How HIEs are Evolving in 2012

Looking at how the state of health IT connectivity is evolving, some interesting wrinkles in “the plan” are emerging.

The original vision put forward by the Office of the National Coordinator for health IT (ONC) and the Nationwide Health Information Network was that there would be the creation of a series of regional or state Health Information Exchange (HIE) hubs, and (eventually) that these HIEs would all be linked together, once the standards were worked out.

Significant seed money was granted by the ONC, as part of the 2009 ARRA’s HITECH provision, to help local organizations create these envisioned regional HIE hubs. And the build-out of such technology is something that is now at different stages of development in various states. Once the initial grant money runs out, however, it is unclear how these HIEs, as stand-alone businesses, will continue to be financially viable.

The idea has been that these HIEs would knit different ambulatory practices together, giving physicians using disparate Electronic Health Records systems a common place to exchange clinical data with each other – at first, it would simply be the summary data (problem lists, medication lists, allergies, immunizations, and lab results) that could be encoded in standard-format transport files (CCDs or CCRs). More robust full-document exchange of complete chart notes, imaging files, etc., would come later.

Besides connecting community docs together, these HIEs were also to be places where different large institutions could connect – hospitals and academic centers could exchange information with each other. More importantly, these HIEs were places where community doctors could connect with their local hospital(s), as well as with clinical laboratories.

Such a vision stems from a historically hospital- and academic medical center-centric view. Creating a hub is a natural approach that a hospital or academic center, seeing multiple EHRs used by docs in the community, would want to employ in order to set up connections. Creating regional HIEs that would be independent of local hospitals, but would serve to connect hospitals to community docs, and to connect community docs to each other, is an understandable architecture based on this way of thinking.

How it has been playing out
Has this been the way that actual experience in-the-field has emerged? Well… not exactly. What has emerged instead has been the co-evolution of 3 different ways of connecting, each coming from different perspectives.

The traditional “hub-based strategy” has been pursued both by state-level HIEs and by hospitals directly. Those hospitals with sufficient modern health IT capability have created hubs centered around themselves, for local community docs to connect with. We have seen examples of this emerging in many locations.

This kind of approach has lagged in adoption/subscription. Why? One reason is the integration costs, borne largely by community practices wishing to connect with the hospital hub, which can be in the thousands of dollars for each connection. A given practice – especially a subspecialty practice – may work an a variety of local hospitals, and spending that kind of money and effort to connect with each and every hospital’s local hub (if they have one) is simply not feasible or affordable. The approach is not scalable.

The question arises, then, as to how these now-emerging hospital-based local connectivity hubs will relate to the separate statewide HIEs as envisioned by the ONC. Will the hubs connect to the HIEs, in a daisy-chained fashion? Will the state HIEs become aggregators of local hospital hubs? That issue has yet to be resolved, and little experience exists in this arena to date.

Other approaches to connectivity
Apart from the hub-based approach to connectivity – institution-centered as it is – other ways of connecting docs to each other have emerged. They tend to fall into two different categories: (1) direct point-to-point connection, and (2) extending the platform (possible with new web-based EHR technology).

The point-to-point way of data exchange is mainly embodied by the Direct Project. The advantage of this approach is that a broader array of data can be sent, in ways similar to (but more secure than) traditional faxing. Whereas summary data may be sufficient for hospital-based health data exchange (which is what is allowed currently in the HIE/hub approach), for real clinical exchange between docs in the community – the things needed when referring a patient from one doctor to another – much more complete data is generally needed: full chart notes, lab tests, imaging reports, in addition to the summary data (problem lists, medications, allergies, etc.). Such full-document data sharing is possible via Direct Project methods – something clinicians have come to expect via traditional faxing.

Direct Project tools are starting to get implemented in various locations around the country, and may well emerge as a more useful way to get data between ambulatory clinicians, rather than the institution-centric HIE/hub approach.

The other approach to clinical data sharing between clinicians is web-based Chart Share – still an emerging technology. Conceptually, a clinical chart can be earmarked to be shared with a referral-recipient clinician. If that recipient already is on the same widely-held web-based EHR platform, then that chart – the full chart, with chart notes, and all the data needed for a good clinical referral – is visible to both practices. If the recipient is not on that EHR platform, a new account can be created quickly (in a few minutes) and for free (if using a free web-based EHR platform), and the shared chart can be viewed that way. It does not matter what system the recipient physician has (if any) – the shared chart can be viewed side-by-side with anything else.

We have even piloted the “extending the platform” approach to sharing an ambulatory chart with a hospital – for instance, entering pre-operative notes for a scheduled elective surgical procedure from the office, and then retrieving those records from within the hospital. Though Chart Share is envisioned as being mostly used to connect ambulatory docs to each other outside the hospital, the use of such an approach to bridge the gap with the hospital is an interesting new wrinkle in the evolution of clinical data exchange.

Conclusions
The national vision of health data exchange, mediated by regional or statewide HIE hubs, continues to be a central approach. This, however, may end up being mainly utilized as a method of data exchange between hospitals, academic centers and other large institutions with local enterprise EHR technology. Local hospitals are setting up their own hospital-centered HIE hubs, resulting in many small single-hospital hubs existing in a community. These are emerging faster than the regional HIEs are, and the question of how to relate the current hospital-centered HIEs to the envisioned hospital-independent statewide HIEs has yet to be worked out.

But such a hub-strategy may turn out to be mostly an institutional play. Small community docs may end up using other quicker and less expensive methods of getting their patient’s data to each other when needed for medical treatment – Direct Project tools will play an important part here, as will the “share the platform” approach of web-based EHR technology (which had not yet emerged as an important method of EHR adoption among smaller practices at the time when the national strategy was being thought out).

2012 will be a time when much of this activity will mature. Hospital-centered local hubs and the regional and statewide HIEs will need to work out their connectivities. Direct Project tools will need to be made widely and cheaply available to docs in their offices. And Chart Share via web-based EHRs will emerge as an important feature of these newer technologies. It will be an interesting year indeed.