Health Information Exchange In the U.S.
Introduction. According to the HIE directory “Health information exchange is the transmission of healthcare-related data among facilities, health information organizations and government agencies, according to national standards for interoperability, security and confidentiality.” After more than two decades of working to achieve effective and efficient health, this goal is still not fully actualized. The utilization of personal health information is still not fully exploited to support optimal care because the creation and storage of data is fragmented since information tends to be isolated within physician practices, hospitals, pharmacies, laboratories, or clinics. In an effort to improve the quality of healthcare delivered, recent policies and actions by federal government is in support of adopting the health information exchange (HIE) to address the issue fragmented personal health information. However, there is a recurrence of challenges from the inceptive efforts to facilitate HIE, and without new strategies these challenges will continually present itself.
1. History of HIE. As stated by Vest, Joshua R., Gamm, Larry D., J. Am. Med. Inform. Assoc. (2010), the Hartford Foundation during the early to mid-1990s founded the Community Health Management Information Systems (CHMIS). The CHMIS was to fulfil the purpose of having centralized data repository in geographically defined communities that stored patients’ personal demographics, individual level demographic, medical information and information that determined their eligibility in terms of medical benefits. However, many participants struggled in terms of obtaining technology that was cost-effective, building stakeholder trust, and lack of strong political support. Incidentally a program that reflected the CHIMS was initiated in the mid-1990s known as Community Health Information Networks (CHINs). Unlike the CHMIS experiment that focused on quality assessment objectives, CHINs priority was the cost effective moving of data between providers (Vest, Joshua R., et al, 2010). Not wanting to give up data to a centralized repository, CHIN resigned to employ a transaction-based method that would retain the independence of each provider's personal database. Regardless of CHIN’s having many systems in many communities, most failed to survive.
Upon entering the 2000s a regional health information organization (RHIO) was established, it was made as a neutral, third-party organization, which would facilitate the exchange of information between providers within a defined geographical area, in an effort to achieve healthcare that was more efficient and effective. RHIOs, unlike preceding efforts, was developed in a time when support from the political arena was momentous. RHIOs gained traction after it was identified by the ONC as the basic infrastructure of national health information, but became prominent after the influential Institute of Medicine (IOM) boosted the awareness of the serious issues in the healthcare system in regards inadequacies of quality and safety. Currently, RHIOs utilize either the CHMIS approach or the CHIN model, or some mixture of the two, since the ONC does not promote any of the two model. RHIOs can legitimately claim both general quality and cost savings as objectives, since quality as defined by the IOM includes the extent of effectiveness and efficiency.
2. The Challenges of HIE. The challenges of CHIN in some instances were similar to CHMIS, apart from the lack of affordable and effective technology, and failure to transition from being a grant funded system to a self-sustaining system. CHIN had problems of competition arising in order to protect what providers called proprietary information, as members limited the information being exchanged by the amount and type, as well as opting to partake on a read only basis. According to Vest, Joshua R., et al, 2010, the technology vendors, those who provide the electronic transmission created more challenges as they eroded the interests of potential partners and hospitals and community physicians against each other. However, the ultimate challenge for CHIN was the return on investment (ROI) problems, which caused focus on community to become minimal and leaned more to the bottom line. To top it off, the financial benefits expected from the capital costs to build infrastructure was not materializing.
According to Gregg, Helen, 2013, currently there are three major HIE challenges, interoperability, financial stability, and competitive concerns. In terms of Interoperability, there is significant concern among exchange organizations about the extent to which the systems and devices are able to exchange and share data because it is difficult and expensive to connect several systems. Over the past decade HIEs have increased their financial stability to some degree as illustrated by Helen Gregg, studies done by the eHealth Initiative in 2013, revealed that from a total of 52 organizations, as many as 49 are still dependent on grants if even partially. There are 17 of the 49 organizations that are expecting funding from public sources including the federal government, to continue bearing the burden for the significant portion of their income. Hospitals and other stakeholders knows it is good sense to have access to patient information in order to coordinate optimal care but in the same breath they are weary of competitors using their data to take away their business. In order for health reforms to be successful, it is necessary to exchange data, and customers are also demanding to have access to their data. Which makes this time the perfect opportunity for HIE to demonstrate its abilities, but instead HIE is being handicapped by competiveness.
