Describe several organizations known as Health Information Organizations (HIOs)

Describe several organizations known as Health Information Organizations (HIOs)

After viewing the presentation, viewers should be able to:

Identify the need for and benefits of health information exchange (HIE) and interoperability

List healthcare data that should be shared

Enumerate HIE challenges and barriers

Describe several organizations known as Health Information Organizations (HIOs)

Summarize the newest HIE models

Learning Objectives

Health Information Exchange (HIE) is the “electronic movement of health-related information among organizations according to nationally recognized standards”

Health Information Organization (HIO) is “an organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards”

Important Definitions

Regional Health Information Organization (RHIO) is “a health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.”

Interoperability is defined as “the ability of two or more systems or components to exchange information and to use the information that has been exchanged”. This implies that the data is computable and that standards exist that permit interoperability

Important Definitions

Foundational: refers to the technology or platform used to exchange information

Syntactic: means messages have a structure and syntax that is understandable. Uses XML and HL7 standards

Semantic: terminology and coding must be the same for the sending and receiving organizations

Interoperability Levels

Exchange (sharing) of health information is vital for healthcare reform at the local, state and national level

The next two slides will demonstrate the types of healthcare data that should be shared

If electronic health records don’t share data, then we have moved from paper siloes of information to electronic siloes; not the goal of anyone

HIE is part of the Meaningful Use program, discussed in the module on electronic health records

Introduction

Clinical results: Lab, pathology, medication , allergies, immunizations and microbiology data

Images: Actual images and radiology reports

Documents: Office notes, discharge notes and emergency room notes

Clinical summaries: Continuity of Care Documents (CCDs); XML-based documents that standardize and summarize care

Financial information: Claims data and eligibility checks

Medication data: Electronic prescriptions, formulary status, and prescription history

Healthcare Data Potentially Shared

Performance data: Quality measures like blood pressure or diabetes control, cholesterol levels, etc.

Case management: Management of the underserved and emergency room utilization

Public health data: Infectious diseases outbreak data, immunization records

Referral management: Management of referrals to specialists

Healthcare Data Potentially Shared

Note that the term RHIO is inexact because HIOs do not have to be regional; they can include only one city or an entire state

Furthermore, HIOs are being created for specific populations such as those on Medicaid or the uninsured

We will use HIO when addressing health information organizations (noun) and HIE to describe the act of moving or exchanging (verb) health information

Introduction

The US federal government had the vision of creating a nationwide sharing of healthcare information; for patients who travel, military members and to provide sharing with government agencies

NwHIN is not a specific network but instead a set of policies and standards that permit secure information sharing

We will not present the history as outlined in the textbook but summarize by saying that the NwHIN has a select number of members who exchange some information but there has been limited growth. The schema is outlined in the following slide

Nationwide Health Information Network (NwHIN)

NwHIN Schema

The reality is that HIE is expensive to create and maintain and the interest in national sharing is limited

For that reason the federal government funded a state level HIE program we will discuss later and they also created a simple secure messaging (email) service to help with Meaningful Use because many hospital and healthcare systems refused to share (more in other slides)

In 2012 NwHIN was renamed to the eHealth Exchange and became managed by HealtheWay, a government and private consortium. Later the same year, the initiative was renamed the Sequoia Project

NwHIN

eHealth Exchange: group of federal and private organizations that share data

Carequality: trust framework to connect current and future healthcare data sharing networks

RSNA Image Share Validation: tests vendor compliance for exchange of medical images

Sequoia Project Components

With the slow adoption of HIE nationwide an alternative plan had to be developed for Meaningful Use

The Direct Project involves secure messaging (email) between clinicians, patients, hospitals, etc. Consults and discharge summaries could be attached

The Project requires all parties to apply and register for a unique email. The project is administered by multiple health information service providers (HISPs) that can be almost any organization

This is simply “push technology”, see next slide

Direct Project

Direct Project Schema

Here is an example of a secure message address b.wells@direct.aclinic.org

The goal will be for EHR vendors to include this mechanism within the EHR email system and not an external email

Continuity of Care Documents (covered in the data standards chapter) will be a standard way to summarize care and attach to a secure email

Patients will email their clinicians this way

It is difficult to gauge the success of this program

Direct Project

Another avenue to allow healthcare data sharing is to allow patients to download their records and results using a recognized “blue button” (see above icon)

This approach was taken by the VA and other healthcare organizations

Blue Button Plus Project will use data standards such as the CCD so downloads can be printed or shared and assist with Meaningful Use requirements

Meaningful Use mandates data sharing so HIOs can assist (next two slides)

