5 Pillars of a Successful HIE
by Debra Gordon
In April, five of the country’s largest health systems announced they were creating their own health information exchange (HIE).
That action on the part of Geisinger Health System in Pennsylvania, Kaiser Permanente in California, the Mayo Clinic in Minnesota, Intermountain Healthcare in Utah, and Group Health Cooperative in Washington state-coupled with the release last year of $547 million in federal grants for state HIEs-may finally be enough to push the promise of the HIE into reality. The question is, will the reality be sustainable? And furthermore, what separates a successful HIE from a failed one?
To find out, we turned to several experts in the field and canvassed recent research on existing HIEs to identify the pillars needed to support the structure.
Here's what we found.
Pillar 1: Physician Involvement
An HIE without strong physician buy-in is like surgery without anesthesia: a disaster. To get physician buy-in, you have to involve doctors early in the planning process and identify and nurture physician champions, who make it easier to get buy-in from other clinicians, according to our experts. Too often, says Greg Miller, senior vice president of Medicity, the nation's largest HIE provider, HIEs-particularly publicly funded ones-have a build-it-and-they-will-come philosophy, meaning they don't even start marketing to physicians until after the system exists, a plan doomed to fail.
"The HIE only gains value with the greatest number of healthcare entities participating," says Thomas M. Deas Jr., MD, chief medical officer for HIE vendor Sandlot, LLC, and a gastroenterologist with North Texas Specialty Physicians in the Dallas/Fort Worth area, which started Sandlot. "But getting to that critical mass can be challenging. It requires the cooperation of multiple stakeholders in a community," he said. And that, of course, runs into issues around politics, finances, and egos.
"We do 2,000 hand audits a year. With our paper charts, that's 20 minutes per chart. Do the math."
Thomas M. Deas Jr., MD, chief medical officer for HIE vendor Sandlot, LLC
Physicians are motivated by both external and internal factors to join HIEs. External motivators include legal requirements to join the networks, Medicare's e-prescribing incentive, and other pay-for-performance incentives. Internal motivators include anticipated cost savings resulting from increased efficiencies in workflow and improved patient care. As one quality manager for a physician office said when asked why she wanted to join an HIE, "We do 2,000 hand audits a year. With our paper charts, that's 20 minutes per chart. Do the math."
What separates a successful health information exchange from a failed one?
Pillar 2: Focus on Patients
Dr. Deas relates a case involving a patient with primary biliary cirrhosis and concurrent alcohol abuse. The 64-year-old woman presented with jaundice and confusion consistent with mild hepatic encephalopathy and was too confused to provide an accurate medical history. Through the HIE, the doctor accessed data from the patient's visits to the emergency department, including her diagnostic studies, medication listing, allergy information, and diagnoses during the previous year. The information helped keep her out of the hospital and avoided redundant tests, resulting in total savings of $15,000. That kind of situation will become more important as shifts in health care require greater accountability for costs from doctors.
Vermont Information Technology Leaders (VITL), a nonprofit, statewide HIE, hosts a "connect-a-thon" each year in which they invite providers from around the state to interact with electronic medical record (EMR) vendors and get personalized demonstrations of VITL's HIE. "We want to build excitement in the community and trust that the system runs, is secure, keeps patient information protected, and that we're following all security and privacy rules," explains Chuck Podesta, chief information officer at Fletcher Allen Health Care in Burlington, Vermont, and a board member of VITL. Members of VITL also visit practices throughout the state to demonstrate its value. Perhaps most beneficial, however, was recent legislation mandating that the state's hospitals connect to the system by a certain date. "You'll see more of that with other states," Podesta predicts.
Shifts in health care require greater accountability for costs from doctors.
Pillar 3: Clearly Define Goals and Objectives
"This sounds fairly obvious," says Miller, but because most organizations are new to HIEs, "they don't know what they don't know." Hence, there is a tendency to jump in with both feet and try to be all things to all people.
HIEs that fail, says Brett Furst, vice president with HIE vendor Covisint, do so because their stakeholders don't understand the value proposition. The ones that succeed build their systems from the front end based on expected outcomes. For instance, they might implement the system with the goal of improving diabetes care in a population rather than the goal of simply connecting everyone to everything. Focusing development in this way helps organizations understand which data needs to be shared, who should participate, what type of systems are needed, and what type of information should be presented, he says.
That approach also fits with Miller's favorite saying in the HIE world: "Crawl, then walk, then run." Or: "Trying to boil the ocean and employ all the technology at once is a recipe for disaster." He compares building an HIE to building with Lego: "Deploy the foundation platform and then build upon the foundation with incremental capabilities over time, not all at once."
