Healthcare Information Exchanges: The Glue Holding Together Value-based Healthcare
A tidal wave of medical information
For many years, the medical profession has struggled to devise a simple, secure way to share its extraordinary volume of data. This has been particularly difficult because healthcare delivery organizations have arguably lacked compelling incentives to exchange data from their electronic health record systems. This situation reflects the data crisis in healthcare today: the care of patients is burdened with paper-based record systems and information stored within different provider systems. To solve these problems, electronic health record (EHR) systems were designed but a lack of interoperability has frustrated everybody. This deficient state of health information liquidity and interoperability has proven to be a barrier in the transition to value-based healthcare.
To address this situation, Health Information Exchanges (HIEs) emerged in 2009 with passage of the Health Information Technology for Economic and Clinical Health Act, to promote the electronic movement and use of health information among organizations using nationally recognized interoperability standards.
Then, in 2016 TEFCA, or the Trusted Exchange Framework and Common Agreement, was drafted to create a network of networks, connecting authorized participants or end users including payers, vendors, networks, government agencies, health information exchanges (HIEs) and individuals. TEFCA strives to establish a single “on-ramp” for health information exchange (HIE) that enables a wide variety of healthcare stakeholders to automatically connect to and participate in nationwide health information exchange.
The objective of TEFCA is to utilize HIEs as the building blocks for the nationwide exchange of medical information. And reassuring evidence is accumulating that HIEs are not only a more convenient repository of data but an essential means for converting data to value, not just as measured by ROI, but as experienced by patients and their healthcare providers as quality of care. For example, according to a recent study by researchers from Notre Dame University, accessing and using data through HIEs can reduce Medicare costs by $3 billion per year (an average saving of $139 per Medicare beneficiary every year, or a 1.4% decrease in spending per individual.) In addition, the number of lab tests was reduced by 25% and the number of radiology exams cut by 26%.
Health Information Exchanges have evolved in many ways. Some are government-led, some operate as public utilities with governmental oversight, and some are private sector-led with government collaboration.
Whatever their business model, these HIEs allow doctors, nurses, pharmacists, other healthcare providers and patients to access and securely exchange vital medical information electronically. They facilitate care coordination by providing a complete view of the patient, enabling real-time intervention at the point of care, determining risk and providing actionable data.
What HIEs are doing
HIEs integrate electronic health records (EHRs) into broad IT interoperability networks. They yield better care for patients because they provide physicians with access to all relevant information they need. Working together, they are improving nationwide interoperability by, for example, alerting and sharing records among HIEs when patients require treatment outside their local community.
However, many HIEs were financed by public programs whose funding limits have now been reached. A 2015 study supported by the Robert Wood Johnson Foundation reported that 44 of the 202 public and private HIEs being tracked had to be removed from the list. But, of the rest surveyed, (with an 80% response rate), 106 were operational and 21 were in the planning phase; 32 were public statewide HIEs supported by federal money. It is noteworthy that 78% of the leaders of the public HIEs surveyed were optimistic they could make it financially, despite the technical complexity of accessing more than 500 different medical record systems, most of which do not employ the same technical standards and may not communicate easily with one another.
Nobody believed it would be easy – and it hasn’t been. To take just one example: electronic health records (EHRs) residing in hospitals and health systems nationwide are jammed with duplicate patient identity records. A recent Black Book Survey of 1,382 health technology managers shows the average duplicate rate across healthcare organizations is 18%. Hospitals without comprehensive enterprise master patient indexes are liable to have 33% of patient claims denied costing the average facility $1.5 million in 2017. The average cost of repeated medical care due to inaccurate patient identification with a duplicate record, for example, is roughly $1,950 per inpatient stay and more than $800 per emergency department visit.
How does this happen?
Problems like this can be best explained by considering the diversity of the institutions housing patient data:
- Independent physician practices of all sizes
- Long-term care, nursing facilities
- Behavioral health facilities
- Federally-qualified health center
- Community-based organizations
- Home care
- EMS (emergency medical services?)
- Health plans
- PPS leads
- Medicaid health homes
- Independent pharmacies
- Independent labs and radiology centers
- Correctional health services
- Medicaid claims
- Veterans Administration
Scattered within each of these data sources are more than two dozen types of data, covering demographics, allergies, medications, medication allergies, smoking status, immunizations, encounters, observations, vital signs, pharmacy fill data, lab tests, radiology reports, diagnoses, procedures, functional/cognitive status, care plans, discharge instructions, advanced directives, care plans, EMS run sheets, image exchange, Medicaid claims data, and social determinants.
