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October 2, 2006
EHR systems serve as the steering mechanisms that guide the development of RHIOs and other health information exchange structures. Although far from widespread, the development of regional health information organizations (RHIOs) and health information exchanges (HIEs) is certainly accelerating, especially as forward-thinking organizations realize benefits such as improved clinical outcomes, enhanced patient safety, and reduced healthcare costs. In these early development stages, the lynchpin for successful RHIOs and HIEs has proven to be the technology partner organizations adopt—individually and as a group—to facilitate data sharing. The healthcare information systems—particularly electronic health record (EHR) systems—used by each participating entity must provide a foundation that will allow information to be exchanged easily. In addition, the group must agree on and develop a common technology structure that helps it accomplish the mutual goal of communicating and sharing health information. EHR Selection Vital One important characteristic is the type of database that serves as the heart of the system. Some EHR systems are simply clinical note generators, providing no functionality beyond recording the provider’s documentation. However, to facilitate information exchange, the system should feature a structured database, where discrete pieces of information flow between sections of the record. This allows providers to have instant access at the point of care to vital information impacting diagnostic and treatment decisions. With structured data fields, healthcare organizations can sort and categorize the data for reporting and analysis purposes. This level of database functionality is particularly important when evaluating how well the EHR system and companion systems manage health information that comes from outside systems, including lab results, radiology reports, and consultants’ findings. Ideally, the systems should allow the data to be uploaded and integrated into the patient chart. If this information is scanned or otherwise appended outside the medical record, providers are not able to access comprehensive information in a convenient and timely manner. Likewise, healthcare organizations must seek out EHR systems that comply with emerging HIM standards such as Health Level 7, which enables disparate healthcare applications to exchange key sets of clinical and administrative data, and SNOMED, which standardizes clinical terms. Models like these create the equivalent of a common language, so healthcare organizations can exchange information even if each partner uses different technology. To ensure that these features are inherent to the system they ultimately select, healthcare information professionals should investigate whether the vendor is certified by the Certification Commission for Healthcare Information Technology (CCHIT). The CCHIT is a private-sector collaboration between the AHIMA, HIMSS, and The National Alliance for Health Information Technology. The organization has been sanctioned by Health and Human Services to certify HIT products, including ambulatory EHR systems for office-based providers, inpatient EHR systems for hospitals and health systems, and the network components these organizations use to share information. Patient-Focused, Provider-Friendly
Systems Are Ideal Of course, provider and administrative representatives must play an active role. In addition, leaders from the finance department should be involved. They must, however, guard against automatically championing an EHR system offered by the same vendor that provides their practice management system simply because it is an easy choice. In some cases, the same vendor may be appropriate—but only if its companion EHR system is designed specifically to support the provider’s clinical priorities. Likewise, IT professionals should be at the table because their assessment regarding technological concerns is invaluable. However, these experts must acknowledge that an EHR system should not be selected only on the basis of its technical attributes. They should not make recommendations based solely on ease of implementation, for instance, or because a particular system will require minimal interfaces with other systems. Instead, they must make sure that the application is compatible with existing or anticipated hardware and software, that the security of the system is sound, and that it will mimic providers’ workflow, which is vital to successful adoption. Data Exchange Depends on Technology
Infrastructure Stage one of this journey is inviting representatives of potential member organizations to the table—including various local physician practices, health systems, hospitals, etc—to the table. This can be a challenge because it requires competing interests to put aside their own agendas to focus on achieving a common goal. Most of the time, however, providers recognize the benefits to individual patients and the community. Often, these groups appoint or hire an administrator to help them navigate the maze of issues that face a RHIO or an HIE. Once an agreement has been reached and the organization has been formed, the next hurdle is identifying a funding source. While some federal money is available, most existing RHIOs and HIEs have relied on local support—communities and state governments have provided grants, as have private payors. In other instances, local health systems have been the driving force behind these coalitions. To be successful, however, these organizations have needed to address Stark restrictions. A common strategy has been to establish an independent corporation, or Integrated Clinical Network, to avoid the perception that the hospital is giving equipment or technical resources to physician practices. Many health information professionals anticipate that concerns about Stark will diminish in the near future, thanks to proposed legislation relaxing regulations and allowing more extensive joint efforts. Partners Must Address Technology,
Access Issues As the data exchange is being developed, the partners must agree on numerous issues. For instance, will they establish a central data repository, where patient information is collected to be fully accessed by all? Or will they adopt a federated “gated” model in which organizations needing information request or are granted access to discrete pieces of patient information from other providers? Then, the coalition must achieve consensus about how it will identify patients. Currently, there is no national patient identification system for healthcare, although there has been discussion about establishing a program similar to Social Security. In the meantime, RHIOs and HIEs often establish a community master patient index (MPI) to which providers refer whenever they see a patient either to establish a new record or access an existing one. Alternatively, a RHIO or an HIE may use an existing MPI—perhaps one developed by a local hospital. Participating members can then “crosswalk” patient identifiers with their own internal system for easy reference. Another significant issue—perhaps the biggest—is determining what type of information will be shared. Some providers are highly protective of their patients and loath to share what they consider to be proprietary information. Others believe exchanging data can lead only to better care, which will cement their relationships with patients even when those patients see other specialists in their community. In any event, each RHIO or HIE must decide whether it will share only basic information—such as medication, allergy, and problem lists—or whether it will make available comprehensive records that may include even demographic and insurance data. Either way, it must ensure that data exchange is secure and all confidential information is protected. Lessons Learned Drive Future
Development The trend toward RHIOs and HIEs is still in its early phases. Nevertheless, several important lessons have been learned: • The process takes time and setting expectations too high guarantees failure. RHIOs and HIEs may take several years to get established and member organizations must be willing to invest in up-front planning to enhance success. • From a technological perspective, these collaborations must be designed from the ground up to make patient information available quickly and in a usable fashion. If the data exchange is hard to use or if vital information can’t be incorporated efficiently, providers will not rely on or contribute to the system. • The EHR system used by each partner in the RHIO or HIE must reflect the workflow of its providers. If the member is unable to get buy-in within its own system, it will be impossible to convince providers that a broader network is beneficial. • Each EHR system must exhibit functionality and comply with interchange standards that allow it to be networked with others in the community. Greatest Benefit Perhaps the greatest advantage is enhanced quality of care. For example, internists treat a number of patients with diabetes. Let’s say a patient recently saw an ophthalmologist, who recorded a significant change in the individual’s vision. If the internist has access to that information, he or she will be alerted to the fact that the patient’s diabetic status needs reassessment. Besides resulting in better care and outcomes, this knowledge will also prove invaluable as pay for performance influences reimbursement. It will become increasingly important for providers to know the breadth of care their patients receive as payors scrutinize disease management and health maintenance programs. For example, primary care providers will need to report annual well woman screenings such as pelvic and breast exams or Pap smears as part of pay-for-performance requirements. If a patient has the primary care provider do a portion of her annual checkup, while going to her gynecologist for the well woman components, neither provider will be able to report the comprehensive nature of the preventive service. With RHIOs and HIEs in place, that data will be easily accessible to improve payor reporting. In short, the advent of RHIOs, HIEs, and other collaborations promise great benefits to providers and patients alike. While still in its infancy, this trend will no doubt accelerate and become a defining characteristic of the healthcare landscape. Health information and technology professionals will play a significant role in the development of these coalitions, since success is highly dependent on the functionality of each provider’s EHR system, as well as the network infrastructure the partners will share. — Sarah T. Corley, MD, FACP, is a primary
care internist in the metropolitan Washington, D.C., area and also serves
as chief medical officer for NextGen Healthcare Information Systems.
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