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May 24, 2010

Dialed in to Data Exchange
By Lindsey Getz
For The Record
Vol. 22 No. 10 P. 10

Verizon’s launch of a commercial HIT platform sparks excitement but also raises questions about meaningful use and cost factors.

In this new era of HIT adoption, the HITECH Act states that providers must prove meaningful use by participating in some sort of health information exchange (HIE) in order to qualify for the allotted dollars. However, the effective—and secure—exchange of health information continues to be one of the bigger challenges facing healthcare organizations.

There are currently three types of health information exchanges. State/government-supported efforts are typically built off a combination of Medicaid/Medicare databases and any state university hospital system record databases to establish critical mass. Backed by the American Recovery and Reinvestment Act (ARRA), State Health Information Exchange Cooperatives received more than $500 million in funding.

The second type of HIE are those that are vendor sponsored, such as the ones from Axolotl (the largest) or Epic. In many cases, these HIEs connect with only provider organizations that use the sponsoring vendor’s software.

Finally, there are commercial HIT platforms that attempt to establish themselves as a national warehouse for all other exchanges to feed into. This would include the exchange recently launched by Verizon, which has received a lot of buzz since the company formally announced the project at the annual HIMSS conference in March.

For many, using an exchange is another step toward achieving meaningful use, but Dale Kivi, MBA, head of business development for FutureNet Technologies, warns there’s more to it than that. “Routing a document through an exchange vs. sending it as a fax does not constitute meaningful use,” he says. “If the primary benefit from an exchange is point-to-point electronic delivery of documents from a provider organization to a remote physician, they’ve completely missed the point. For the information contained in the reports to truly deliver what the government is looking for in meaningful use, it must go beyond what is needed for the direct care of an individual patient by the physicians who administered care (and generated the report) and those that they directly copied (as facilitated in today’s preexchange EHR environment). ARRA funding is not a gift for simply doing what has been considered common industry practice for over a decade.

“The true benefit of an exchange is the ability to gain meaningful use in how reports, or, more specifically, actionable data, can be extracted from the exchanges,” continues Kivi. “In the end, it is this extractable data that will be used to improve the efficiency of care management processes, enhance patient safety, increase the effectiveness of care, and deliver a measurable effect on population health, including reduction of disease incidence and prevalence, as is called for in the currently proposed definition of meaningful use. Accordingly, efforts such as the Health Story Project, which provides data structure guidelines for the most common document types, may serve as the ultimate key in unlocking actionable data from the soon-to-be-available huge repositories of clinical information.”

Verizon’s Launch
The Verizon platform, known as the Verizon Medical Data Exchange, has generated a lot of curiosity within the industry. It provides a way for medical transcriptionists to share digitized patient notes detailing care and treatment with doctors, hospitals, and other healthcare providers. The company developed the platform for the Medical Transcription Service Consortium, whose founding consortium members MD-IT and MedQuist are currently using the platform. According to Verizon, by August, when the exchange is expected to be in use by all of the consortium’s members, 350,000-plus physicians, more than 2,700 clinics, and nearly 2,500 hospitals will be supported.

“The Medical Data Exchange is a highly secure means of connecting and allowing multiple parties to share medically related files and to do it in an unstructured or open format file exchange,” explains Steven Archer, head of Verizon Business’ innovation incubator group. “The exchange will also meet the requirements of the Nationwide Health Information Network, which has established guidelines for passing secure information.”

The Verizon Medical Data Exchange will not change physician practice patterns, except to make the exchange of information easier. According to Peter Preziosi, CEO of the Medical Transcription Industry Association (MTIA), users will appreciate the simplification that comes along with the exchange. “Physicians have complained that documenting care within an EHR is cumbersome, and many don’t like EHR templates because it takes longer than the dictation process and distracts from the patient relationship,” he says. “During the recent [Association for Healthcare Documentation Integrity]/MTIA Advocacy Summit on Capitol Hill, members of these associations mentioned that it can take an additional 90 minutes a day for physicians to document care using EHR templates. As healthcare reform rolls out with 30 [million] to 32 million more Americans going to doctors’ offices, clinics, and hospitals to receive care, it will be even more important for physicians to be efficient in delivering care. The dictation-transcription process can be a much more efficient way to capture health information and one that doctors already prefer. Dictation-transcription also enables narrative reporting of the healthcare encounter, providing clinically rich information to improve patient safety and care coordination.”

Preziosi adds that the exchange of narrative reports is a better way of telling a patient’s “story.” “If you’ve ever read the outputs from a templated document generated from an EHR system, it can be confusing,” he notes. “The report is a listing of discrete data elements that appear disjointed. But if you compare that same encounter from a narrative report, generated from the dictation-transcription process, there is a context and story that is much easier for clinicians and patients to understand and read. With the Verizon Medical Data Exchange, transporting digital narrative reports from hospitals to clinics to doctors’ offices will be made simple and accelerate EHR adoption.”

Lynne A. Dunbrack, program director of provider IT strategies at research firm IDC Health Insights, says the Verizon exchange will help physicians making the switch to an EHR maintain their current workflow. “I think some of the challenge now for physicians is that some of the information in EHRs can be awkward. They are so used to dictating,” she says. “Now they can still continue to use the dictation that they’re comfortable with and then have those dictated notes be inserted into their EHR.”

In terms of affecting transcriptionists’ work, Steve Dunkle, CEO of Superior Global Solutions, says the exchange will put the burden more squarely on their shoulders—and on the shoulders of providers—to ensure accuracy. “That’s going to wind up being both a personnel and a technology issue,” he says. “Now that this information is available through an exchange, people are going to rely more on the outcomes of the information they access publicly, perhaps even more so than they do while sitting in front of their personal physician and getting an explanation. That will lead to more scrutiny on the person transcribing.”

