In a nation of 300 million residents over 3.5 million square miles, there are 193 HIEs in various stages of development, according to eHealth Initiative, a Washington-based industry advocacy organization. By self-attestation, 57 of the HIEs are operational. Most HIEs don't have a sustainable business model, and getting a critical mass of regional stakeholders to cooperate in exchanging their data remains an extremely difficult proposition.
There are other reasons that many observers say HIEs should not be relied on as an anchor of an eventual national health information network, the vast, interconnected system ballyhooed by the federal government. Some argue that a network tantamount in scope - namely, the network of claims clearinghouses - already exists and also could handle clinical transactions. Or, mandated use of data standards and the Continuity of Care Document, a standardized summary of care, coupled with a now-mature Internet infrastructure, could do most of the work that HIEs are supposed to do. In one state where several HIEs are developing, the government is helping fund tests of an alternative model, called health records banks.
On the flip side, fueled by several years of momentum, and recently $300 million in funding via the American Recovery and Reinvestment Act - plus matching state funds - the number of HIEs is growing. One hundred and fifty HIEs responded to eHealth Initiative's survey this year, up from 130 in 2008. The organization then confirmed that 43 HIEs that responded to the 2008 survey but not this year's were still functioning for a total of 193. The 57 reported operational HIEs this year that are actually delivering test results, care summaries and other information was a 36% increase from 2008, which was 31% higher than 2007. And in 2009, 67 HIEs responded to the survey for the first time, compared with 18 a year earlier.
Further, a wide range of HIE models have emerged to meet local needs, and there are several established and proven models to copy. HIEs exchanging laboratory and radiology reports, and outpatient and emergency episodic data, increased significantly in the past year, according to the survey. And hospitals increasingly are realizing that better communication with physicians is good health care and good business, and HIEs can help them link with physicians.
So, does reliance on HIEs to form the network-of-networks mean a national health information network is doomed to fail? Or, are HIEs progressing at good speed and proving to be the model that will work? The Obama Administration, embroiled in deliberations to develop rules that will govern its national health I.T. strategy under ARRA, did not respond to requests to interview Chief Technology Officer Aneesh Chopra and David Blumenthal, M.D., the National Coordinator for Health Information Technology. For others, let the debate begin.
Lay of the Land
Consultant Michael Mytych is a wary proponent of HIEs. "I believe the HIEs can play a very important role, but if they're not set up and are not properly funded, we'll be in big trouble," says the principal of Health Information Consulting LLC, Menomonee Falls, Wis.
Mytych calls the data exchange work already being done in regions across the nation "the Wild Wild West of HIE." The different initiatives are trying to do the same thing, only in a hundred different ways. Asked if HIEs are the right or wrong road to a national network, he adds, "We'd better come to a conclusion pretty quickly because with 193 HIEs out there, there's a lot of money being spent."
For a national health information network to succeed, HIEs need uniformity in handling patient identity and consent, content checking, the Continuity of Care Document and a host of other issues, he contends. "Some of them aren't even paying attention to the need in their own market for EHRs to exchange data with each other."
That's a real problem because Mytych doesn't see many HIEs offering the opportunity to exchange information in discrete data elements that can be uploaded into physician EHRs. And it still is not easy to pull data out of many hospital information systems. HIEs often make laboratory results, medication lists, patient histories and other information available in view-only mode. But if physicians are using this information as part of their clinical decision making process, HIEs have to find a way to get the data into EHRs, he says.
National HIE standards - not just for moving data but for policies such as handling patient consents and behavioral health records - are needed across the board, Mytych believes. He notes that the New York City region has multiple HIEs. "What if specialists have to participate in all of them? That's a lot of coordination to do."
A federal mandate to use a standards-based, machine-readable Continuity of Care Document would be a big step toward showing the value of HIE, Mytych contends. He believes another mandate is necessary but doesn't see policymakers willing to pull the trigger to make it happen. "If the government really wants a national health information network, it would have a national patient identifier. That itself would save billions of dollars."
A Working Model
After exchanging clinical messages for a decade, the HealthBridge HIE serving the greater Cincinnati region is proof that with the right business model, a regional effort can succeed.
Some 5,600 licensed physicians are in HealthBridge's service area. In a typical month, the HIE pushes 3 million lab results, transcribed documents and notifications of admission, discharges and ER visits to more than 5,000 of the doctors, says CEO Robert Steffel. Ninety-six percent are delivered electronically via e-mail, fax or an inbox on a portal. One-third of these 3 million messages comprise discrete data elements that go directly into the EHRs of 1,300 physicians.