Ken Willett

Healthcare IT, integration, and making patient care better

A Reality Check on HIEs

With news that a number of public HIEs are struggling or have already terminated services, it seems time to look closely at the HIE landscape and see if we are really on the right path. If the goal is to have a place where all the relevant data about a patient can be accessed for the patient’s care, by all providers involved with that care as well as by the patient, it doesn’t seem that we are making significant progress.

The private HIE market, i.e. HIEs owned and operated by health systems to meet their own needs, is seeing robust growth. Large health systems have a variety of internal interoperability challenges, as well as a need to provide specific types of information to providers in their community, such as lab results. But these private HIEs rarely incorporate patient data created outside the health system. Connecting ambulatory EHRs to the HIE remains a slow, expensive process, and neither the practice nor the health system have been able to build the business case for doing this.

State and regional HIEs have used their stimulus funding to try a variety of architectures. The one that seems to have the most traction is based on NwHIN Direct, which allows a provider to send patient information securely to another provider. There are currently significant policy challenges in allowing Direct communication across HIE boundaries, because each HIE has its own strict rules on participation. These Direct-based HIEs generally provide a web portal for sending and receiving messages, but don’t provide integration into each provider’s EHR. As a basic email-like messaging system Direct is useful, but it doesn’t address the need to provide an overall view of the patient’s health or allow later access to existing data.

State and regional HIEs that were intended to provide a database or repository of patient data for query access have run into a number of significant barriers: cost, complexity, consent requirements and access control policies to name a few. These are the HIEs that are currently struggling the most, because large entities that might fund the operation of the HIEs (insurance companies, health systems, or the states themselves) haven’t seen the value.

Even if these HIEs were sustainable, the barriers imposed by regional and state boundaries will inhibit creating a consistent view for many patients who seek care in different states.

Health Information Exchange is enormously complex and we shouldn’t expect to see results immediately. But it is critical to assure that we are moving in the right direction or we’ll never get there. I believe some critical elements of a successful approach are:

– A data architecture organized around the patient, not around existing political and business boundaries.

– A radically simpler and more lightweight data model than currently defined by HL7 and IHE standards.

– An open architecture and business model that allows vendors, provider organizations, consultants, and government entities to build and deploy connections to the data with minimal legal and financial barriers. Cloud-based technology seems like a natural fit for this but most of the challenges are not technical.

We have learned a lot in the past few years as HIEs have been started across the country, and the stimulus funding has allowed rapid progress in a number of areas. Now we need to assure that we are moving in the right direction.

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