2a. How is Health Information Currently Exchanged? Health information is transmitted similarly to sending an email over the internet, the data being sent is encrypted to ensure security, and to guarantee the reliability of the data. Presently, there are three ways to exchange health information securely and maintain reliability. According to Williams, C., Mostashari, F., Mertz, K,. Hogin E., & Atwal, P. (2012), there is the directed exchange, which allows health information to be securely sent and received electronically, in an effort to support coordinated care among providers. There is the query-based exchange, generally used in unplanned care, such as emergency room situations. Finally, there is the consumer medicated exchange, which is a portal that allows patients to manage their health information, in a way similar to managing finances via online banking. (Williams, C., et al, 2012)
2b. Privacy & Security Concerns. There are concerns from participants about the privacy of the information being exchanged, and how are sensitive information being exchanged securely. Privacy and security concerns among participants include but are not limited to, unintentionally revealing patient information, particularly information deemed as sensitive, such as mental health or substance abuse treatment details. Secondly, many information centers are not confident about the separation of data, hence, when data being exchanged have areas with sensitive data, the separating of data is necessary. Lastly, Sifting through a mixture of privacy laws for various states - the state and federal laws are very inconsistent, and this poses a continuous challenge for members who serve patients in multiple states (McGee, Marianne K. 2013).
2c. Implementation of the System. Hook, Julie M., Snow, John., Grant, Erin., Hamilton, Booz A., Samarth, Anita., ASTECH Consulting. (2010), illustrates that the implementation of HIE tends to be challenging, specifically as it relates to Health Information Technology Systems. The success or failure of a HIE system rest heavily on the level of involvement from the IT staff and the selection of vendors, and service providers. As cited earlier, challenges of HIE were the technological difficulties, providers prioritization of data and vendors creating strive between current and potential stakeholders. These challenges could have been mitigated with the hiring of a project manager to organize and implement the input of the various stakeholders. Therefore, it is recommended to acquire the expertise of a high-level project manager to work in tandem with the necessary clinical inputs, which will provide necessary support to the organizations and their stakeholders during the planning and implementation of a HIE system.
3. Benefits of HIE. Various studies have shown that HIE can improve healthcare services, in areas such as chronic care management, medication safety, and complying with treatment rules. HIE also allows hospital workflow to be more efficient and reduces the overall cost of medical care by utilizing health information technologies. HIE technologies such as electronic prescribing, electronic health records (EHRs), clinical decision support, computerized provider order entry, and telehealth, along with other technologies for improving the overall efficiency, cost, and quality of the health care system (Hook, Julie M., et al, 2010).
3a. Underlying Justification of HIE. HIE is beneficial to the entire healthcare system, however, being able to transmit information between various organizations seems to be of greater importance and necessity for providers that care for underserved populations. Patients in these underserved populations tend to be temporary, hence, they will seek care from a variety of organizations, such as a county health department or an emergency division. Hook, Julie M., et al, 2010 believes HIE offers considerable benefits to patients seeking care from providers because the use of decision support and disease registries allow providers to effectively manage patient care between multiple treatment locations, as well as institutionalized patients, such as persons in nursing homes or prisoners.
4. Role of Networks. Networks ensure the continuity of optimal healthcare as it allows providers to really focus on the welfare of patients by removing waste and duplication from the healthcare system. It enables the connection and coordination of healthcare providers and patients because working together will make it easier to navigate necessary data that makes healthcare more efficient and more effective. Also a shared healthcare plan will allow organizations to advance to a state that enables them to administer evidence-based, comprehensive care in everyday medical environments.
4.a. How Multiple User Needs for Data and Data Exchange are met? When providers have the information they need at their fingertips, they are able to make better-informed decisions to treat and engage their patients. Patel Sandeep. From The New Mexico Department of Health says, an availability of patients information fosters better medical decisions and risk analysis, which helps improve patient treatment. The use of patient portals gives the patient the ability to be engaged in the diagnosis and treatment of their ailment, and this gives a sense of being a part the decision making of the care received. Networks also provides medical organizations the tools to conduct transactions, and saves time by reducing the time spent in searching for patient records. Therefore, healthcare professionals are able to make more informed decisions to engage and treat patients when they have the required information at their immediate disposal.
5. Privacy and Security. There is much value in HIE when healthcare professionals have access to necessary information when it is needed. Therefore it is of great importance to maintain public trust when it comes to the exchanging of data electronically. There is no guarantee of 100% privacy and security when exchanging health information, not even if paper medical files were being used. However, the information available through HIEs should not entertain undue risk, but should increase value to the stakeholders. Therefore, the approaches in technical and policy guidelines must be completed in a way that protects patient privacy and improves health care safety and quality.
