Exchanging Health Information
Februaury 2008

Exchanging health information – eHealth Initiatives in the USA : Susan Thomas, eHEALTH

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eHealth Initiative and its Foundation
The eHealth Initiative and its Foundation are independent, non-profit affiliated organizations sharing the same mission – to drive improvements in the quality, safety, and efficiency of healthcare through information and information technology.

eHI engages multiple stakeholders, including clinicians, consumer and patient groups, employers, health plans, health IT suppliers, hospitals and other providers as also its growing coalition of more than 200 state, regional and community-based collaboratives, to reach an agreement on and drive the adoption of common principles, policies and best practices for improving the quality, safety and effectiveness of healthcare through Information and Communication Technologies.

Health information exchange (HIE) is defined as the mobilisation of healthcare information electronically across organisations within a region or community. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable and patient-centered care.

Formal organisations are now emerging to provide both form and function for health information exchange efforts. These organisations often called Regional Health Information Organisations, or RHIOs, are generally geographically-defined.

They develop and manage a set of contractual conventions and terms, and arrange for the means of electronic exchange of information, and develop and maintain HIE standards.

The results of eHealth Initiative’s Fourth Annual Survey (2007) of Health Information Exchange at the state, regional and community levels in the United States of America indicate that at least 125 communities across the U.S. are continuing to bring together multiple stakeholders to focus on the secure exchange of health data to improve health and healthcare for patients.

Of the 130 initiatives included in the 2007 survey, 20 are just getting started, 68 are in the process of implementation, 32 are operational, five are no longer moving forward, and five did not respond to the survey question regarding stage of development.

Need for information exchange
Many patients visit more than one provider at various sites of care over time. In order to make the best decisions for their patients, providers need accurate, complete and up-to-date data. In which case, well and securely managed health information exchange has the potential to increase efficiency, lower costs and increase safety and effectiveness.

Today healthcare costs are also on the rise, due to lack of up-to-date patient information which makes healthcare delivery inefficient and often unsafe, as also due to unnecessary costs stemming from factors such as duplicate testing.

Health care spending in the United States as reached an all time peak. In the eHI survey, 99 percent of HIE organisations said healthcare provider inefficiency due to a lack of information to support patient care was a significant or moderate driver for the project. And more than half (60 percent) said rising healthcare costs were a significant driver for their activity. Standardisation, and secure information exchange would improve quality and safety of care while  eliminating costs.

Patient privacy and security concerns
Information exchange in the healthcare domain is a most sensitive issue, more so than even in the financial sector, since lives are at stake. Accuracy and timeliness are of paramount importance, as are the security of the data exchanged.  However, a key difference here is also, the multi-point accessibility requirements of this kind of data.

Planning for a safe, secure data exchange is therefore a priority for HIE efforts. Most place a priority on exchanging data that leads to better patient care first.

A majority of these HIE efforts are exchanging (or expecting to exchange within six months) data related to outpatient and inpatient episodes, laboratory results, emergency department episodes, pathology results, and enrolment and eligibility information. More than three out of four (76 percent) are employing the use of standards to exchange data electronically.

Primary focus of HIE initiatives
Overall, the percentage of health information exchange initiatives exchanging data is on the rise with 34 percent of 2007 respondents currently exchanging lab data and 32 percent exchanging data related to outpatient episodes, up from 26 percent and 21 percent respectively, in 2006. Exchange of emergency department episodes, inpatient episodes, outpatient laboratory results, and radiology results are also up from 2006, with 30 percent, 28 percent, 28 percent, and 26 percent, respectively, offering these services in 2007.

Supporting direct care delivery continues to be the focus of health information exchange efforts, but providing population health related services continues to be an emphasis for some�particularly more advanced stage initiatives.

In terms of supporting care delivery, twenty-nine percent of 2007 respondents provide “results delivery” services to the users of the health information exchange initiative-up four percent from 2006, while 25 percent offer clinical documentation services, and 21 percent offer enrolment or eligibility checking services.

At the same time 16 percent of 2007 survey respondents are offering chronic care management services, while 11 percent are offering quality improvement reporting to clinicians. HIE initiatives are increasingly adding support functions to augment data services.

Leadership and organisation
HIE initiatives are continuing to formalize their operations through the creation of formal legal entities. They are continuing to establish legal entities to support their operations, with more than half (55 percent) having established legal corporations, 14 percent continuing to be incubated within another organisation, and eight percent remaining a “loose group of collaborators”.

For those who have created a legal organisation structure for their efforts, more than two-thirds (68 percent) have chosen a non-profit corporation model, while eight percent have chosen a limited liability company model, five percent have chosen a for-profit corporation model, and five percent have chosen a “virtual model”–which is not a legal entity, but an initiative formed under contractual arrangement.

Clinicians, community health centers, employers, health plans, hospitals, patients, and quality improvement organisations are most likely to play a governance role in health information exchange efforts.

For the most part, health information exchange initiatives have migrated to a model whereby multiple, diverse stakeholders are participating in the effort.

