The impact of web-based EHRs on HIEs
One of the central features in the emerging national policy around Health Information Technology (HIT) is the need to connect everyone together in a way that is both seamless but also secure and private.
Traditional paper-based medical offices basically have their records walled-off in a silo (a paper database), so that the overall health information on any given patient is fragmented across many different locations. Medical data is scattered into a large number of places – each one with an incomplete story, and with possible discrepancies and needless duplications inherent in that status.
When the early Electronic Medical Records (EMR) systems first started coming onto the market over the past 10 or more years, their initial scope was mainly to replace a doctor’s paper record system with it electronic equivalent. Great strides forward were made by doing this – legibility, finding “missing” charts, etc. – but the overall distribution of health data across the landscape did not change much.
Tying those databases together has been the next big challenge. Mainly, the kinds of connections that have become relatively mature are lab-test reporting from large regional and national reference labs (like Quest and LabCorp), so that these results could be dropped into doctor’s EMR systems. However, that is not sufficient in order for a longitudinal unified patient record (an Electronic Health Record – an EHR) to emerge.
As physicians begin adopting EHR systems in increasing numbers, the challenges of connecting everybody-to-everybody becomes significant. It is not practical to think that point-to-point connection between every doctor’s office, every hospital, every lab, and every data registry is feasible – especially not for the small practice with little-or-no margin for HIT.
The need for HIEs
The response to this challenge has been the concept of a Health Information Exchange (HIE), which acts as a local hub – similar to billing clearinghouses that transmit billing inputs from a myriad local offices (or their billers) to a large collection of insurers. The notion at the national policy level has been that HIEs will develop locally and regionally – some state governments have tried funding statewide HIEs, and some insurance companies have created their own HIEs as well – and that these HIEs will then connect together into a Nationwide Health Information Network (NHIN). In order to succeed, a number of issues need to be resolved: (1) all the HIEs need to use a truly standard method of data exchange, without the need for any customizations each time, and must be the same standards that all EHRs, hospitals, labs and registries use; (2) HIEs need to find a workable business model to remain in business, after federal seed-money grants run out.
In the past couple of years, a new technology has entered into the EHR market, which challenges many of the assumptions made around the role of HIEs: web-based EHRs. Why is this technology such a challenge? Let’s take a look at the landscape, and consider the health care delivery system as a sort of pyramid.
The delivery pyramid
At the top of this pyramid are the large hospitals, university systems and integrated delivery networks (e.g. Kaiser). Such networks have invested in HIT over the years, and have created systems that work in a cohesive manner within their walls. Epic and Cerner are dominant players at this level. As an example, Kaiser spent billions modifying and implementing an Epic-based system, and it works well across the entire Integrated Delivery Network (IDN) without needing an HIE. However, external access to their data is more problematic and difficult (and still often relies on paper – a fax).
In many parts of the country, these large hospital-based systems are buying up local community doctors’ practices like crazy, eliminating much of the HIE issue by simply absorbing such practices into their own installation of a universal EHR. Will everyone eventually use Epic? Probably not, but their distribution into the community often follows this top-down pattern.
The middle tier of the delivery pyramid are the moderate-size practices, often single-specialty or multi-specialty groups. They may have 20-100 docs and multiple sites, and are major inputs to the local hospitals they serve. Vendors such as NextGen, Allscripts and GE/Centricity are big players in this tier. Given that their EHR is external to the hospital, connectivity with local hospitals (often multiple ones, each with different systems) is important. This is the main need which HIEs are designed to fix.
The base of the delivery pyramid are the small community practices, often Primary Care Physician (PCP) practices. Two-thirds of office-based physicians still practice in groups of 3 physicians or less. Connecting all these “myriad small practices” into HIEs has been the point-of-overwhelm for those conceptualizing HIEs. It is in this strata, however, that the lowest EHR adoption has traditionally taken place (obvious reasons), so the way in which these practices make the leap to EHRs has often been speculative, based on a projection of how the larger groups have done so.
What has changed in this picture is that the “base of the pyramid” has been adopting EHRs via web-based solutions in droves – not as locally-installed systems needing robust HIEs to connect to others. With a web-based system, these practices are already connected – one does not need to re-invent the Internet to connect them!
The impact of the web on HIEs
Let us visualize a scenario, for the sake of argument. Let’s say that the entire “base of the pyramid” adopts a single web-based EHR (not all that outlandish, actually, given that Practice Fusion has grown to over 70,000 users and 7,000,000 patient records, and continues to add around 200 new users every single day). What does this mean?
Firstly, not unlike the Integrated Delivery Network (e.g. Kaiser) that is able to share data within its system without needing an HIE, the web-based EHR has the capability to share health records between other users of the same system without the need to invoke an HIE.
This changes the role of the HIE considerably. No longer is it needing to connect each-and-every separate, disconnected small practice (an overwhelming task) – instead, its much-reduced burden is to connect (1) the regional IDNs, (2) large group practices using their own local systems, and (3) the web-based EHR (and therefore all the networked small practices, in one fell swoop).
The emergence of web-based EHR technology challenges much of the traditional thinking that is going into HIE discussions at the national policy level. Small practices, by virtue of adopting web-based EHR technology in droves, are already connected – and, in fact, are as connected as IDNs are. HIEs, therefore, are no longer needing to shoulder a vast array of point-to-point connections – instead, their role is to connect networks that are already in place. HIEs don’t have to re-invent the Internet. Their role is actually much simpler, and much reduced.
Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR