This is the first in a 4-part series on the HIPAA implications of Health Information Exchange (HIE). We will present a framework for understanding the different kinds of HIE in the first 3 of the series: (1) the community chart-sharing approach; (2) the point-to-point connection approach; and (3) the library-style approach. In the 4th article of the series, we will try to present an framework for HIPAA that can address all 3 HIE styles, and at the same time “keep it simple” to the patient end-user.
Community-based chart sharing
A widely-used web-based Electronic Health Record (EHR) system, like Practice Fusion, holds the potential of health information exchange that is quite different than the traditional thinking of how health data can be shared between a referring doc A and a recipient doc B.
If both physicians are using the same web platform – even though they only experience the system as if it were local to their practice – they actually are connected to each other (though they may not realize it). Within a practice, of course, all patient charts of that practice (and only the charts of that practice) are shared amongst member clinicians, nurses and staff (with role-based access) – this is how Practice Fusion is organized, an is also how traditional paper chart access is organized.
Now, if a patient is to be referred from a given practice (doc A) to a recipient practice (doc B) – a referral from a primary care practice to a cardiologist, for example – then it is technically possible for the patient’s record to be flagged in such a way that it is visible in both doc’s practices (assuming they are both on the Practice Fusion platform). The whole chart (or, in a more sophisticated scenario, specific identified elements of the chart) is now shared between two distinct and unrelated practices – the recipient doc B can see all the thinking, medications, lab tests, reasons for referrals, tests and studies performed that have already been done by doc A.
The clinical value of such a referral is tremendous. No longer is the recipient of the referral (doc B) at a loss as to why the referral has been made, what the medications are, and what tests have already been ordered. Instead, the full chart is shared, as if the two docs were in the same practice together. In addition, entries to the chart made by both parties are thus visible to each other – likely accompanied by a system of messages and alerts when someone outside the practice makes an entry on a shared chart. This “closes the loop” of information exchange from an originating practice to a referral practice and back to the origination practice source.
This sort of capability is not yet “in the field” with Practice Fusion, but is on our near-term roadmap.
Community-based Chart Sharing works when both doc A and doc B are on the same platform – the Practice Fusion web-based EHR. As the adoption of Practice Fusion becomes wider (140,000 users and 23 million patients), there is significant likelihood in many communities that this will be the case.
In fact, given that Practice Fusion is free, and an account can be created with a quick self-service signup (“Live in Five”), if the recipient (doc B) is not on Practice Fusion, a message can be sent to doc B with a “stub” of a new account. When doc B accepts the “stub” and creates a full account (remember – free, self-service, quick), then doc B’s new Practice Fusion account will contain the one shared patient’s record. It does not matter whether doc B already has an EHR – the shared chart can be viewed side-by-side with whatever system might already be in place, and information can be easily cut-and-pasted back an forth at the local doc B’s desktop. If doc B is still on paper, then they have just been given a free EHR for them to use, if they wish.
Since Community-based Chart Sharing does not involve packaging up any data into standard-format records (summary records like CCRs and CCDs, or full-record documents like CDAs), and transporting those records safely across the Internet to some recipient (who must be able to interpret them), it is intrinsically safer. It is technically a matter of setting up a system of permissions to view records, and everything stays within the same web server. No external data is sent out.
An analogy with email might help underscore this point. Let’s say that both doc A and doc B have free web-based email accounts (like Yahoo mail). Let’s say that Yahoo created a feature that allowed doc A to tag a specific email (a patient’s record) so that it becomes visibile in doc B’s Yahoo mail account. Doc B, in addition to all his own emails, will also be able to see doc A’s record (the specific email to be shared). Of course it needs to be flagged or decorated so that it is clear that it is a shared mail item. Both doc A and doc B see the same record. An no email has left the Yahoo server – it is all contained within the system.
Now, if doc B also has an Exchange Server account at his local hospital, and uses Outlook to view those emails, that would be fine – the Yahoo web mail can be opened side-by-side and data can be cut-and-pasted between the two, if desired. The cutting-and-pasting happens on doc B’s local computer, and therefore no data is exchanged across the Internet in order to achieve that goal.
Sending an email (in this analogy) from doc B’s Yahoo mail account to the Exchange Server Outlook account might also be done, but this involves packaging up the message and sending it outside the Yahoo server to the Exchange Server across the Internet. This kind of data exchange is “point-to-point” data exchange, which will be covered in the second part of this series.
A new paradigm
Health information exchange via Community Chart Sharing is a new paradigm. It has not been something that has been considered in HIE policy discussions heretofore, mainly because there has not yet been a widely-held web-based EHR system connecting such large numbers of docs before.
Even within certain large enterprises (e.g. Kaiser), chart visibility can be created to accomplish something similar, but essentially all the patients are in the same “practice” – like if a very large practice used Practice Fusion and enrolled thousands of physicians in it, with millions of patients in that practice. All the patients would be visible to all, in that scenario.
Chart Sharing is a little different – it involves separate practices (not all in the same enterprise) sending a specific patient chart to be shared with another outside practice, and only the shared chart is visible to both. It also involves the potential for quick enrollment on the free web platform (like having a recipient open a free Yahoo mail account, even if they have an Outlook Exchange Server account).
This is the first method of Health Information Exchange models we will review. In the following segments of this series, we will review “point-to-point” data exchange, and “library-style” data exchange. We will pull it all together in the last installment of the series and address how HIPAA can address each of these information-sharing scenarios in a unified way.