For instance, VITL began in 2006 with a small pilot program designed to provide electronic medication histories for all patients entering the emergency department within seconds of their arrival. They chose the project based on feedback from physicians and nurses throughout the state. The project was simple; it took only three keystrokes to access the information. It was also popular with patients, with more than 90 percent opting in. As patients were admitted to the hospital, inpatient physicians asked to be able to get information from the HIE, and then outpatient physicians became interested.
For successful HIE implementation, a compelling vision needs to be balanced by reasonable expectations and the ability to deliver a demonstrable benefit to providers.
Not consulting physicians before the system exists is a plan doomed to fail.
Pillar 4: Choose the Right Technology
Any HIE is only as good as the technology underpinning it, says Podesta. "You need to select the right vendor for the model you're trying to create," he stresses. For instance, Fletcher Allen's HIE uses a federated approach, in which data is captured and pushed out to providers, rather than the non-federated approach, in which the data flow goes the other way. Other HIEs opt for a hybrid model.
And HIE must also meet doctors where they are on the technology curve, says Miller, rather than expecting them to jump into an HIE at full operability. That means designing systems to connect with the physician with an established EMR who tossed the fax machine years ago, as well as the physician who wishes his office didn't even have a computer.
Also important is designing a seamless connection between physician EMRs and HIEs. "If a physician must get out of his or her EMR and go to another portal to access the information, the physician will say, 'no way,'" Miller says, because of the time and money involved. Conversely, if physicians haven't adopted an EMR and must access the HIE via a browser, he says, the interface has to "mirror the workflow in the office. It's all about workflow and saving time and money."
That same workflow analysis should occur when implementing HIEs between hospitals. For instance, when MaineHealth, Maine Medical Center, and other healthcare providers developed an HIE to allow institutions to share radiology films, they found significant differences in workflow between rural and urban hospitals.
Oleg Bess, MD, an obstetrician/gynecologist practicing in Culver City, California, and chief executive officer of the EMR company 4medica, is affiliated with several HIEs. He agrees on the importance of seamlessness. In his system, laboratory test results are automatically deposited in the patient's EMR, with a reminder sent to review the results. On the hospital side, patient charts can be accessed from the office or online for patients who are hospitalized, while physicians can access the patient's office-based EMR from the hospital. The integration of the EMR and HIE has changed how he practices. "It gives me a much fuller view of the patient. I don't have to search for lab results or match current ones against older ones; the system alerts me to changes," he says.
Still, Dr. Bess sees room for improvement. He'd like to see more linkages between patient parameters, clinical guidelines, and alerts; more connectivity to other physicians in the community; and synchronization of patient charts across all platforms.
Meet doctors where they are on the technology curve.
Pillar 5: Plan for Sustainability
Without question, the sustainability of HIEs remains a major challenge. A 2009 survey of 131 HIEs found that just 55 (42 percent) were actively exchanging data (although only a few were exchanging comprehensive patient data), and 34 (20 percent) either had already or were in the process of shutting down. Of those with at least 5,000 patients, just 41 percent of operational HIEs were covering their operating costs with membership revenue.
"While you can get money up front in terms of grants, at some point that money will run out," notes Podesta. "So you have to provide value in a sustainable model so that the providers, whether a single physician practice or a hospital, see value in exchanging that information." For instance, some organizations are leveraging information in the HIEs to improve physician compensation at local, state, and national levels.
A 2008 analysis of 81 regional health information organizations (RHIO) involving at least 5,000 patients conducted identified several characteristics that seemed to increase the likelihood an RHIO would be sustainable:
- More participants had been engaged in the planning.
- The focus was on a narrow set of data.
- Participants were willing to support the HIE before it became operational.
- Participants included ambulatory physician practices.
- Return on investment was demonstrated.
Of course, being able to show a return on investment is one way to ensure sustainability. Medicity's analysis of an integrated health system in the Midwest found that connectivity between the hospitals and 11 physician clinics evaluated would save an estimated $1.2 million a year, with an average savings of more than $134,000 a year for practices with an EMR and $44,000 for those without an EMR.
A sustainable HIE demonstrates return on investment.
Four hospitals in the group interviewed estimated annual savings/revenue improvement between $20,000 (for small institutions) and $393,613 (for large institutions) in enhanced workflow and reduced courier costs. They also reported increased physician referrals and laboratory revenues, as well as improved clinical decision-making and patient care.
Meanwhile, an analysis of 114 community-based HIEs found that HIEs have the potential to reduce uncompensated care provided in the emergency department (ED) by up to $500,000 for every 20,000 visits, patient time in the ED by 26 percent, and the cost of tests by a third.
The bottom line, says Furst, is that participants in the HIE must know why they are in the game or they simply aren't going to play.
