“We’re maturing from HIE 1.0 to HIE 2.0,” Micky Tripathi proclaimed. “We’re in a new world now.”
A raft of technologies including broadband, cloud computing, cheaper storage, and mobile devices, among others, is driving the transformation. At the same time, market expectations regarding standards of care are changing, as are younger providers’ relationship with health-specific IT. All those factors are also sparking the move toward decentralization and a bottom-up phenomena in which consumers begin asking for electronic access and for those records to be shared across providers.
Another “of the things that’s driving [HIE 2.0] is the limited success of the prior model,” Tripathi, CEO of the Massachusetts eHealth Collaborative and chairman of the ONC information exchange working group (IEWG) said during his "The State of HIE" keynote before a rare joint meeting of the HIT Policy and Standards committees January 29. “There have been pockets of deep success, but it hasn’t been uniform, and those have been real pockets of success with a lot of hard work to get them going.”
[See also: Physician approaches to HIE vary widely.]
Hudson River Valley
Perhaps more a large region than a small pocket of success, the Hudson River Valley in New York is home to HIXNY, an exchange brimming with a 94 percent affirmative consent rate that patient information be shared.
Based just outside New York’s capital city, Albany, and established in 1995, HIXNY is a mature HIE serving 23 hospitals in 16 counties, but the electronic exchange ramp-up has happened rapidly, according to CEO Mark McKinney.
[See also: Mostashari spotlights ROI in HIE.}
“We had one CCD document in October of 2011,” McKinney said. “In May of 2012 we had 250,00 and in July 325,000.” As of February 2013, more than 1.4 million CCDs have been pushed to HIXNY’s HIE, which boasts a Master Patient Index 2.3 million records strong.
It would appear that at HIXNY such exchange momentum begets momentum. And even the stalwart HIE is looking ahead to the next phase of exchange.
“We’ve sho
wn physicians the future, to some extent, and now that they see the potential they want more,” said Kallanna Manjunath, MD, CPE (pictured at left) and the chief medical officer at Whitney M. Young Jr., Health Centers, an Albany, NY-based community hospital and a HIXNY participant.
To that end, prospective physicians and patients are asking Manjunath questions along the lines of: Why aren’t I getting the discharge information, the hospital consult? Why are the specialists not joining? They just want our data but why are they are not sharing?
“In my view this really has to be driven by patients. If the consumers demand [HIE] of more doctors, more hospitals, more specialists it will become necessary for them to do it,” Manjunath said. “We want the public to speak up because it’s also in their best interest to have the most updated information for treatment. And the more specialists that use our information the better for our patients. We want more people to join.”
The more patients and providers that align with the HIE, the more data HIXNY can access. That opens opportunities to consider for the future, McKinney said, including potentially hooking into the New York State Universal Public Health Node; the initial use case is feeding patient information into the immunization registry. Future ones might include newborn screening and syndromic surveillance.
Willamette River Valley
Whereas Direct secure messaging and patient look-up gained purchase in HIE 1.0, this new breed of use cases is also under consideration elsewhere.
Across the contiguous United States in Salem, Oregon — coincidentally 25 miles due north of Albany, Ore and situated in another river valley, the Willamette — Carol Robinson is contemplating similar use cases for the future of HIE in the Beaver State at the Oregon Health Authority (OHA).
The State coordinator for Health IT and director of health information technology policy design when Government Health IT spoke with her in mid-December, Robinson (pictured at right) has since left to found her own consulting firm, Robinson and Associates. During the interview, Robinson said that among the use cases OHA might consider for the future are a pilot program under which hospitals can report into syndromic surveillance programs through Direct, as well as ensuring providers and hospitals can access their records, and patients can download them, and making that functionality available for other health reporting moving forward. Another one under consideration is Blue Button implementation.
“The Direct secure messaging tool, as simple as it is, providers that have not been able to exchange information with others outside of a fax or a phone, their eyes light up when we show them if they get their medical trading partners in, this is more secure and it will fit nicely into your workflow,” Robinson said. “Their eyes just light up at the simplicity. So when EHRs start certifying for Stage 2 and it gets embedded into the electronic health records, I anticipate that will be really significant in helping the interoperability that has been so challenging.”
