What organization creates national standards for real time electronic exchange of healthcare information?

Abstract

Health information exchange (HIE) has been promoted to improve the efficiency, cost-effectiveness, quality, and safety of health care delivery. This chapter describes the evidence base to support that assertion, describing a systematic review of the effectiveness, use, usability, implementation, and sustainability of HIE. The review identified 136 studies: 34 on effectiveness, 58 on the use of HIE, 22 on usability and facilitators and barriers to use of HIE, 45 on facilitators or barriers to HIE implementation, and 17 on factors related to sustainability. No studies reported on clinical outcomes (eg, mortality and morbidity) or identified harms. Low-quality evidence generally finds that HIE reduces duplicative laboratory and radiology testing, emergency department costs, hospital admissions (less so for readmissions), and improves public health reporting, ambulatory quality of care, and disability claims processing. Most clinicians attributed positive changes in care coordination, communication, and knowledge about patients to HIE. The use of HIE has increased over time, but within organizations the number of users or HIE-accessed visits was generally low. Barriers to HIE use were lack of critical mass of data, inefficient workflow, and poorly designed interface as well as update features. Greater usability was associated with greater use but not with effectiveness. Facilitators of HIE implementation were characteristics of the organization (eg, leadership) or the HIE system, while barriers included competition or lack of a business case for HIE. Although the evidence supports a benefit of HIE in reducing the use of specific resources and may improve quality of care, the full impact of HIE on clinical outcomes and potential harms is inadequately studied. Future studies should address comprehensive questions, use more rigorous designs, and employ a standard for describing types of HIE.

24.3.2.1 Example 1

A Medical Information Systems Committee (MISC) is charged with overseeing the design and implementation of clinical information systems for the organization. The MISC is also responsible for ensuring that the clinical information systems conform to all regulations, JCAHO requirements and the organization’s policies.

The MISC has multi-stakeholder representation and reports to an Executive Medical Committee.

The MISC has a subcommittee that oversees the development of CDS. This subcommittee receives requests from various task forces, committees and user groups. The subcommittee requests IT assessment of the costs and time required to fulfill the request. The subcommittee recommends priorities and forwards its recommendations to the MISC for approval.

Health Information Managers (HIM Professionals)

Health Information Management (HIM) professionals are members of the eHealth team trained in the discipline of HIM [15,16]. The Canadian Health Information Management Association (CHIMA) defines HIM as the discipline that focuses on health care data and the management of health care information, regardless of the medium and format [15]. The American Health Information Management Association (AHIMA) defines health information management as the body of knowledge and practice that ensures the availability of health information to facilitate real-time health care delivery and critical health-related decision making for multiple purposes across diverse organizations, settings, and disciplines [16].

Research and practice in HIM address the nature, structure, and translation of data into usable forms of information for the advancement of health and health care of individuals and populations. HIM roles are described as health information managers, clinical data specialists, patient information coordinators, data quality managers, information security manager, data resource administrator, and research and decision support specialist. The HIM practice domains also broadly include planning (administration, policy development, information governance, and strategic planning), informatics, and HIT [12,15].

Abstract

Health information exchange (HIE) seeks to facilitate the electronic sharing of patient information across organizations so that it available when and where it is needed by clinicians and other key stakeholders. While HIE has been pursued at both policy and organizational levels for many years, it is still a work-in-progress. Some types of information are routinely electronically exchanged while others are not; some communities have achieved robust interconnectivity while others have not; and some countries have mature HIE policies while others are early in their development. Thus, HIE will continue to be an active domain and is increasingly the top priority of countries that have invested in electronic health records. This chapter begins by describing near-term, pressing HIE challenges, which are the focus of current efforts to advance HIE and then addresses the opportunities created for informatics research and for professionals. We conclude by discussing long-term trends that are anticipated to shape the future direction of HIE.

