The HIE: Part 1

One of the great mysteries of the recent healthcare reform movement is why “HIE” has been used as the acronym for both Health Insurance Exchanges and Health Information Exchanges. As the Affordable Care Act health insurance exchanges continue to garner media coverage, the original HIEs—health information exchanges—continue to struggle.

The 2009 American Recovery and Reinvestment Act (ARRA) is familiar to anyone working in healthcare policy. It gave rise to Health Information Technology for Economic and Clinical Health (HITECH) and provided $36B in funding for the meaningful use of health information technology.

From this money, $2B was allocated to states and territories to improve health information exchange. According to a Black Book report, $542M has been allocated directly to public HIEs.

And yet those HIEs are struggling.

In the past, we’ve blogged about the need for HIEs to adopt a clear business model. That need hasn’t changed. Indeed, the need is more pronounced than ever before. According to the Black Book report:

83 percent of the nation’s 220 operating public HIEs are stalling as federal grants supporting half of the state and regional HIEs are dried up.

Why is this such a challenge? We believe the issue lies in the fact that healthcare financing and healthcare data are inherently complex. Creating a business model that delivers value from information technology to a mix of end users—patients, providers, payers, and financiers, has proven too great of a challenge to the HIEs.

MediCenter Experience

HMS’ experience in HIE is based on EpiCenter, our community health surveillance system that collects predominantly emergency room data from over 500 hospitals, and MediCenter, which built on the EpiCenter foundation to provide medication history in the emergency department. MediCenter was a specialized health information exchange that gathered data from data aggregators, payers, clinics, pharmacies, and previous history to provide medication history at the point of care.

MediCenter challenged us to develop a business case for clinical health information exchange. The system demonstrated time savings and improvements in quality of care during the very first trial. But how could a hospital account for those savings? Would fewer total hours spent researching information on a patient be the result? Would there be improved job satisfaction among hospital employees?

MediCenter also challenged us regarding the exchange of healthcare data. MediCenter focused on a thin slice of data—medication history. Medication history is required at every patient interaction. Because it’s asked for so frequently, many patients believe that it’s readily available to all providers, no matter where the patient goes.

Even given MediCenter’s very specialized tasks, the exchange of data was still a challenge.

An accurate medication list is hard to get from a patient. Prescriptions needed to be matched to medication fills and generics matched to branded drugs. And patient identity needed to be established between organizations. We discovered that there was missing medication, duplicates, and anomalous medication that the patient had never taken before. There were patient privacy concerns regarding the medication list being checked in front of parents or spouses, in case a drug name would reveal a previously unknown condition. And, on a routine basis, men over the age of 50 would lie, forgetting or disclaiming medication they were on for import conditions like heart disease.

Moving toward an HIE Business Model

The outlook for public health information exchanges is dire. Despite the hard work and earnest effort of many stakeholders, the prediction for 2017 is that as few as 5% of the existing public exchanges will be functional. That estimate is likely alarmist; organizations will naturally adapt and extend the viability of their time frame.

72 percent of HIE stakeholders forecast that by 2017, without more effective processes, participation schemes, revenue or funding streams, and effective business models, as few as 10 of the currently functioning public exchanges will sustain operations .

Based on our experience with EpiCenter and MediCenter, we believe that functional health information exchanges can be created by:

1. Limiting Exchange to Local Regions. The real business of health information exchange is intensively local. As a general rule, patients do not venture far from a small set of providers.

2. Limiting Exchange to Specific, Useful Data. Healthcare data is not general. Additionally, systems are not—and will not be—highly interoperable in the near term.

3. Focusing on Economic Return to Stakeholders. Who benefits from the exchange of data? Payers and providers need to participate in creating accounting models that capture the return from the exchange so that the value is captured and realized.

4. Minimizing Technology Requirements. Technical dependencies kill projects. It is incumbent upon the exchange to take data in whatever form the provider has and return it in whatever form the provider needs. This could be HL7, it could be Direct, or it could be a text document. In some scenarios, it might even be a fax.

 This entry is part one of what will be a three-part series on HIEs.