Health Information Exchanges: Considerations for Your Practice

HIE (Health Information Exchange) activity can enhance virtually any clinical function by providing a broader set of data to enhance clinical decision-making. Although there are many benefits of HIE, key benefits for practitioners are to support:

• care coordination — the ability to view more comprehensive patient information
• patient engagement
• reporting of quality measures, immunizations, and syndromic surveillance

HIE is a powerful tool. HIE is, or will soon be, a part of your workflow. The need to exchange information is being driven by a desire to improve care coordination, recent legislation, a more involved consumer, as well as additional quality and public reporting requirements.

The goals of this article are to both inform and assist your planning around workflows and implementation or upgrades of EMR (electronic medical record) software. The article will discuss electronic HIE. Electronic HIE can replace the inefficient paper processes of requesting paper records from other providers and patients carrying their information from one provider to the next.

What Is HIE?

The following summary is from HIMSS (Healthcare Information and Management Systems Society): “In its most conservative definition, HIE (the verb) is the activity of securing health data exchange between two authorized and consenting trading partners. Data exchange occurs between any two trading parties — a data supplier and a data receiver. To add complexity, a third party could also be storing data from and on behalf of the data supplier and be transmitting data on behalf of the data supplier ….”

HIE models include: central, where the data is stored at the HIE entity; federated, where the data is stored at each provider; and hybrid, which has some data stored centrally and some federated. Most successful HIE implementations have incorporated a hybrid model using an HIE entity, who is a third party.

HIE can take place in one of two basic ways: push or pull. Push means the data arrives unsolicited, i.e., the user did not have to do anything to get the data other than be associated with the patient. Pull means the data exchange is a result of a query/request by the user.

What Can HIE Do for You?

Key examples are summarized below. Connections to the stimulus’ HITECH meaningful use legislation criteria will be made as appropriate.

Care Coordination: Labs

The most common HIE is sharing lab results with all providers associated with a patient. The performing lab sends the results back to the ordering physician through the HIE entity. The results are sent — pushed — to the other providers via email, fax, or directly to an EMR.

Care Coordination: Beyond Labs

The same method used for labs can be used for encounter summaries, radiology results, and other data where there are sharing agreements.

Care Coordination: Comprehensive View

Let’s take a new-patient visit as an example and assume the patient has lived in the San Diego area for 10 years. Let’s also assume for the moment that San Diego has already implemented a community HIE solution.

The patient verbally provides his or her history, current medications, perhaps some recent lab results, and a paper encounter summary from a visit to another physician. All of this information is being recorded by you and your staff in your EMR.

Because the patient has lived in the area, you are fairly sure that there is data from previous providers. While in your EMR, you have a button on the screen that is labeled “HIE.” You select “HIE,” and a summary of clinical information is displayed. The information has been pulled and aggregated from a central HIE database, other providers, labs, pharmacy benefits management sites, and other sources. You may even have information displayed from a patient’s PHR (personal health record). The source of each piece of data is clearly identified. You are able to drill down on any items of interest to you. You are also able to select items in the display and have them instantly downloaded into your EMR. It’s important to emphasize that to minimize information overload, the data is in a summary format when displayed.

You now have a much more comprehensive view of the patient. Even before you are up and running on an EMR, you may be able to still do this query.

A similar scenario occurs during an ED or Urgent Care encounter.

Related MU Stage 1 requirements are: providing an electronic summary care record for each transition of care and referrals; and exchanging clinical information electronically with other providers and patient-authorized entities.

Patient Engagement

Patient portals, PHRs, wellness sites, and recent legislation have accelerated patients’ ability to actively participate in their healthcare. Stage 1 MU criteria require that patients be provided with an electronic copy of their information upon request, and that patients have timely electronic access to their information. When a patient requests a copy of his or her record, there’s a button that says “print to paper” and/or “print to a CD, memory stick, or some other electronic media.” At the end of each visit, selecting the “encounter summary button” produces an electronic version of the encounter.

Patient access to information is achieved through patient portals that are being offered now by practically all of the major EMR and HIE vendors. Many healthcare delivery systems have developed their own portals. The portal can be a view into a single EMR or a display of EMR data from several EMRs.

Although PHR exchange is not explicit in Stage 1, it is anticipated that Stage 2 requirements and demands by consumers will result in copies of patient information being sent to PHRs. Several EMR and HIE vendors are already outputting data and sending it to PHRs.

HIE supporting patient engagement will result in better informed and more engaged patients.

Reporting Requirements

Most EMR vendors know that they must have the ability to send data to CMS, states, immunization registries, and public agencies for Stage 1 compliance. There will be, for example, an “output to public health agency button” providing an electronic file that can be sent to the agency in de-identified formats.

With the increase in reporting requirements, electronic production and transmission of these reports will reduce your office’s workload.

New Methods for HIE Are Emerging

NHIN Direct is a new model of exchange that does not use an HIE entity but instead relies on two parties directly sharing information. In the past year, this model has gained considerable traction.

Health record banks use PHRs as the coordination tool. Providers would only need agreements between themselves and the bank, and not with every other provider. The State of Washington is implementing this model.

How Close Are We to This Care Coordination Vision in San Diego?

To answer, we need to separate HIE into two categories: enterprise HIE and community HIE. All the major healthcare systems in San Diego have and/or have efforts under way to ensure that EMRs in their system are sharing information both within the system and with affiliated providers, i.e., information that is exchanged across the enterprise.

San Diego is behind other communities in defining a community HIE solution. The community solution will be the glue for exchange of information for all providers whether they are part of a system, or a group, or a solo practitioner. There are several worthwhile projects that are under way for coordinating care; however, an overall strategy has not been developed.

With the market for HIE being driven by MU, consumerism, as well as a recent $15 million award to a consortium of the key San Diego healthcare delivery stakeholders, the opportunity for the San Diego community HIE is promising.

Summary

Electronic HIE can provide care coordination, patient engagement, and reporting benefits. To achieve the benefits of HIE, changes to workflow and EMRs need to be implemented. As you implement or upgrade your system, keep the functionality/buttons in mind. If vendors cannot clearly show how they can achieve MU and that they have the right functionality, move on.