It's been said time and time again. Simply putting paper records in a digital format does not transformation make. How would the data get to the patient or to the specialist who needs to see it, or to a hospital ER in another state across the country? It's the ability to move critical data where and when it's needed that makes the difference.
Therein lies the value of health information exchange, and that's why ONC chief Farzad Mostashari likes to say he prefers to think of HIE as a verb.
Through the HITECH Act (part of the American Recovery and Reinvestment Act) the government authorized $564 million to help states with health information exchange across the healthcare system.
Massachusetts the first to garner approval for HIE funding, receiving $17 million to help create the infrastructure.
"When fully implemented, this technology will support our goals of providing high quality care while slowing the growth of costs," said Massachusetts Gov. Deval Patrick on Aug. 3 when he announced the state would receive the federal funds.
Fast forward a few months, to Oct. 16, and the commonwealth was, as John Halamka, MD, put it, "making history."
"At 11:35 a.m. Governor Deval Patrick and his physician sent the governor's healthcare record from Massachusetts General Hospital to Baystate Medical Center," Halamka, CIO of Beth Israel Medical Center in Boston, writes in his blog. "It arrived and was integrated into Baystate's Cerner medical record. The Massachusetts HIE is now open for business."
As former U.S. Chief Technology Officer Aneesh Chopra sees it, HIE is of national importance, and that is why the federal government is helping with the development of both statewide exchanges and the nationwide eHealth Exchange, which cut its federal strings on Oct. 11 to stand on its own as a nonprofit entity.
Twenty-eight partners, a mix of public and private entities, share health information across eHealth Exchange; they include CMS, DoD, SSA and VA as well as Kaiser Permanente, Marshfield Clinic, MedVirginia and Idaho Health Data Exchange. Five hundred hospitals are already connected, 30,000 clinical users, 3,000 providers, and a patient population of about 65 million people, and 1 million shared records, according to Mariann Yeager, its interim director.
The federal government has driven the nationwide exchange, from concept to pilot to standing on its own with public-private participation.
There are three reasons the government played a role in healthcare information exchange, says Chopra, who served as the nation's first chief technology officer, from 2009 to 2011:
1. To build the digital infrastructure for a 21st century healthcare system,
2. To serve as convener for establishing standards for interoperability
3. To help with opening up government data.
The administration felt that building the infrastructure merited a boost from the American Recovery and Reinvestment Act, he says.
On the standards front, the government played a convening role, he says, validating what the private sector had created. It was not willy-nilly participation, but rather carefully outlined in a memo Chopra wrote while at the White House.
"While the government called for such standards, and ultimately incorporated them into meaningful use," he says, "the actual standards development had been, rightly so, the work of the private sector."
Chopra points to the Direct Project as the most tangible element of HIE.
Opening up government data is another important role for government, as Chopra sees it.
"There I would say choices like Blue Button, which started initially as a government initiative, is really now morphed into a national initiative with government as but one exemplar.
"So, if you think about the role of government, it is invest in the building blocks of innovation for 21st century infrastructure. It is to set rules of the road, like standards that build very heavily on the collaboration of our private sector, and it is unleashing the power of open data to help contribute to problem-solving."
Jonathan Bush, CEO of athenahealth, a cloud-based EHR company, does not contest that government has a role in HIE - but sometimes government gets in the way, or does not move fast enough to satisfy Bush.
"I've seen some progress," he says. "So I'm not as hysterical and upset about it as I was before." That ONC chief Farzad Mostashari "is talking about health information exchange as a verb, and not a thing you buy from Lockheed Martin, and each state at one of the hospitals puts it in its data center is fabulous."
The Office of the Inspector General recently gave athenahealth permission to charge $1 for supplying information to those who request it.
"In every other industry it's called a commission or a supply chain fee," Bush says. "In healthcare it's called kickback, and you go to jail. Now you don't go to jail, you're allowed for $1 - only $1.
"When you think about getting cash out of a machine, you exchange three data points and it's worth $2.50, the idea of exchanging a chart for $1 is a little crazy," he says, "but anyway it's something. So there's been progress."
"I think there's progress in getting health information exchange being thought of as a verb - and to allow the definition of health information to flex and move, and be really narrow for some and broader for others and permission and willingness to say out loud that it should be paid for," says Bush. "All of that is starting to happen, but there's a long way to go."
In spite of marked progress and bright examples of health data exchange, there is no lack of work left to do, challenges to meet.
"One reason that costs are high and health care quality suffers is that care is typically delivered in a fragmented delivery structure - in silos," the Bipartisan Policy Center, wrote in its recent report, Accelerating Health Information Sharing to Improve Quality and Reduce Costs in Health Care.
The Washington D.C.-based think tank offered recommendations and called for more government help, specifically for a national strategy for accelerating interoperability and electronic information sharing; improving the accuracy of patient monitoring, updating laws, particularly for Stark Law exception for payments associated with the electronic transmission of data that accompany a referral or order; and to improve privacy and security laws.
Through the think tank, former Sen. Tom Daschle, a Democrat, and former Sen. Bill Frist, MD, a Republican, work together on these issues.
"Major hurdles block the exchange of health data," Frist said when the Bipartisan Policy Center released its report on Oct. 3. "An overwhelming majority of more than 70 percent clinicians surveyed believe that the lack of interoperability and exchange infrastructure and the cost associated with those are major barriers."
