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Overview

All sectors – providers, consumers, public health, employers, and health plans - are actively engaged in HIE at a level never seen before in this country. The federal government has taken a lead in driving the formation of HIEs across the country. President Bush’s vision has been to have widespread adoption of electronic medical records (EMRs) by 2014.1 The new administration of President-elect Obama appears to be equally supportive of electronic health care as a tool to improve health care delivery and has indicated that health care is a priority for the nation. “A key feature of Barack Obama and Joe Biden's health care plan is the use of health information technology to lower the cost of health care. Most medical records are still stored on paper, which makes them difficult to use to coordinate care, measure quality, or reduce medical errors. Processing paper claims also costs twice as much as processing electronic claims. Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records.”2

While community, regional, and state-level HIEs continue to grow and become operational, financial sustainability continues to be a big issue. More HIEs are establishing multi-stakeholder entities enabling the HIEs to obtain funding from multiple sources. State government, employers, and payers are using their funds to leverage participation.

At the same time that community and state-level HIEs are organizing, many smaller HIEs (“network neighborhoods”) are being established by integrated health networks, physician practices, groups of clinics, quality initiatives, and many other HIT/HIE initiatives. This creates more confusion about the role of community or state-level HIEs, but also more opportunity. In addition, there is a growing movement among the private sector that HIE can be driven by the consumer through the personal health record. Widespread adoption of HIE requires national, state and local efforts to address issues around the privacy and security of patient data, interoperability (the ability to easily exchange data across organizations), liability, adoption of electronic tools, and cross-state data exchange issues. State-level entities are emerging as convener/collaborators to address these issues. Physicians have emerged as leaders in the adoption of HIT and HIE to encourage all physicians, not just a few, to become electronic. Physician leadership is being driven by the desire for patient-centered care, the push for quality and value performance, and the increasing affordability of some of the electronic tools.

Key National Trends in HIE

1. Federal leadership is framing the transformation to and implementation of electronic health care - The federal goal set in 2004 was to have widespread adoption of interoperable electronic health records (EHR) by 2014.3 Today that vision is slowly becoming a reality as EHRs, PHRs, and home telehealth proliferate; national standards, interoperability, and privacy and security issues are addressed; collaborative governance models are developed; and a nationwide health information network (NHIN) is seen as a possibility, even if the form it will take is not as originally envisioned. In June 2008, the Office of the National Coordinator articulated two primary goals – patient-focused health care and population health.4 Federal leadership may take a new form with the new administration, but there is the general belief that electronic data exchange will remain a priority.

2. Health Information Exchanges (HIEs) show continued growth - According to the 2008 eHealth Initiative survey there are 130 HIE initiatives; 36 of these are in the implementation stage and 42 have identified themselves as operational. There were 18 new HIEs not reported in the previous year.5 Among these initiatives are state-level HIEs that continue to grow also. In 2007, at least 208 bills were introduced across all 50 states calling for the adoption or implementation of health IT on some level, 30 of which have been signed into law in 19 different states.6 State level entities are facilitating governance oversight for leveraging resources, reconciling cross-jurisdiction laws, and convening stakeholders. Some of the smaller states also provide the technology infrastructure. Of particular note is the need for states to help normalize regulations between states since many regional HIEs cross state lines.

3. More paths to sustainability are being explored; a few HIEs close down – Community and state-level HIEs are becoming creative in establishing funding streams. Many HIEs have received federal grants such as the 2004-05 AHRQ demonstration project grants or the 2007-08 Medicaid Transformation Grants. State governments are engaged in start-up funding and, in some cases, sustainable funding. Purchasers of health care are leveragingtheir buying power to demand provider and health plan participation. Payers are more engaged as participants, funders and sponsors of programs that utilize the HIE (e.g. quality initiatives). Public health brings funding and grants for specific programs. Researchers are being asked to pay for the access to data. Despite this surge of efforts to ensure sustainability, a handful of HIEs are closing down. A notable example is the well known Santa Barbara County Care Data Exchange. With the advantage of hind sight, observers of HIEs recognize some of the requirements for sustainability: local community financial commitment, multi-party stakeholder participation to spread risk, building value propositions for participating entities, use of grants for start-up rather than sustainability, commitment to physician adoption, and low cost rather than high cost solutions.

4. Privacy, security and confidentiality are paramount to achieve consumer acceptance - As more HIEs become operational, community groups are demanding that greater attention be given to privacy and security issues. There is a growing body of information that surrounds what an HIE needs to have in place in terms of technology, policies, and procedures to ensure the privacy and security of protected health information (PHI). Yet, many questions in this realm are still unresolved and are being addressed by state-level entities, the National Health Information Network (NHIN) efforts, the Health Information Security and Privacy Collaboration (HISPC), and others.

