it any other way. Health information, however, is still largely walled off from one institution to another. Experts say that fewer than 40% of physician’s offices have the ability to share that information with other providers via a health information exchange (HIE), and many physicians don’t know what HIEs provide.

Although most physicians recognize the clinical benefits of efficient electronic exchange of health information-for example, an emergency department being able to access a patient’s medications, allergies and problem lists-the incentives have yet to outweigh the challenges of widespread interoperability, according to Joseph C. Kvedar, MD, founder and director of the Center for Connected Health, a division of Partners HealthCare; a board-certified dermatologist; and associate professor of dermatology at Harvard Medical School.

“Sadly, in healthcare, the business model to reward participants for making those data streams interoperable hasn’t been figured out yet,” he says. “The federal government is saying that you have to be on an exchange-it’s a regulation-and people are complying. But from a financial perspective it hasn’t really become clear to anyone why that would be a good idea.”


What is an HIE?

Another reason for the low participation is confusion, says Rosemarie Nelson, a principal at Medical Group Management Association Health Care Consulting Group and a Medical Economics editorial consultant.

For starters, the acronym ‘HIE’ could be misunderstood to stand for ‘health insurance exchange,’ which is actually abbreviated as ‘HIX.’ And even in the correct realm, ‘health information exchange’ is also frequently used as a verb referring to the movement of the data. For clarity (which may unintentionally make matters worse), some organizations refer to the noun form as a ‘health information organization,’ or HIO.

“Some people don’t even know that this concept of health information exchange exists,” Nelson says. “It’s nebulous-more nebulous than the cloud. And here’s a mechanism that would use the cloud to share information, but it’s even more esoteric.”

HIEs vs. RECs

To help address knowledge gaps, the American Medical Association (AMA) has published a list of physicians’ frequently asked questions about HIEs. Aiming to sort out even more alphabet soup, the authors explain the distinction between HIEs and regional extension centers (RECs).

RECs are entities funded by the U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology (ONC) to assist physicians-and small practices in particular-implement and maintain electronic health records (EHRs).

When looking to learn more about joining an HIE, your local REC is a great place to start. In Massachusetts, however, the Massachusetts eHealth Institute (MeHi) is both the ONC award grantee for health information exchange and the REC, notes Laurance Stuntz, MeHi executive director. Nationally, many HIEs are leveraging RECs to help sign up providers, he says. “Extension centers, as part of their ongoing sustainability, are trying to figure out how to deliver value-added services to keep themselves in business and help keep the knowledge base that they’ve developed. Many of them are offering some HIE connections,” Stuntz says.

HIE availability varies

Also potentially slowing HIE enrollment is a perceived lack of availability of HIEs to join in some areas, notes Nelson. “Even in New York, we have only a couple of initiatives,” she says. “We have one that’s driven more upstate and another more driven in the New York City area. It offers great access to information, but it’s not always easy to import and download data into your EHR, which takes us back to the whole integration issue and easy sharing across disparate vendors.”

Estimates vary, but there are as many as 280 HIEs in the United States that enable the electronic sharing of health-related information, according to the Agency for Healthcare Research and Quality. “So it’s not that there aren’t that many HIEs, because they seem to be pretty widely dispersed and every state has at least some activity in HIE,” Stuntz says. “To me, the challenge is really integration with the EHR. We’ve really not seen good integration with EHRs or HIEs.”

Meaningful Use 2 requires that EHRs support electronic exchange of information, he explains, but 2014 certified EHR systems are not yet widely deployed.



The case for connecting

Once a practice adopts an EHR system, the additional expense to connect to an HIE typically is minor. In Massachusetts, for example, MeHi enrollment costs $5 per doctor per month, Stuntz says, adding that many EHR vendors charge similar rates to connect to their HIEs.

And in theory, that investment should pay for itself in increased efficiencies. For example, offices can save time and money by avoiding the manual printing, scanning and faxing of documents; not having to physically mail or fax records and follow up by phone to verify delivery; and less need to recover missing information or conduct duplicate tests. “What we see is that organizations that start to use health information exchange don’t stop,” Stuntz says.

To aid in evaluating HIE contracts, the AMA has published a worksheet delineating key questions for physicians to ask before going into an agreement. One of many important considerations, for example, is how the HIE handles and guarantees privacy of patient information. Because patients’ explicit consent is required before sharing their medical information over an HIE, you want to be able to confidently assure their records are safe.

Bigger drivers to come

Perhaps the biggest barrier to wider HIE enrollment is not so much driven by objection, but by the myriad competing priorities physician practices are facing today. Stuntz and Nelson agree that the looming deadline to convert to the International Classification of Diseases-10th Revision (ICD-10) coding system is taking up a lot of practices’ focus at the moment.

But as the healthcare industry increasingly moves away from fee-for-service reimbursement and more practices begin to enter quality and risk-based contracts, interest in HIEs will likely build, Stuntz predicts. “I think there were limited direct incentives for HIE in the past, but as HIE becomes a critical piece of supporting alternative payment arrangements, I expect a change over the next couple of years,” he says.


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