By Dr. Chris Hobson, chief medical officer, Orion Health.
For nearly a decade, Health Information Exchanges (HIEs) have been looking for their long-term sustainable business model. This is part of the journey toward the future state of the HIE, which will be a ubiquitous healthcare utility that makes data available to all stakeholders across the healthcare landscape. Today, their work and future plans are driven by a desire to support value-based care initiatives, enhance interoperability, and leverage and manage a wider scope of data.
Representing a broad swath of HIEs, a 2019 Survey on HIE Technology Priorities uncovered various key trends and changing priorities in the sector. To become a sustainable healthcare information provider, HIEs must understand and leverage data to gain insights that improve patient outcomes while containing costs. Additionally, other trends include joining national exchanges, introducing value-added capabilities, enhancing integration of clinical and claims data, and growing payer participation in HIEs.
Participation in various national initiatives is an important driver for HIEs as it requires successful HIEs be more active across traditional geographic and state boundaries. Mechanisms for participation include the Trusted Exchange Framework and Common Agreement (TEFCA), the national eHealth exchange, Direct Trust and Carequality. Participation in Patient Centered Data Home, an event notification service that includes HIEs across the U.S. led by the Strategic Health Information Exchange Consortium (SHIEC), had the highest level of interest across all surveyed HIEs.
Like a utility, the next generation HIE must fit into the growing “Network of Networks” ecosystem, providing shared services to multiple HIEs (e.g. EMPI/record locator, patient directory, provider directory, data aggregation). This also means bringing together disparate entities into a local HIE network connecting a variety of different end-points – including practices, hospitals, systems, labs, long-term care facilities and more – while simultaneously making the local information shareable with other regional and national HIE networks. HIEs will need to support population-based use-cases and assist safety-net providers and small, independent providers to access larger interoperability initiatives across the U.S., such as TEFCA and the e-Health Exchange.
While consolidation of HIEs at the statewide/regional level is likely, it is possible that smaller groups (i.e. small networks, ACOs) will need some or all of the HIE’s core functionality, increasing HIEs as a broadly utilized utility. Adding additional valuable capabilities such as care coordination, secure messaging, e-referrals and medication reconciliation are near-term priorities to create a healthcare information utility. Medication reconciliation at point-of-care transitions, such as hospital discharge, still represents “low-hanging fruit” for enhancing HIE capabilities and offering value to providers.
For the next-generation HIE to evolve, payer participation through an increased integration of claims and clinical data is crucial. The initial impetus for payer involvement in HIEs came from their interest in moving providers to value-based care. Providers told their payer partners that they needed more reliable high-quality data if they were going to participate as equals in value-based care payment contracting models. Payer participation in HIEs also helps meet provider needs for improved data for contracting and population health management. Looking ahead, payers will need clinical data from EHRs to supplement their government quality reporting and improve performance on star rating assessments.
HIEs must address several technical and business challenges as they advance into modern information utilities. These include enhancing key technical capabilities and enablers such as easier integration through APIs, managing the ecosystem of applications that APIs enable, providing access to payer claims data, providing clear value and easy-to-use features to end-users, including integration of EHR and HIE workflows, offering additional services such as HIE-to-HIE exchange and easy integration, and participating in national initiatives.
For HIEs to become sustainable, stakeholders need to trust that the data within is secure at all points, that patient privacy is protected and that there are safeguards against unethical data use. Perennial issues of privacy and security span all of the technical challenges. These risks are always important considerations as HIEs contain increasing types and quantities of data and end-user numbers are expanded, including providing access to non-traditional providers.
A related set of issues pertains to the ethically and legally permissible use of data, making strong data governance models and information sharing agreements necessary before embarking on the journey toward becoming a utility. For example, it would be inappropriate if social determinants of health data lead to patients being denied care. These considerations lead to the inevitable need for strong data and clinical governance at all points.
Healthcare information is just as useful as any water, power or gas utility currently available. HIEs that are able to create useful, reliable, connectable hubs as part of a national HIE will have a larger utility. Regional HIEs are already making great strides in many of these variants as they have a head start becoming an essential model of the healthcare infrastructure. If regional HIEs continue to develop these capabilities, they will continue long into the future delivering more accurate and precise treatments, creating interventions in targeted patient cohorts and having a readily demonstrable impact on health and process outcomes.