5. The drive toward interoperability continues with the formation of the public/private partnership AHIC Successor, Inc. – Interoperability, the ability of a system or a product to work with other systems or products without special effort on the part of the customer, is extremely difficult to achieve. Yet, interoperability is essential to the long-term success of HIEs. In November 2008, AHIC Successor, Inc. replaced AHIC, formed in 2005 as an interim advisory body to the Secretary of the Department of Health and Human Services. AHIC Successor, Inc. will continue as the hub around which a broad community of stakeholders can build consensus around interoperability. Other federal efforts that will coordinate with AHIC Successor, Inc. include the Health Information Technology Standards Panel (HITSP) to establish standards, the Certification Commission for Healthcare Information Technology (CCHIT) to certify EHR products and their networks, and the National Health Information Network (NHIN) to establish demonstration projects.

6. More types of data exchange initiatives proliferate; community, regional and state-level HIEs link them together, often around medical referral regions - In only a few short years, new forms of HIEs have emerged: hospital portal strategies, ePrescribing initiatives, integrated health management systems, practice to practice networks, safety net clinic networks, employer and health plan sponsored personal health records, quality initiatives, and health plan clinical data exchanges, among many others. These data exchanges focus on specific needs. The need for community, regional and state-level HIEs is expanding to help link these “network neighborhoods” together. Often these HIEs are organizing around medical referral regions that follow common provider referral patterns.

7. Consumer driven health care takes on new forms and new players that could transform health care delivery and the role of HIEs – Personal health records have been available for several years, but renewed energy to encourage their use is emerging. The Health Record Banking model is being piloted in Washington and Oregon with the personal health record driving the formation of the HIE. Both Microsoft and Google have introduced consumer driven personal health records (Google Health and Microsoft Health Vault) representing a large and growing effort by the private sector to engage directly with the consumers in managing their health care. Led by the private sector and consumers, interest in the Health 2.0 movement is growing with the intent to “use social software and light-weight tools to promote collaboration between patients, their caregivers, medical professionals, and other stakeholders in health.”7 HIEs will be challenged to embrace these efforts with their own and to educate stakeholders on how the community and state-level HIEs can play an important role in feeding provider data into these and other consumer personal health records.

8. HIE is seen as a vehicle for overcoming health care disparities - According to the Alliance for Health Reform’s November 2006 report, “Racial and Ethnic Disparities in Health Care,” African-Americans, Latinos and other racial and ethnic minorities in the U.S. often receive a lower quality of care than their Caucasian counterparts even when minorities have health insurance and are of the same social class as Caucasians. Other reports from AHRQ, Commonwealth Fund, Kaiser Family Foundation and others add to the mounting evidence of health care disparities. HIEs promise improved access to care, better chronic disease management, cultural competency tools, and affordable electronic tools for minority primary care physicians.

9. Physicians are playing a larger role in the formation of HIEs - Today, more physicians have experience with hospital and practice based EMRs, recognize the value of data exchange in patient centered care, understand the benefits of EMRs with decision support tools, and want access to more patient data sources, not just a few. As a result, physicians are becoming advocates of community-wide HIEs, which facilitate data flow with health systems, other providers, and physicians. With lower cost “EMR “Lite”” solutions available, EMR costs are less of a barrier than in the past, enabling many physicians to use electronic tools and to participate in data exchange.

10. All of these trends suggest that the HIE movement is expanding the focus from fixing healthcare to transforming health care - Transitioning from paper to an electronic system eliminates inefficiencies and reduces errors. However, more HIE leaders are using language that speaks of transformation or changing the nature of the healthcare system. One such example is Health and Human Services (HHS) which has become a leader in defining and leveraging value-driven health care. HSS outlines four cornerstones for achieving efficient, quality (value-driven) healthcare: health information technology standards, published quality standards, increased incentives for performance measurement, and price standards.8

1.Executive Order No. 13335, 69 FR 24059, (April 30, 2004).

2.Science, Technology and Innovation for a New Generation, http://www.barackobama.com/issues/technology/, (accessed December 1, 2008).

3.Executive Order 13335 (2004).

4.Office of the National Coordinator for Health Information Technology, The ONC-Coordinated Federal Health Information Technology Plan: 2008-2012; Synopsis, htt://www.hhs.gov/healthit/resources/HITStrategicPlanSummary508.pdf (accessed November 15, 2008).

5.eHealth Initiative, Fifth Annual Survey of Health Information Exchange at the State and Local Levels – Overview 2008, http://www.ehealthinitiative.org (accessed September 15, 2008).

6.eHealth Initiative, Fourth Annual Survey of Health Information Exchange at the State, Regional, and Community Levels , (2007), http://www.ehealthinitiative.org (accessed December 20, 2007).

7.Health 2.0, 2008, http:www.health2con.com/Faq.html (accessed November 15, 2008).

8.US Health and Human Services, Value Driven Health Care. http://www.hhs.gov/valuedriven/fourcornerstones/index.html (accessed November 15, 2008).