- Several years have passed since federal funding spurred the development of health information exchanges across the country, yet many of these facilitators of health data exchange and interoperability are still struggling to demonstrate value to the healthcare industry.
"It continues to be the Achilles' heel of HIE, a catch-22 of is there value and to whom. Until you build it, you don't know. Once you build it, are they really convinced that the value is there? It becomes a vicious cycle," Julia Adler-Milstein, PhD, recently told HealthITInteroperability.com.
According to the University of Michigan professor and researcher, part of the problem is how and when these organizations came into existence.
Following the passage of HITECH, federal officials at the Centers for Medicare & Medicaid Services (CMS) were moving ahead with the EHR Incentive Programs and the adoption and use of certified EHR technology. Around the same time, the Office of the National Coordinator for Health Information Technology (ONC) launched the State HIE Cooperative Agreement Program, a federal initiative to facilitate health data exchange at the state level in the years to come.
"One of the decisions made was to have EHR adoption come first and have interoperability come second," Adler-Milstein recalled.
But in choosing that path, federal officials may have inadvertently put the cart before the horse. "That led to the proliferation of systems weren't built to be interoperable with each other and we're now trying to retrofit that interoperability," she added.
Where did it go wrong?
For some parts of the country, health IT interoperability is nothing more than an abstract concept. In others, it's a concrete reality.
"There are pockets where interoperability exists and is working well, but still for the majority of patients who change healthcare providers that information is not moving seamlessly," said Adler-Milstein.
So why the disparity? The answer to that question, again, comes down to timing.
When the State HIE Cooperative Agreement Program launched, states were in various stages of preparation for state-level health data exchange. For those states already considering the role of health information exchanges, federal funding was a boon.
"For the states that had already been about and investing in HIEs, the State HIE Cooperative Agreement Program was enormously helpful," Adler-Milstein maintained. "It wasn't perfect; there were some challenges. But it really allowed them to take what they were doing and take it to the next level. They were already attuned to issues around sustainability. For the mature states, it was beneficial."
For those states behind the eight ball, those funds had little chance to have lasting impact:
For the states that had never thought about HIE before and the State HIE Cooperative Agreement Program was a reasonably generous amount of money on a shot time scale, those were the states that struggled the most because they were trying to figure everything out at once — what should we build, who are the stakeholders that will be engaged, what is the right governance model. It was almost as if they didn't have the bandwidth to also think about long-term sustainability. They had to be so focused on meeting the timeframe of the program. In some ways, it was hard for them to focus on the long run.
To lay all the blame at the feet of the ONC-led HIE program is too simple a conclusion, and not one that Adler-Milstein would make. However, the way the program has played out highlights the paradox that is health IT adoption and use — to prove value requires buy-in, to achieve buy-in requires proof of value — and hence the "vicious cycle" plaguing health information exchange.
Setting a corrected course of action
While some health information exchanges are still struggling to demonstrate value to end-users and remain viable, others are experiencing success and serving as valuable use cases in support of HIE adoption and use.
In Alder-Milstein's own backyard, Michigan, health information exchange is alive and well.
"Here in Michigan we have similarly seen a use-case focused approach and it has worked very well. It has allowed payers to get on board, such as Blue Cross Blue Shield of Michigan, and be a key pillar of sustainability because with each use case that is valuable to them they can create incentives for providers to participate in it," she noted.
But use cases needn't be as sophisticated as those in Michigan given the success of early health information exchanges.
"Most early HIEs started with test-result reporting," Adler-Milstein asserted. "Those were hospitals that understood that they could save money by sending test results electronically. Still today, for some of the most mature and stable HIEs, that is their bread and butter."
Use cases, however, are not an end in and of themselves. To be successful, they must serve as a stepping stone to future advancements and improvements.
"It's the right way to go, but the challenge is keeping the big picture in mind because you don't want to build in such a use-case specific way that in the long run you can't build toward more comprehensive interoperability. That's the challenge — you have to have that long-term vision but see the use case building blocks that will get you there," said Adler-Milstein.
A new threat to HIE viability
In her most recent published research, Adler-Milstein was part of research teams observing two important trends in health information exchange — the decline in the number operational HIEs and the increased role of EHR vendors in the HIE space.
The latter represents a new threat to the existence of independent health information exchanges because of how easily EHR vendors are able to make inroads in the HIE marketplace:
EHR vendors are in the provider's workflow. Ultimately, we want interoperability to be in the provider's workflow. They see that they have such an advantage in some ways because they are already there — they have the information and it's what providers are looking at. From that perspective, they clearly have a leg up over standalone HIEs that are separate, third-party. It's a hard road for them to compete in that space.
One finding from this study noted that the dominance of Epic Systems in hospital referral regions correlated to less HIE activity among non-Epic EHR hospitals, potentially pointing to information blocking or other business practices in the way of robust information sharing.
Adler-Milstein, however, cautioned against this inference considering that the entrée of EHR vendors into the HIE space has increased health data exchange among hospitals nationwide:
Once the EHR vendors were there, they realized they could pursue HIE. It's a way strategically beneficial to EHR vendors, but there's also more HIE happening because they are doing that. I'm glad Care Everywhere exists. It is being used and improving care. I don't think we should criticize Epic for doing that, but we have to figure out how Epic is motivated to play well with all the other people who are trying to do Epic-to-non-Epic connectivity.
If anything, the success of EHR vendors in the HIE marketplace points to their ability to get technology in front of providers and demonstrate its value, said Adler-Milstein.
The ability of EHR vendors to make a name for themselves in health information exchange is by no means widespread, added Adler-Milstein who also noted that health information exchanges have a role to play in the workflows of providers not using EHR technology from the most dominant EHR vendors.
The challenge for health information exchange remains the same — proving their value in addressing the health data exchange and interoperability needs of the healthcare industry.