Nevertheless, in the midst of this blizzard of essential statistics, HIEs are surviving and successfully serving the healthcare community with:
- Master Patient Indexes that correctly match patients with their clinical data
- Record Locator Services that retrieve copies of the patients’ records stored in decentralized provider systems
- Transport and Content Standards that enable communications among different health data systems
- Messaging Services with processes and software to exchange various types of data
- User and System Interfaces which access physician portals on the HIE and data embedded directly into a physician’s EHR
- Consent Management Mechanisms through which patient consent is obtained regarding the sharing of their personal health information
Dealing with the surge of data: Some examples of success
Leveraging social determinants of health for HIE
According to the Centers for Disease Control and Prevention (CDC), social determinants of health include the condition of the places where people live, learn, work, and play. These conditions can affect a variety of health risks and outcomes. Unstable housing, low income, unsafe neighborhoods, and substandard education are some of the major factors that can influence patient health. Incorporating social determinants of health data into patient EHRs can improve individual and population health management.
Patients facing the challenges of low health literacy and social determinants are more likely to fall through the cracks for transitions in care. Using risk stratification to target the most-needy, high-quality data delivered by the HIE and automated matching of the CCD data with other medication sources, makes it possible to identify patients needing immediate follow-up.
Predictive analytics fueled by HIE
Real-time clinical data can determine and identify potential costly patients who are liable to become high-cost frequent users of the healthcare system. With predictive analytics, care managers find more potential at-risk patients, thus lowering readmission rates. They use analytics and predictive tools to study market share, clinical performance, population health and patient risk – all in real-time.
By merging clinical data from EHRs and claims data from payers, predictive analytics can prevent problems before they arise, which is particularly critical for Medicaid patients who often face socio-economic challenges, behavioral health issues and barriers to care access. Indeed, adding claims data can help connect the dots for patients who may skip around the care continuum, visit multiple providers, or receive care from organizations that do not have the capability to connect the main stream of information flowing across the state.
Patient-centered data home
The Patient-Centered Data Home (PCDH) is a cost-effective scalable method of exchanging patient data among health information exchanges. It triggers episode alerts, which notify providers that a care event has occurred outside of the patient’s “home” HIE, and confirms the availability and the specific location of the clinical data, enabling providers to initiate a simple query to access real-time information across state and regional lines and the care continuum.
- Shares patient encounter “alerts” from “away HIE” to “home HIE”, based on ZIP code look-up tables
- Enables away HIEs to query home HIEs for clinical data to aid the provider at the time of treatment
- Permits home HIEs to alert away HIEs and simultaneously allows home HIEs to alert patients’ usual “home” doctors
- Can give the away HIE the power to query records for the home HIE
- Delivers away HIE records to the treating care team and shares post-encounter summaries to home HIEs
HIEs and natural disasters
In Georgia, the Regional Academic Community Health Information Exchange (GRAChIE) serves healthcare groups and providers in that state and its HIE is setting up connections with South Carolina, North Carolina, Virginia and Florida members of the eHealth Exchange — a national health data-sharing network that includes 75 percent of U.S. hospitals. GRAChIE and the eHealth Exchange conducted a coordinated effort to meet the medical needs of patients forced from their homes by the devastating Hurricane Florence. The NC Health Information Exchange Authority also worked with its colleagues to ensure that North Carolina residents didn’t suffer worse outcomes because they were far from home and without their medical data. In disaster situations such as hurricanes, physicians must have instant access to electronic patient histories to provide safe and effective care, and as such, HIEs play a significant and critical role in hurricane response.
HIEs: The ties that bind
HIEs are delivering continuous value to their communities. They have demonstrated enhancement of administrative efficiencies and cost containment. Healthcare providers rely on them to:
- Improve safety of patient care
- Provide clinical decision support tools for more effective care and treatment
- Eliminate redundant or unnecessary testing
- Improve public health reporting and monitoring
- Allow community-based providers to coordinate care with other caregivers
In conclusion, robust and optimal HIEs are critical to individual and community health, and healthcare delivery organizations are taking advantage of the capabilities offered today in the marketplace.