State and regional HIEs: 'Don't count us out just yet!'
Once upon a time, not too long ago, state and regional health information exchanges were really where it was at when it came to interoperability in the U.S. Earlier this decade, the betting was on those HIEs across the country to help build the infrastructure and use cases for nationwide data exchange.
That's why programs such as ONC's State HIE Cooperative Agreement Program disbursed $548 million to 56 awardees in 2010 to help them "develop and advance resources" for interoperability and, eventually, become self-sustainable. As we all know, many of them did just that – but many of them did not.
"That money came and went," said John Kansky, president and CEO of Indiana Health Information Exchange, one of the HIEs that is still standing and self-sufficient. "Some of it was put to good use some of it wasn't.
"But the reality is that as you look across the nation there are some states and regions with very good, very strong, very valuable health information exchanges, and there are some regions that have none," he added. "Some regions have an HIE that still struggles to kind of find its value proposition – and therein lies, I think, the problem when you look from a national perch."
But there is hope – and huge potential – for the HIEs still operating in the U.S. At HIMSS19 next month, Kansky, alongside Indiana Health Information Exchange COO Keith Kelley, will offer a presentation whose title paraphrases Mark Twain: "Said the HIE: 'Reports of Our Death Are Greatly Exaggerated.'"
In recent years, a new nationwide model for interoperability and exchange has emerged and gained momentum, of course, this one largely driven by electronic health record vendors. Groups such as CommonWell Health Alliance and Carequality have built out membership, infrastructure and user base, gaining ground nationwide.
As they have, some in the industry may now give less thought to more traditional HIEs than they used to, said Kansky, or may criticize them for complexity and expense, failure to evolve with the times or develop more robust and sustainable business models.
Some of those criticisms may have merit, depending on the specific state or regional exchange being discussed, he admits. But the larger picture is more complex. In their HIMSS19 presentation, Kansky and Kelley will take a historical look at HIEs – describing why some failed and others have flourished. But they'll also look to the future – highlighting the enduring value such exchanges can bring to the table, especially as they work in concert with other vendor-driven interoperability efforts.
"I want to be clear about our talk: It is not a couple of HIE guys getting on the stage and whining that no one appreciates us," said Kansky. "Because half of our message is to the other HIEs – saying there is great opportunity for HIEs to deliver value if we adapt."
More traditional HIE networks have a role to play in the current interoperability landscape, he said, and many will continue to evolve and demonstrate value for providers, payers and and vendors who partner with them – to say nothing of the patients who benefit from them.
Kansky recently offered some further thoughts on that topic with Healthcare IT News.
On the existing data exchange landscape in 2019:
"Many HIEs are still going strong and making great progress – even on the national level, which they are not known for, since HIEs are thought of as regional or state things. But despite making progress they're a little bit forgotten or under represented in the national conversation about interoperability."
On how HIEs and vendor-driven networks need to work together:
"If you look at interoperability nationally, it's hard to say, 'HIEs can be a solution,' because it's too easy to point to this state here or that region there where its HIE is weak or nonexistent. And so you go, 'Oh well, then they can't be the national solution because there's gaps.'
"But it's too easy for people to say, 'Well, this other thing isn't tied to any region or state, this EHR vendor-driven thing – EHR vendors are everywhere, right? Or what about Direct? People use Direct everywhere!' But when you start digging down into the practicality of any one of those solutions achieving national interoperability, you don't get very far.
"The HIE story is messier. But the reality is that most of healthcare is local. And that and that if you are interoperable local, or interoperable in a region, you're providing a heck of a lot more value than if you're a tiny bit interoperable, nationally.
"I guess that's what concerns me about the direction that the conversation nationwide is going in: We've oversimplified. We're placing our bets on these national approaches and we've forgotten about the regional HIEs because in some places they look a little dead – hence the title of our presentation. But in other places they're the workhorses of interoperability today and, you can make the case, for decades."
On the different ways interoperability can be defined:
"The EHR vendor-driven approaches, if you think about it, are trying to achieve one thing: There's the doctor using their software, or a nurse, who needs information about the patient in front of them who's from somewhere else.
"Is that national interoperability? If I can get a piece of data about a patient that came from somewhere else into my EHR, am I done? I don't think so. Isn't it a lot more complicated than that? What about notifying people about clinical events? What about population health? What about community health records? What about electronic delivery of clinical results? Aren't all those use cases part of what we need to declare ourselves interoperable as a healthcare system?"
On whether an HIE should be thought of like a public utility:
"Yes, and a darn useful utility that keeps chugging along. There have been some big success stories related to the California wildfires, or recent hurricanes in the southeast where the HIEs came in pretty handy. That's another log on the pile for the value they bring."
On how to maximize that value and build it out on a wider scale:
"With regard to the EHR vendors, it maybe seems like I'm trying to detract from their interoperability efforts. That's not at all what I mean.
"Because if I'm talking to a bunch of other HIEs, I would say: 'Well, wait a second we're supposed to be making the nation interoperable, right? And the problem we had 10 years ago was that there weren't a enough clinicians using electronic health records, right? And then we complained five years ago that those EHRs that they were starting to use weren't good at exchanging data and didn't have good interoperability capabilities, right? Well now they do. So that's an asset not a problem, right?'
"The fact that the EHRs are more ubiquitous and the fact that they have better interoperability capabilities – Commonwell, Carequality. Care Everywhere, Outside Record Viewer – those are all assets in the equation of making the nation more interoperable.
"But what's often forgotten is that if you go looking for the people that have the last mile wired and/or have the data available – and in some cases have it in normalized, curated repositories, ready to be exchanged – it's the HIEs.
"So if I'm going to argue that those EHR capabilities are assets, then the vendors should be willing to acknowledge that the HIEs are assets too."
On how the vendor-led approach evolved the way it did:
"I don't think it's necessarily just profit-motivated or not being cooperative. I empathize and I occasionally lecture my HIE peers: If you're an EHR vendor that has to be able to do business in 50 states and six territories, and there are, you know, 10 states that don't have an HIE worth a darn, how do you come up with a solution that works in all your markets? So to an extent they designed their solutions around there not being an HIE there.
"What I wish they were better at is adapting to a circumstance where, 'Hey in this market, there is a great HIE! So let's have more than one approach, let's take advantage of the assets that exist in the markets where we do business. They need to be adaptable, just like the HIEs need to be adaptable.'"
On whether the two approaches will eventually cohere into real nationwide interoperability:
"We are closer to that. And that's why I like to say we're doing this the American way. The American way is 13 different people trying 13 different things all at the same time. And then chaos and the free market economy ensues. And the next thing you know, we've figured out something that is overly complicated, but works.
"Just look at the American healthcare system. Or the American transportation system or the American telecommunications system. It's all really complicated but it works.
"Some people from other industries, talking to people who are trying to achieve healthcare interoperability, they like to throw in our face the example of the financial system: 'Why can't it just be like I got my ATM, I go anywhere in the country or the world, and I can get money?'
"It's like, do you have any idea how complicated the system that makes that possible and how many different networks and standards are involved and how many decades it took for that to be the case? People just assume it's simple. It's not. We're just grossly oversimplifying the solution for healthcare interoperability."
Kansky and Kelley's presentation, "Said the HIE: 'Reports of Our Death Are Greatly Exaggerated,'" is scheduled for Thursday, February 14, from 2:30-3:30 p.m. in room W311A.
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