Healthcare leaders charged with implementing health information exchange (HIE) networks in and across healthcare organizations are performing an extremely challenging balancing act on an ongoing basis. Whether leading a state-wide or regional information exchange effort or focused on providing information exchange throughout a private integrated delivery network (IDN), they are under a lot of pressure to roll out a meaningful information exchange infrastructure as rapidly as possible. Simultaneously, they must consider future organizational needs such as changing reimbursement arrangements, compliance with legal requirements, keeping astride of evolving standards or face the specter of committing to a platform that simply isn't designed for the long term. Increasingly, it is viewed as a strategic infrastructure decision.
The reality is that the intrinsic nature of a connected, complex environment such as an HIE makes it challenging to completely understand the entire system and how it works. Yet, whether operating in the public or private sector, no healthcare executive wants to switch infrastructure platforms in order to respond to future requirements. It is clear to pace-setting organizations, public or private, that simply capturing and sharing the data are not enough. The ability to analyze, understand and act on the data will deliver the value that has been elusive to so many efforts.
The key challenges facing those leading healthcare organizations interested in information exchange include:
• Financial Challenge - Today's regulatory and reimbursement environment demands that healthcare providers collect and analyze demographic, financial, and clinical data in ways that were not considerations when most current systems were designed. And, the future holds additional changes that cannot realistically be envisioned at this point in time. Amidst all of this is the continual pressure to leverage existing health information technology investments in a challenging economic environment.
• Outreach Challenge - Healthcare technology executives face a need to connect an ever-increasing number of providers and other stakeholders, all of which have different needs, work on different data platforms and have different requirement for accessing and managing data. It's likely that the enterprise has rapidly changed over the past few years as a result of ARRA/Meaningful Use, passage of healthcare reform legislation, emergence of new reimbursement models such as Accountable Care Organizations, medical homes and bundled payments.
• Strategic Challenge - Most healthcare organizations are typically burdened with the overhead of managing multiple financial, administrative and clinical systems on a variety of platforms, all of which have integration issues. And, all of those systems have requirements for maintenance, upgrades and patches or fixes on a regular basis. The challenge is to develop and execute a long-term strategy that will meet urgent and important interoperability needs that affect fiscal and clinical outcomes, while placing the organization in the best possible position to face downstream challenges or harness future opportunity.
Adding to the convolution of these challenges, there are multiple models for information exchange and organizations can be transitioning from one model to another over time, as the environment and enterprise needs change. These include point-to-point methods, the latest of which is the Direct Project, as well as central repositories, federated architectures, and robust bi-directional exchanges employing Integrating the Health Enterprise profiles.
Evolving Requirements for Delivering Value
U.S. governments at multiple levels stimulated the information exchange market with grants that funded initial efforts, modifying fiscal and regulatory frameworks to provide incentives and, in some cases, requirements for HIE networks. This support resulted in some early adopter success. At this point in time, the HIE market has matured to a stage well past the initial government-funded efforts - one characterized by changing delivery system models and an ongoing need to improve the value equation in healthcare.
Through working with both public and private HIEs, it's become possible to identify some best practices for building a foundation that provides the flexibility essential for rapid HIE innovation in a fast-changing market.
It is essential to accept that the clinicians and administrators who are the end-users of the HIE network become interested in broader access to patient information if it is delivered when they want it, where they want it and in the right dose. They are more often interested in highly relevant, nuggets of information rather than the entire patient history. Physicians are often rapid adopters of technology where there is a clear value proposition to them. For instance, the rate at which they have embraced the iPad and the Apps it offers has been remarkable. It is a direct reflection of the ease of access that they are both accustomed to and demand.
It's equally critical to realize that the vast majority of information that physicians require for daily decision-making lies in unstructured data that is in the form of free text, such as progress notes, diagnostic reports, discharge summaries, as well as images, and streaming data such as from an EKG. The informational technology professionals have come to realize that classical relational databases cannot effectively handle unstructured data.
Taking all of this into consideration, it seems clear that successful information exchange now and in the future requires technology that can effectively manage unstructured as well as structured information and organizations worldwide are increasingly making that capability a critical requirement when considering HIE platforms.
Best practices in HIE also call for efficiently and securely connecting and integrating multiple platforms, databases, and users, both internal and external to the enterprise. The HIE infrastructure must include a fully integrated interface engine that provides seamless access to data repositories and applications running in virtually any environment. Without this type of engine, the risks to patient outcomes that are almost inevitable when there are information gaps between departments, stakeholders, providers and platforms are simply unacceptable. And, the costs associated with ad hoc approaches, maintenance and upgrades to multiple systems that are not connected by a fully integrated solution are prohibitive. That is why a growing number of HIEs ranging from countrywide networks like the one now running in Sweden to local IDNs require transparent access to a complete EHR - a requirement that can only be fulfilled via the connectivity delivered by a stable, reliable and fully integrated interface engine.
An additional aspect of pursuing best practice in information exchange lies in addressing how to take strategic advantage of the information that is accessible through a fully connected and complete EHR. Traditional approaches to data analysis rely on retrospective data views, most of which contain only structured and thus, extremely limited data. In addition, it has been difficult, if not impossible, to meaningfully relate data from different systems and sources - financial versus clinical, for example. What’s needed for the transformed medical practice model that forward-thinking providers are planning to implement is a real-time view of data that is normalized and aggregated across all sources and encompassing all data types. This approach makes it possible to understand the organization’s business in new ways and to take advantage of comprehensive and up-to-the-minute information. Even more important, real-time active analytics offers the potential of cutting costs as well as length of hospital stay, leading to improved outcomes and reduced risk.
In summary, today's leaders must consider healthcare informatics from a strategic dimension in order to make optimal technology platform selections. Only in this way will they be capable of reaching well-informed business decisions and of enabling the best possible care delivery now and in the future.
Dominick Bizzarro is former CEO of the Healthcare Information Xchange of New York (HIXNY) and current HealthShare Business Manager at InterSystems Corporation in Cambridge, MA.