Two-Party Agreements

The two-party HIE participation agreement model comes into play when an HIE entity exists and it needs to contract with HIE participants to facilitate exchange. Under this model, the HIE signs an agreement with each HIE participant. The HIE will want the multiple agreements it signs to be as similar as possible, but in all likelihood there will be variation in the agreements it signs. The HIE participants only have a contractual relationship, or privity, with the HIE entity. They do not have contractual relationships with each other. This model has been used by numerous HIE entities across the country. The challenge to this model is that variation among the agreements the HIE signs can create challenges for the HIE entity in administering its exchange. If the HIE has different obligations to different HIE participants, the administrative costs of running the HIE will increase. Further, if the HIE wishes to make changes to its agreement, for example, to allow for a new data use, the HIE must go to each HIE participant and ask for a contractual amendment. This creates additional administrative overhead and could lead to “hold out” problems if some of the HIE participants are not willing to agree to the amendment. Further, because the HIE participants do not have direct contractual privity with each other, they will not have contractual rights against each other in the event of a breach. For example, if an employee at HIE participant A wrongly discloses PHI that was obtained through the HIE from HIE participant B, HIE participant B may have breach notification obligations, but does not have contractual recourse against the bad actor at HIE participant A. HIE participant B would only have a contractual right against the HIE entity (who then in turn would have a contractual right against HIE participant A), which could be problematic as the HIE entity might lack sufficient capital or insurance coverage to make HIE participant B whole.

Summary

HIE on any real scale has existed less than 20 years. During that period, the advancement of technology and standards and the government’s involvement in HIT policy-making has been dramatic. The pace of change in the American health-care system has been equally dramatic. In that context, HIE businesses have emerged and their growth and evolution has accelerated. The national obsession with HIE sustainability is an understandable byproduct of those environmental circumstances. HIE businesses can be run sustainably. There is ample opportunity in our fragmented and inefficient health-care system to create value—especially when technology and information are your tools. Any business that can create value can figure out the combination of mission, organizational, structure, business model, services, and disciplined financial management that are required to succeed.

Challenges

HIE adoption has several layers of challenges:

Technological issues. (1) Harmonization of the existing standards and (2) overly complex standards.

Legal definition. (1) Mandatory use of standards for information exchange; (2) exchange of data between different countries; (3) HIPAA-like rules for patient confidentiality and privacy (outside the United States); (4) storage of patient information outside the country (e.g., cloud); and (4) use of “apps” for healthcare.

Economic-administrative issues. (1) Investments in infrastructure; (2) investments in training; (3) set HIE as a priority for healthcare; (4) economic sustainability of HIE initiatives; and (5) informatization of healthcare facilities in developing countries.

Much of the necessary efforts to face these challenges are already being addressed, but the progress is still very slow. The HIE is a desire of healthcare consumers, but it still not the major priority. The growing availability of access to digital information will increase the demand for access to EHR and related patient data making necessary a faster adoption of solutions for interchange.

Summary

HIE has been linked to benefits in healthcare utilization, health care costs, and coordination of care. Moreover, major changes to how hospitals and other providers are reimbursed are increasing the need for seamless exchange of clinical data. HIE is now considered an important prerequisite for a modern health care system. However, most HIEs are still in their early developmental stage. In fact, as an organization type, HIEs need further maturation which will involve innovations and technology that are expected to continue to evolve. As more and more providers adopt HIE, and more data is exchanged leading to the creation of ever larger data sets, opportunities open up to truly unleash the potential of improving the quality and cost of care. Benefits accrued from these developments may eventually address shortcomings that have plagued the health care system in the United States. Globally, HIEs have the potential to strengthen and transform health systems that are similarly facing challenges.

ICT Systems

HIE as we have defined it necessitates electronic transfer between ICT systems. Therefore ICT systems need technical methods for facilitating exchange of information. In ICT speak, there must be a sender and a receiver. For example, a laboratory information system (LIS) sends lab test results to an EHR system to record the results in a patient’s records. Yet an LIS can also receive an order to perform a lab test from an EHR system. These electronic transactions provide the technical foundation for HIE. Almost any ICT system in health care can be either a sender or a receiver depending on the scenario. Therefore the potential configuration of technical networks involving ICT is many. Regardless of which ICT systems are involved in HIE or the direction in which information flows, there will be senders and receivers. Several chapters in the book describe in greater detail the technologies that support sending and receiving health information among networks of ICT systems.

Abstract

Demonstrating the effectiveness of health information exchange (HIE) in reducing costs, improving outcomes, and creating more efficient care delivery systems requires evaluation. To evaluate is to measure the significance or value that HIE brings to patient and population health. This chapter describes strategies and methods for evaluating HIE, principally from the perspective of a health system or other entity engaged in the implementation and use of HIE. The chapter begins with a review of the various types of evaluation, including research. Then the chapter outlines a strategy and the methods for the evaluation of HIE. Finally, the chapter provides guidance for how to disseminate outcomes from HIE development, implementation, adoption, and use. Only by evaluating HIE and sharing lessons can we expand the evidence base for HIE in support of adoption and sustainability.