Those organisations that are participating in the governance of health information exchange efforts include hospitals, primary care physicians, health plans, community health clinics, local public health departments, patient or consumer groups, speciality care physicians, employers and quality improvement organisations.

Trends for HIE organisation are beginning to emerge. A majority are led by a neutral, multi-stakeholder entity. More than half are incorporated, and 70 percent of these efforts are following non-profit models.

Challenges
As in 2006, and consistent with findings from eHI’s June 2007 report, the most difficult challenge for health information exchange efforts is the development of a  sustainable business model.

This was identified as a very difficult challenge by 56 percent of 2007 survey respondents. One of the primary reasons that health information exchange sustainability has been such a difficult issue for both national and local leaders is that the current reimbursement system, which largely rewards both volume and fragmentation, serves as a disincentive for sharing health information across healthcare stakeholders.

Funding is another challenge for all HIE efforts. Ninety-one percent of all respondents cited “securing upfront funding” as either a very difficult or moderately difficult challenge. Just under half (46 percent) of all HIE efforts report federal government grants and contracts as a current revenue source for upfront funding. Alternative funding sources for sustainability include advance payments from data sources. Some of these HIE efforts receive advance payments from hospitals and physician practices. A smaller number of advanced HIE efforts receive advance payments from other stakeholders, including public health, laboratories, payers, and purchasers to support ongoing operations.

While health information exchange initiatives continue to rely on federal and state agencies for up-front funding, the level of funding provided by hospitals is up considerably from 2006, moving ahead of government funding as the top funding source.

In 2007, the top sources of upfront funding for health information exchange initiatives were hospitals (53 percent), federal government grants and contracts (44 percent), state government (43 percent), private payers (32 percent), and philanthropic sources (31 percent). Funding for ongoing operations is increasingly reliant upon non-governmental sources. Although HIE efforts vary greatly in organisation and structure, yet they share another common challenge- accurately linking patient data and engaging health plans.

Vision for the future
Despite difficulties with achieving sustainability, the 2007 survey report indicates that at least 32 health information exchange initiatives across the U.S. have made progress, identifying themselves as “operational” or “transmitting data that is used by stakeholders”, as compared to the 26 initiatives which identified themselves as operational in 2006.

The operational HIE initiatives identified by the survey are actively exchanging data including outpatient episodes (84%), laboratory results (73%), inpatient episodes (64%), and radiology results (63%). Three quarters of operational HIE initiatives are “delivering results” (such as laboratory results) as a service to their customers and 63 percent are providing “clinical documentation” services.

In addition more than one fourth of such initiatives are offering services that are designed to improve population health, including disease or chronic care management services (32%), quality improvement reporting for clinicians or purchasers/payers (29% and 26% respectively), and providing laboratory results reporting for public health agencies (28%).

While one-half of advanced stage, operational initiatives received up-front funding from the federal government, many are now receiving ongoing revenues to support operations from non-governmental sources including hospitals (58%), private payers (46%), physician practices (46%) and laboratories (33%), and three-quarters of such initiatives are no longer dependent on grants to support their sustainability.

eHI is working closely with operational initiatives to gain much needed insights regarding a set of near-term business cases for the use of electronic clinical health information to continue to advance both policy and on-the-ground progress in this area.

For the first time since the survey was conducted, the government was not cited as the top provider of up-front funding for all health information exchange initiatives. According to the 2007 survey, 53 percent of all initiatives received start-up funding from hospitals, while 44 percent received start-up funding from federal grants and contracts and 43 percent received funding from state agencies. One third of all initiatives have received start-up funding from private payers.

The eHealth Initiative began both tracking and supporting the efforts of multi-stakeholder efforts at the community level in 2003, recognizing the importance of not only national leadership, but also leadership at the local levels where care is delivered. In addition to national focus on both standards and financing to address sustainability, both leadership and collaboration among multiple stakeholders at the community level is needed, to build social capital for information sharing, build business cases for sharing the costs of an infrastructure that benefits everyone, and facilitate the flow of the clinical information needed for care delivery, much of which resides locally.

Learning by example
eHI’s 2007 survey report highlights 32 health information exchange initiatives that have identified themselves as fully operational. These organisations share some common characteristics that offer guidance for a path forward.

Three quarters of operational initiatives are no longer dependent on “non-operating revenue”, which are described as grants or advance payments. Operational initiatives derive their revenues for ongoing operations from hospitals, physician practices, private health plans and so on.

Most operational initiatives utilise subscription fees or membership fees from data providers or data users to support ongoing operations. A majority of operational initiatives charge transaction fees to data users while a large number charge transaction fees to data providers.

A strong majority of operational initiatives are exchanging outpatient episodes (84 percent), outpatient laboratory results (76 percent), laboratory results (73 percent), inpatient episodes (64 percent), and radiology results (63 percent).

