The Ongoing Journey towards Health Information Exchange
By Maria Liu, M.S., Manager of Data Standards & Interoperability and Kelly J. Ko, Ph.D., Director, Data Governance and Interoperability, Sharp HealthCare
The past two decades have no doubt been transformational for health information technology, starting with the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 which catalyzed the digitization of health data through Electronic Health Records (EHRs). While the majority of attention rightfully focused on the implementation of EHRs, HITECH also kick-started the widespread adoption of Health Information Exchanges (HIEs), which were viewed as a critical tool in helping manage care across the continuum. While the Meaningful Use program (which was part of HITEC) was largely successful in the birth of regional HIEs–they were mostly targeted at acute care health systems and ambulatory groups and entire cohorts of the medical community were left behind. For example, post-acute providers were exempt from Meaningful Use requirements—setting the stage for uneven progress and creating critical data exchange gaps that persist today.
While HITECH may be viewed as successful through the lens of adoption, how it was implemented and perhaps more importantly, where it wasn’t, serves a valuable lesson for the industry, especially as the idea of a national HIE gains momentum.
The Emergence of National HIEs
Currently, HIEs are largely regional in nature; however, as the industry evolved, the discussion has shifted towards the need for a broader information exchange network, specifically on a national level. In fact, a few notable national exchanges already exist in CommonWell and CareQuality, both of which were led by industry partners, but have been received favorably by the healthcare community.
In 2016, it was estimated that CommonWell and CareQuality represented more than 90% of the acute EHR market and 60% of the ambulatory EHR market with over 15,000 healthcare organizations having implemented the CareQuality framework or CommonWell network.However, not all health systems or provider groups have been able to take advantage of these national exchanges. Notable barriers include technical feasibility or skill deficits, conflicting regulatory mandates, and of course, financial resources as participation comes without federal or state incentives. Not surprisingly, a health “tech-quity” gap has become increasingly clear, despite well-meaning intentions.
With dwindling resources and the addition of state and federal level mandates pushing for improved health information exchange, survival for many regional HIEs rests on improved strategic and sustainable business plans.
Outlook for Regional HIEs
While federal funds to jumpstart the regional HIE movement was successful, the sustainability of those regional HIEs has been mixed at best, as the loss of state and federal financial incentives has proven to be a devastating blow to many. It was reported that the number of HIEs decreased by 25% across the US between 2012 and 2019. Additionally, the number of financially viable HIEs decreased by another 6% between 2014 and 2019.To make matters worse, healthcare organizations are also facing new mandates, such as the Office of the National Coordinator (ONC) Final Interoperability Rule and the 21st Century Cures Act, both of which include large technical and resource investments.
While existing regional HIEs could and potentially should have played a larger role in federal interoperability efforts, in many cases, regional HIEs were unable to assist due to a lack of resourcing and technical expertise—further diminishing their position. For example, the 21st Century CURES Act mandated hospitals to send electronic admission, discharge, and transfer (ADT) notifications from hospitals to downstream providers. Ideally, regional HIEs were well positioned to fulfill this requirement, however many healthcare organizations met this requirement through other means.
With dwindling resources and the addition of state and federal level mandates pushing for improved health information exchange, survival for many regional HIEs rests on improved strategic and sustainable business plans.
Trusted Exchange Framework and Common Agreement
As we look to the future, things do not appear to be getting any easier, as the ONC recently released its most ambitious interoperability effort to date with the release of the Trusted Exchange Framework and Common Agreement, also known as TEFCA. Established within the 21st Century Cures Act, TEFCA was created to support a common set of standards and policies to catalyze the growth of national HIEs. Those who meet these standards, would be designated a qualified health information network (QHIN), symbolizing shared standards for data sharing across networks.
While this may be good news for more mature regional HIEs, TEFCA may strike a further blow to smaller HIEs who have already been struggling financially and potentially unable to adhere to the technical requirements necessary to become a QHIN. Furthermore, TEFCA also comes without any financial incentives, making it that much harder to participate.
Conclusion
As we imagine an equitable healthcare future, we cannot get there without the right information that is readily accessible across the care continuum. The idea of HIEs was supposed to deliver just that; however, realizing that potential has been challenging. While there have been bright spots such as the growth of CommonWell and CareQuality, and of course, the release of a national exchange via TEFCA, challenges remain, many of which we have seen before.
Based on where HIEs have been, we focus on three key lessons. First, we must not leave behind smaller community-based providers or post-acute care facilities to truly achieve nationwide data exchange. Second, healthcare remains a local experience, any information exchange efforts must have local or regional support to sustain operations, in other words, states need to take more of a vested interest in the success of their respective HIEs. Finally, there is a need for established standards to minimize the impact of fragmented exchanges. While these factors do not guarantee success, we should learn from prior experiences; otherwise, the aspirational nature of nationwide exchange will be within reach for many, and the gap will continue to widen for others.