Why Go Commercial?
While many have shown interest in the Verizon platform, one question that has been raised is how it will differ from state-funded exchanges being established with government dollars. Health and Human Services (HHS) has asked all states to ensure their providers have at least one option for meeting the HIE meaningful use requirements. And unlike these public options, there will be a cost associated with participating in Verizon’s exchange, though the company has emphasized that it does not intend for it to be cost prohibitive. Archer says there is no single answer as to how much it will cost to participate, as the expense will be on a scale based on an organization’s size and its goals. The price tag will be in the form of an annual fee, not per transaction, and Verizon will offer discounts to MTIA members. “It’s definitely not built to be cost prohibitive,” reinforces Archer. “Smaller companies will pay less.”

However, Kivi suggests that providers may consider anything that charges a fee to be cost prohibitive if the state-funded exchanges are free or substantially less expensive than their commercial counterparts. “If the objective is to participate in an HHS-recognized HIE in order to qualify for ARRA funding, the half-billion dollars in grants directed to the state exchanges should be a pretty clear indication of where providers will look to sign up first,” he says. “Any decision to participate in additional vendor-sponsored exchanges should then be made by standard business drivers such as a return-on-investment analysis.”

Dunkle agrees that the success of a commercial HIE will be largely dependent on cost. “Like most things, if it’s made easy for the consumer to buy, they will,” he says. “If it’s cost prohibitive, and there has been talk that it will be expensive, then I think it will be a real barrier to entry, especially in this economy.”

While Dunkle says acceptance of Verizon’s Medical Data Exchange may come down to dollars, he adds that it was only a matter of time before a large company such as Verizon jumped into the data exchange arena. “The government has tried to do it, and the general view is that it has not been very successful,” he says. “So to have a private sector company such as Verizon step up to the plate only makes sense. From a privacy and security standpoint, a private company will be able to better provide assurances to the public that their data exchange is secure.”

Robin Daigh, vice president of marketing and business development at MD-IT, agrees privacy and security are both critical factors and that the Verizon platform will be welcomed by those who have long said EHRs are good at capturing patient data but not exchanging useful clinical information. Congress identified three main goals for the EHR incentive program: e-prescribing, electronic exchange of health information to improve the quality of healthcare, and information submission on clinical quality and other measures, continues Daigh. “Of these three, providers report that the most difficult part of achieving meaningful use is the electronic exchange of information, and the Verizon Medical Data Exchange solves that problem. In addition, while providers may ask us to go through a number of hoops in order to document the security of our IT systems, the [Verizon] exchange will simplify that process. Users … will be certified, helping ensure that software and processes meet all privacy and security requirements for HIPAA and for meaningful use. In the future, providers should feel confident that any organization that is a member of the exchange is fully compliant.”

In addition, many also say that data exchanges, including Verizon’s, are another productive step toward EHR adoption. “We see the Verizon HIE as an important project as their success could mean a significant step toward accelerating the adoption of EHRs and overcoming the lack of an interoperable, nationally available platform,” says Mark Ivie, chief operating officer at M*Modal. “M*Modal shares in the vision that all clinical information required for good patient care, reporting, and research needs to be readily available electronically, including information from narrative documents.”

 Although Verizon’s launch is a positive step toward EHR adoption and achieving meaningful use, Rich Temple, an executive consultant with Beacon Partners, says there’s more to the exchange of information than what Verizon offers. “It’s a health information exchange option on a small scale,” he says. “It’s really confined to transcribed notes that go through one of their vendors. Though there are some big players included and a lot of notes out there, it’s still just one piece of all the data that needs to be exchanged. It doesn’t include medication history and other clinical data. I think it’s going to be effective and may even open the door to the electronic exchange of information, but it’s still just one piece of the pie.”

Temple adds that for many, Verizon’s Medical Data Exchange may be a stepping-stone toward demonstrating meaningful use, and that’s important for getting those economic incentives. “There are many things that need to happen in order to demonstrate meaningful use, but this can help providers with stage one: the ability to pass electronic results back and forth,” he says.

A Common Portal
With its nationwide launch, Verizon expects those participating in their state and regional HIEs to become users of its exchange. The company doesn’t see itself as a replacement for these public options but instead as an option that will connect them as a whole. “When you look at what’s happening with HIEs in any given state, their focus is typically around where they are—their location and their end users,” explains Archer. “But on a national level, we’re looking to pull the smaller HIEs together and connect them.”

And with that ability, many do see a lot of value. “A common portal makes a tremendous amount of sense,” says Dunkle. “What the individual states are doing with online personal information portals is a good effort, but there are issues. If you even take the Northeast, for example, there are some people that head to Florida for the winter. So having their information available in one state but not another is counterproductive.”

“Verizon and their partners have brought considerable expertise and resources to this project and are demonstrating that HIEs are not necessarily public or private by nature. Like most significant advancements, we believe that the building of a national, interoperable platform will likely come from a balance of the two,” says Ivie.

Still, with all of the funding that went into creating the establishment of the State Health Information Exchange Cooperative Agreement Program to advance appropriate and secure health information exchange, many can’t help but wonder why those government-funded projects have not been more successful and whether they will be down the road. But the bottom line is, whether the options are public or private, data exchanges are part of healthcare’s future and just another step forward as the industry continues its advance toward going digital in a new, more meaningful way.

— Lindsey Getz is a freelance writer based in Royersford, Pa.