[See also: To date, no one HIE model fits all.]
Profound impacts
Also looking ahead to Stage 2, Florida HIE sees that phase of the meaningful use program as its opportune time to bring EHR vendors into the exchange’s mission.
“We're looking to connect a lot of the EHR vendors — that’s kind of our push for this year,” Florida HIE program director Janet Hofmeister said. “Generally, we’re going to see a lot more use cases, such as an EHR that can use Direct to inform someone of an event.”
Low-hanging fruit appears anytime a patient is admitted to a hospital, Hofmesiter said. That notification can then go to a primary care or any other doctor and to the health insurance company. “That’s just one use case,” Hofmesiter explained in this interview, “but I think it will have a profound effect on healthcare as it’s implemented across the country.”
Podcast: Listen as Janet Hofmeister (pictured at left), Carol Robinson and Micky Tripathi discuss the challenges that HIEs face as the industry sheds its HIE 1.0 skin and share insights about what form the new HIE 2.0 might take.
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Indeed, Stage 2 sets the foundation for attesting providers to exchange records, use the structured information for patient care, incorporate it into an EHR. That same information will also be shared with patients, enabling what national coordinator Farzad Mostashari, MD, described during the Jan 29 meeting as “a new ecosystem of business and technology innovations” that are patient-centric and designed to help users coordinate care, manage health finances, and make critical health decisions based on applicable and available information.
“A milestone that will be looked back on is stage 2 standards,” Mostashari predicted, “and everything else that goes along with making those ‘standards-in-committee’ into ‘exchange-in-communities.’”
The new shape of HIE
In a corner room of the Venetian Sands Expo Center in Las Vegas literally packed with reporters, at last year’s HIMSS conference Mostashari shared a thought representative of other government officials and private sector healthcare professionals working to implement and advance information exchange. Yet, one that had not been remarked so memorably.
“I refuse to speak of HIE as a noun,” the ONC head said. “It’s a verb.”
The phrase took root and has since sprouted. During the same Jan. 2013 meeting wherein Tripathi declared the arrival of HIE 2.0, panelists expressed another sentiment at once obvious and in need of being stated: Business value for providers more than anything else, finally, will drive the growth of HIE.
“Once the cost of increasing information flows has come down, the value has increased, then information will flow,” Mostashari said, adding that he expects it will begin on a first name-basis with patients sharing health data among people they know and trust. “That is happening. We see that growing.”
In describing HIE 2.0, Tripathi echoed both of those statements, saying that the new era of exchange is more verb than noun because “transactions may or may not be mediated by some kind of organization that calls itself an HIE,” rather, the exchange of health records is beginning to be more demand-driven by patients, and healthcare organizations are trying to meet those immediate interoperability needs with whatever tools are available and do so within existing business, legal, and technical restraints.
The presiding notion is no longer to wait for the legislature to pass something that enables large-scale nationwide exchange and, instead, now it’s “let’s try to fit whatever we do within the current paradigm that we have and sometimes that means the technology gets out ahead of policy,” Tripathi added.
Indeed, the next-generation array of health IT services for HIXNY includes providing access to a comprehensive patient health record, automating results delivery and event notification, and further unlocking the HIE’s value through analytics for population health management, HIXNY CEO McKinney (pictured at left) explained, pointing to a potential example in which a chronic-condition patient receives electronic notifications to take actions that maintain or improve health.
“This future is closer than many may think,” McKinney said.
At Florida HIE, HIXNY, and OHA, the supplantation ostensibly mimics the fashion in which the Web evolved into Web 2.0 — a reformation inevitable for HIE as today’s tech-savvier government officials, cadre of physicians, clinicians and medical students, and healthcare consumers eclipse the aging crop of doctors for whom even e-mail with patients is an evil best eluded with career’s end in sight.
“It’s almost impossible to think about a younger generation clinician walking into an MS-DOS environment while streaming Spotify on an Android device,” Tripathi chuckled. “It’s just culturally not going to work.”