Blue Button Project

Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP
Provide patients the ability to view online, download, and transmit information about a hospital admission
Provide clinical summaries for patients for each office visit.
The EP or EH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary of care record for each transition of care or referral
Capability to submit electronic data to immunization registries or immunization information systems
Capability to identify and report cancer cases to a public health central cancer registry
Capability to identify and report specific cases to a specialized registry (other than a cancer registry)
HIE and Stage 2 Meaningful Use

Capability to submit electronic reportable laboratory results to public health agencies
Capability to submit electronic syndromic surveillance data to public health agencies
Record whether a patient 65 years or older has an advance directive
Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through Certified EHR Technology
Provide secure messaging
HIE and Stage 2 Meaningful Use

Read the textbook to learn more about stage 3 Meaningful Use and the Macra/MIPS program

HIE will again be an important component, but with a new administration and head of HHS it is too early to know whether this program will continue or be significantly modified

Stage 3 Meaningful Use and Beyond

HIOs have the potential to link together disparate healthcare systems, offices, labs , etc. into one entity

This permits “pull” technology, where for example, a physician in Cincinnati can search for a patient and pull discharge summaries and other results from a variety of organizations

The technology is the easy part. HIOs must be trusted and deal with fiercely competitive organizations and they must have a long term financial sustainability plan. This is much harder than originally anticipated

Health Information Organizations (HIOs)

Many HIOs were started with early federal funds that are no longer available

HIOs can charge subscription or transaction fees but healthcare organizations have to see value to be willing to pay for this

HIOs can support Meaningful Use and be HISPs

There are some well known well run HIOs in the country, but there have been many failures and stagnation

Next slide will enumerate potential HIO functions

Health Information Organizations (HIOs)

Functionality Functionality
Results delivery Quality reporting
Connectivity with EHRs Results distribution
Clinical documentation Electronic health record (EHR) hosting
Alerts to clinicians Assist data loads into EHRs
Electronic prescribing EHR interfaces
Health summaries Drug-drug alerts
Electronic referral processing Drug-allergy alerts
Consultation/referrals Drug-food allergy alerts
Credentialing Billing
HIO Potential Functions

At last survey (2013), there were about 200 HIOs in the US but only a minority are mature and successful

Many large hospitals/health care systems have decided to create their own mini-HIOs to share only with clinicians and offices in their network; thus thwarting the efforts of state and federal HIE plans to exchange information broadly

HIOs have many challenges outlined in another slide. Next slide presents a successful example

Health Information Organizations

Can be centralized or decentralized (federated)

Can be for profit or not-for-profit

Can be government, private or community based

HIO Facts

Case Study: The Health Collaborative (THC) (previously known as HealthBridge) THC is a not-for-profit HIO serving the greater Cincinnati, Ohio, as well as parts of Kentucky and Indiana that was founded in 1997. It has been quite successful financially with income not based on federal grants, but rather on monthly subscription fees. Provides information exchange for 50 hospitals and 7500+ physicians. Provides access to imaging, fetal heart monitoring and hospital-based EHRs. They are a HISP and participate in the Direct Project. They also offer workflow redesign and disease registries, data analytics, HIE consulting, quality reporting, public health reporting, syndromic surveillance, claims checks and eligibility verification. Alerts for readmission, duplicative radiology, opioid prescriptions
Successful HIO Example

The HITECH Act established funding for HIE within and across state lines. Most states began the process in 2010

Once again, the goal was to align with national HIT policy and support Meaningful Use goals

State organizations were supposed to fill gaps in sharing and to fully embrace and possibly host Direct Project messaging

The SHIECap program ended in 2011

Statewide Health Information Exchange Cooperative Agreement Program (SHIECAP)

Lack of successful business models

Environment is highly competitive

Federal support monies are gone

HIOs seem to work better in high population areas

Return on investment (ROI) is unclear

Proof of benefit is weak

Privacy/Security issues

HIE Barriers

FHIR: covered in multiple other chapters. Will use the FHIR data standard and RestFul APIs to request information from remote and disparate systems. Not standard of care, however

Blockchain: same technology as used for Bitcoins. It is a “distributed transaction ledger” that is difficult to hack. Decentralized approach that is being tested in healthcare

Newer HIE Models

OpenHIE: open source initiative aimed at low to middle income countries. Uses a service oriented architecture (SOA)

EHR Vendor-based HIE: vendors, such as Epic, have options to share to physicians not in the network and with those who are not using their EHR. Product is known as Care Everywhere

Newer HIE Models

One of the major requirements for successful healthcare reform is health information exchange—sharing of healthcare electronic information between clinicians and between clinicians and patients

New Meaningful Use requirements will promote HIE with tools such as patient portals and secure messaging

Our highly competitive and fragmented healthcare system has made sharing (HIE) among disparate organizations very difficult

Conclusions