Health information exchange (HIE), the electronic transfer of clinical patient information between healthcare organizations, has been a struggle ever since electronic health record (EHR) systems came into use decades ago. More and more instances of HIE are thriving, while others have had little utilization or have gone out of business. What differentiates a successful HIE implementation from one that failed?
There have been several analyses trying to determine the key factors that determine successful HIE. The US Government Accountability Office (GAO-15-817) and the Office of the National Coordinator (Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Version 1.0) postulated that there were several keys to success:
1. Payment reform
2. Lower cost of HIE
3. Data/Transport standards
5. Patient matching rules
6. Uniform privacy rules
7. Policies to support interoperability
While these are all important, they are not necessarily sufficient to ensure success. Having led $4 million in research studies on successful HIE over the past 15 years, I can safely say that there are three keys to success:
3. “U” have to develop trust
Usefulness: Every stakeholder needs to find value in HIE. The person who sends the information, the person who receives the information, the patient, the leaders who pay for the HIE. They all need to see that the benefits that they receive from HIE (e.g. better, safer, more efficient care) outweigh their level of effort (e.g. information gathering, looking up addresses) and cost.
Usability: Every stakeholder needs to feel that the workflow for HIE is efficient. Healthcare is busy and often understaffed. It has to be efficient to gather and send the appropriate information. It has to be easy to be made aware that information has been received and to view it. Healthcare providers live in their EHR, and shouldn’t have to look in a separate system or even a separate part of the EHR to find outside information. While reconciling data that are essentially opinions (e.g. the list of problems or medications that should be taken) needs to be done manually, clinical facts (e.g. test results, notes, immunizations, medication dispenses and administrations) should be incorporated into the EHR without manual intervention. It has to be “Hassle-Free HIE”.
“U” have to develop trust: Every stakeholder needs to trust the system and effort. Patients need to feel that their data are safe and will not be seen by their employer or neighbors. Healthcare providers need to feel that the problems, medications, and allergies they receive are accurate. They also need to trust that when they send information that it will reliably be received by the intended recipient. Healthcare organizations need to feel that the HIE won’t be used as a mechanism to steal their patients.
At Reliant Medical Group, a 500 provider multi-specialty group practice in central Massachusetts, we have leveraged these “Three Us” to securely transfer over a million clinical documents each year. We have exchanged patient records with over 1,000 hospitals and 28,000 clinics in 49 states. For example, while we are independent of any hospital, and most of the hospitals in central Massachusetts use EHRs from different vendors, every Emergency Department (ER) automatically sees our patient’s outpatient records when our patient arrives in their ER. This happens under two models: Direct Interoperability “Push”, and IHE XCPD/XCA “Pull”.
Reliant has given each of the hospitals in central Massachusetts a list of all of our providers. The hospitals then use this to automatically send back to Reliant notifications (HL7 ADT messages) of arrivals, admissions, discharges, and transfers for our patients. This “subscription” to our patient information occurs whenever the patient identifies their primary care, referring, admitting, or consulting provider as one that is on the Reliant provider list. When Reliant’s EHR receives an ADT arrival event from an ER, it automatically generates a patient summary document (CCD) which is sent using a secure Direct Interoperability message back to that ER. The CCD is populated with the ER’s own medical record number which Reliant had received on the original ADT, so that the ER can file it directly into their own EHR without any human intervention. In this manner Reliant automatically pushes clinical information into the ER’s EHR within 90 seconds of patient arrival.
Other ERs in the area have configured their EHR to automatically query for patient records. Using IHE XCPD/XCA profiles they are able to securely pull patient information from Reliant’s EHR if the proper patient authorization is in place, directly into their EHR. Indeed, Reliant uses this same process prior to office visits to automatically query for outside records throughout New England, using Epic’s CareEverywhere and Sequoia’s Carequality networks. We currently are able to see records from Epic, Athenahealth and eClinicalWorks EHRs, and by the end of 2018 when CommonWell connects to Carequality, we in theory should have access to patient records from 90 percent of the physicians in the US.
Reliant also leverages Direct Interoperability to automatically push records to clinical registries and referral providers. For instance, Reliant automatically sends CCDs using Direct to the Massachusetts eHealth Collaborative’s Quality Data Center for evaluation and benchmark comparison of quality measures. Later this year, when Massachusetts becomes a member of the DirectTrust trust framework, Reliant will be able to securely send Direct messages to almost 2 million Direct addresses representing over 100,000 healthcare organizations around the country.
While many people around the country are under the impression that HIE is not taking place, they are wrong. It is thriving and in 2019, it will become ubiquitous, as more and more healthcare organizations focus on the three Us: Usefulness, Usability, and “U” have to develop trust.