5a. How Are Privacy & Security Concerns Addressed? McGee, Marianne K. 2013 states that, unintentionally revealing patient information, particularly sensitive data when a non-targeted query is made – Many HIE make it a policy not to provide access to data with sensitive information, such as mental records. Also, many information centers are not confident about the separation of data – Instead of trying to separate sensitive information in HIE, very frequently the data is excluded, as in the case of Rochester exchange, which does not allow substance abuse centers to send information. Another concern is the differences in state privacy requirements are ‘stumbling blocks’ - differing laws in states regarding permission for health data exchange would be simplified if there was a nationwide standard. HIE is working to address this matter.
5b. What Kinds of Restrictions are set in Place? Patients can restrict access to their personal health information by choosing not to participate in a HIE. People who choose to opt out of sharing their personal health information prevents ER doctors from receiving vital information that could assist in administering better care or even save a life (Patrick Ouellette, 2013). There are also patients who places restrictions on the amount and kind of data that is shared, thereby granting limited access to information, this causes healthcare professionals will lose trust in the information they are receiving causing them to refer to paper records, thereby wasting time to search and make verifications. Each state has its own privacy and security laws, hence the option to allow access to personal health information is available for patients to utilize (Patrick Ouellette, 2013).
5c. Who Has Access to What and When? Doctors and their associated staff, who they have given permission are able to access patients’ personal information. Individuals can also request an account of their medical records of up to six years prior to the request. This can provide an overview of a patient’s medical status for the next doctor you visit. HIE also shares information anonymously to registries for public health reporting such as immunization registries and disease registries.
The HIE is an important infrastructure tool in building the optimal healthcare system. Even though many years have passed since its establishment, there is much still to be done. The advancement of the healthcare system is possible if the recurrent challenges are dealt with. From the inception of HIE the same challenges have existed, despite numerous efforts to amend the problems of implementing affordable, easily managed IT system, competitiveness among providers among others. If the regulations and policies are amended to allow the exchange of information to be more easily accessible. While instilling public trust of the safety of their information, and receiving guaranteed funding from various public and government bodies. A well as amending the system to be self-sustaining within a given time period, then the HIE will become the ultimate infrastructure to achieving the optimal healthcare system.
Gregg, Helen. (2013). The 3 Biggest HIE Challenges. Becker's Healthcare. Retrieved from http://www.beckershospitalreview.com/healthcare-information-technology/the-3-biggest- hie-challenges.html
Health information exchange. (n.d.). In Health Information Exchange Directory. Retrieved from. http://www.healthcareitnews.com/directory/health-information-exchange-hie
Hook, Julie M., Snow, John., Grant, Erin., Hamilton, Booz A., Samarth, Anita., ASTECH Consulting. (2010). Health Information Technology and Health Information Exchange Implementation in Rural and Underserved Areas: Findings from the AHRQ Health IT Portfolio. AHRQ Publication, 10-0047-EF. Retrieved from http://www.himss.org/files/HIMSSorg/content/files/AHRQHITHealthInforural%5B1%5 D.pdf
McGee, Marianne K. (2013). HIE Leaders Share Privacy Concerns, Dealing with State Laws, Omnibus Rule. Information Security Media Group, Corp. Retrieved from http://www.govinfosecurity.com/hie-leaders-share-privacy-concerns-a-5860
Ouellette, Patrick. (2013). How patient privacy restrictions may affect HIEs. Xtelligent Media, LLC. Retrieved from http://healthitsecurity.com/2013/05/08/how-patient-privacy- restrictions-may-affect-hies/
Patel Sandeep. (n.d.). Collaborative Care. New Mexico Department of Health. Orian Health Care. Retrieved from http://www.orionhealth.com/health-information-exchange
Vest, Joshua R., Gamm, Larry D., J. Am. Med. Inform. Assoc. (2010). Health information exchange: persistent challenges and new strategies. A scholarly journal of informatics in health and biomedicine, 17: 288-294. doi: 10.1136/jamia.2010.003673. Retrieved from http://jamia.bmj.com/content/17/3/288.full.pdf+html
Williams, C., Mostashari, F., Mertz, K,. Hogin E., & Atwal, P. (2012). The Strategy for Advancing the Exchange of Health Information. Health Affairs, From the Office of the National Coordinator, 31, no.3:527-536. Retrieved from http://www.healthit.gov/providers-professionals/health-information-exchange/what-hie