 

Recipe for success
Although HIE initiatives differ in many ways, survey results and eHI experiences with states, regions and communities indicate that those who are experiencing the most success share the following characteristics:
-Governed by a diverse and broad set of community stakeholders;
-Develop and assure adherence to a common set of principles and standards for the technical and policy aspects of information sharing, addressing the needs of every stakeholder;
-Develop and implement a technical infrastructure based on national standards to facilitate interoperability;
-Develop and maintain a model for sustainability that aligns the costs with the benefits related to HIE; and
-Use metrics to measure performance from the perspective of: patient care, public health, provider value, and economic value.

Source: eHealth Initiative, Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations, August, 2005

Role of the state
State policymakers are continuing to demonstrate leadership in using health information technology and health information exchange to drive improvements in health and health care. As this report shows, a number of states are also moving forward in tandem with federal efforts on the development and adoption of policies for improving health and healthcare through health information technology (HIT) and electronic health information exchange (EHIE).

Recently, America has seen a significant increase in state-level legislative action regarding health IT and quality improvement. While there was virtually no legislation at the state level related to health IT prior to 2005, in 2005 and 2006 thirty-eight states introduced 121 bills specifically focused on health IT, and of those, 36 bills were passed into law in 24 states. Since the beginning of 2007, 208 bills have been introduced across all 50 states that refer to the adoption or implementation of health IT, nineteen of which have been signed into law in sixteen states.

State legislation is becoming increasingly sophisticated, calling for a focus on improving the quality of care through the use of health IT, rather than focusing on health IT alone. Several of these bills also authorize funding of state initiatives, or establish exploratory and investigative task forces to facilitate state progress.

U.S. governors are also playing a critical role in moving forward. To date, 20 executive orders have been issued by governors in 15 states, which are designed to drive improvements in health and healthcare through the use of IT–nine executive orders in 2007 alone.

Some Health Information Exchanges in the US

Few government initiatives such as the latest US$1.3 million grant from the U.S. Department of health and Human Services Centres for Medicare and Medicaid Services that seeks to connect Evansville with a growing network of health care providers that share patient information online of the non-profit Indiana Health Information Exchange, seem encouraging.

The exchange, which consists of 33 hospitals, 7,200 physicians and 2,445 practices statewide, can deliver lab results, reports, medication histories, treatment histories and more in a standard, electronic format.

Another example is that of the Brooklyn Health Information Exchange, organised by Maimonides Medical Center and other healthcare organisations in New York. Incorporated as an independent not-for-profit corporation in New York, the BHIX involves a collaboration of the leading acute, post-acute, and long-term healthcare providers serving residents of New York, scheduled to be operational in July 2008,.

It will provide a secure electronic infrastructure for sharing clinical information among multiple healthcare organizations.

It will facilitate care for approximately 200,000 patients. The initial partners include Maimonides Medical Center, a 700-bed hospital that had almost 40,000 patient discharges last year; Kingsbrook Jewish Medical Center, a 600-bed hospital with almost 10,000 patient discharges last year; four nursing homes; three certified home-healthcare agencies; and two payers.

It is designed to improve care as patients transition from departments or facilities, reduce service duplication, and afford physicians and other healthcare workers with fast access to patient information.

Technology can optimise patient care, minimise the risk of medical errors, and reduce administrative and other operating costs and the BHIX’s goal is to provide exceptional patient care and service through the strategic deployment of technology.

The BHIX exchange, which is to be operational in July 2008, will allow BHIX partners to aggregate and manage patient data in their own clinician practices, while also giving individual physicians and healthcare workers who are members of the BHIX access to patient data at different care settings. Authorised users will be able to access a portal through secure Internet-enabled workstations to view six key data elements of a patient’s medical data: patient demographics; medication lists; allergies; advance directives; information on physicians treating the patient; and a medical problem list. In addition, healthcare workers will be able to employ paper-record scanning and indexing of advanced directives and patient consent forms.

In another example the Ann Arbor Area Health Information Exchange is moving into the pay-for-performance realm with help from a two-and-a-half-year-old data-sharing technology deployment.

The Michigan HIE went live with NextGen Healthcare’s Community Health Solution in the second half of 2005. The product provides a central data repository that lets physicians securely exchange patient data, the company said. HIEs can also use NextGen CHS to track patient safety and quality initiatives.

The Community Health Solution lets the HIE’s four member practices collect quantitative and qualitative data on patients. With the data, Blue Cross Blue Shield of Michigan developed a series of clinical indicators that set the HIE on the pay-for-performance path.

LIGHTing up the world

Nations around the world are growing more interested in how IT can improve the access, quality, safety and efficiency in th eir healthcare systems.  A number of countries have implemented interconnected electronic health infrastructures, either regionally or nationally. In doing so, these countries have faced vexing challenges and have developed a myriad of strategies to address them.

The eHealth Initiative established the Leadership in Global Health Technology (LIGHT) initiative in 2004 to facilitate learning and information sharing among these HIT innovators and other nations, in both the developed and developing world.  The eHI LIGHT Resource Center is designed to inform debate and global dialogue as well as build collaboration and an international learning community around these issues.

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