health information exchanges: improving patient outcomes ...€¦ · health information exchange:...

Health Information Exchanges: Improving Patient Outcomes through Technology & HealthcareA little more than a generation ago, healthcare was characterized as a physician

working with a patient; occasionally involving a hospital. Less than 50 years ago,

doctors still made house calls. Today, in the 21st century, caring for a single

patient could involve a vast network that includes state and local governments,

insurance companies, testing laboratories, any number of specialists, medical

device manufacturers, pharmacies, immunization records, public health services,

Medicare and Medicaid, and home health providers, to mention a few. Healthcare

is now a patchwork of people, systems, and information. Consequential patient

information, collected by any of the providers could be shared among the entire

network when and where it was needed, if there was a system to facilitate that kind

of communication.

For several years, a vision for improving healthcare has been evolving that makes

use of sophisticated technology to compile patient information from multiple

sources and stored in a single database or distributed database system. This

vision, known as a Health Information Exchange (HIE) is intended to facilitate the

electronic movement of health-related information between different organizations

according to national standards like HL71. An HIE, not to be confused with the

Health Insurance Exchange (HIX), is a tightly controlled exchange that oversees,

governs and implements the communication of information among medical

stakeholders for the purpose of improving patient care.

1 Health Level 7 (HL7) and its members provide a framework (and related standards) for the exchange,

integration, sharing, and retrieval of electronic health information. The latest versions of the standards,

which support clinical practice and the management, delivery, and evaluation of health services, are the

most commonly used in the world..

E x E c u t i v E B r i E f

Health Information Exchanges (HIE)

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E x E c u t i v E B r i E fHealth Information Exchange: Improving Patient Outcomes through Technology & Healthcare

p a g E 2 o f 1 0

The concept of a Health Information Exchange is a good idea that will certainly

make it easier for medical professionals to deliver excellent healthcare. The

problem is how to make health exchange organizations work, from either a

technical or logistical point-of-reference.

Technically, the complex architecture required to integrate an enormous variety

of healthcare data from an enormous number of sources, scattered throughout

the country is daunting to say the very least.

Logistically, the processes required to enable ‘meaningful’ patient information

to be securely exchanged and understood2 among the various stakeholders is

yet another intimidating task.

Add to the technical and logistical issues, an even bigger question looms –

who will pay for it?

This whitepaper will focus on how the organizations that are building these

HIEs are dealing with these three challenges: technical requirements, logistical

hurdles, and long-term funding issues.

____________________

2 A complex health care system like the one in the United States needs an interoperable

data exchange environment to make health information understandable to all

stakeholders. Because there are so many different data formats in use, and one size

GRHV�QRW�¿W�DOO��WKH�2I¿FH�RI�6WDQGDUGV��,QWHURSHUDELOLW\�DW�WKH�8�6��'HSDUWPHQW�RI�Health and Human Services is striving to develop health IT data format standards and

facilitate the seamless exchange of patient data among all stakeholders.


p a g E 3 o f 1 0

Health Information Exchanges in practiceThe term Health Information Exchange is both a noun and a verb. It is

an entity, as previously mentioned, that controls the exchange of health

information. It is also a process or act of sharing information between

healthcare stakeholders. Health Information Exchanges have evolved over

the past 10 years as a grassroots type of association that is encouraged and

guided by federal and state governments3, but they are not controlled by the

government.

Government coordination for HIEs began in 2004 when President George

W. Bush issued an executive order for the development and nationwide

implementation of an interoperable health information infrastructure to improve

the quality of healthcare. The primary goal was that all Americans would have

DQ�(OHFWURQLF�+HDOWK�5HFRUG�RQ�¿OH�E\��,Q�FRQWUDVW��+HDOWK�,QVXUDQFH�Exchanges (HIX) are mandated by law in the Affordable Care Act of 2010,

and they are controlled and governed by the individual States and the Federal

government.

Because the HIEs consist of independent stakeholders, they are structured

differently than a HIX. HIEs have more in common with private sector

organizations than do HIXs, even though the Federal and State governments

are often important stakeholders within any given Health Information

([FKDQJH��+,(V�DUH�JUDQWHG�FRQVLGHUDEOH�ÀH[LELOLW\�E\�WKH�)HGHUDO�government to interconnect with other health networks, if that connection will

help to create a more complete electronic health record. HIEs need to have

WKLV�ÀH[LELOLW\�VR�WKH\�FDQ�ORFDWH�DQG�FRQQHFW�ZLWK�WKH�ZLGH�YDULHW\�RI�KHDOWK�care organizations and services that possess different pieces of a single

patient’s health record.

________________

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man Services. It is primarily focused on coordination of nationwide efforts to implement

and use health information technology and the electronic exchange of health information.


p a g E 4 o f 1 0

There are four broad types of government coordinated Health Information

Exchange categories described by the following acronyms:

1. State Level Health Insurance Information Exchange (SLHIE)

The State Health Information Exchange Cooperative Agreement Program,

authorized by the Public Health and Safety Act is designed to promote

health information exchange across the entire spectrum of healthcare. The

purpose of the program is to expand the secure electronic exchange of health

information among organizations according to nationally recognized standards.

This program is a Federal and State collaboration with a long term goal

RI�HQVXULQJ�D�QDWLRQZLGH�+,(�ZLWK�LQWHURSHUDELOLW\��7R�WKLV�HQG��WKH�2I¿FH�RI�1DWLRQDO�&RRUGLQDWRU�IRU�+HDOWK�,QIRUPDWLRQ��21&��DZDUGV�FRRSHUDWLYH�DJUHHPHQWV�WR�6WDWHV�DQG�6WDWH�'HVLJQDWHG�(QWLWLHV��7KH�WRWDO�IXQGLQJ�available to all states and eligible US territories is $564,000,000.

��5HJLRQDO�+HDOWK�,QIRUPDWLRQ�([FKDQJH�2UJDQL]DWLRQ��5+,2�

$�5+,2�LV�D�PXOWL�VWDNHKROGHU�RUJDQL]DWLRQ�FUHDWHG�WR�SURPRWH�WKH�development and growth of health information exchanges. In addition to

LPSURYLQJ�SDWLHQW�FDUH��5+,2V�DUH�DOVR�LQWHQGHG�WR�VXSSRUW�WKH�VHFRQGDU\�XVH�of clinical data for research as well as care providers quality assessment and

LPSURYHPHQW��5+,2�VWDNHKROGHUV�LQFOXGH�VPDOOHU�FOLQLFV��KRVSLWDOV��PHGLFDO�societies and employers within a multi-state region.

3. National Health Information Network (NHIN)

The NHIN, now called the eHealth Exchange, is an initiative developed under

WKH�VSRQVRUVKLS�RI�WKH�21&��7KLV�QDWLRQDO�QHWZRUN�LV�EDVHG�RQ�XWLOL]LQJ�VHFXUH�email to exchange healthcare related information between patient stakeholders

on a nationwide level.

4. Health Information Exchange (HIE) Networks

The HIE Network is the blanket acronym that describes the program,

established during President George W. Bush’s administration, to improve

patient healthcare through better communication between stakeholders. It is

also often used to describe the local information exchanges that are usually

more homogeneous in terms of patients and stakeholders, focused on a

GH¿QHG�JHRJUDSK\��DQG�LV�VSHFL¿F�WR�D�W\SH�RI�VSRQVRU��H�J��WKH�&OHYHODQG�&OLQLF¶V�+,(�FDOOHG�'U&RQQHFW��


p a g E 5 o f 1 0

Each of these categories emerged over the past few years as a result of

hundreds of medical professionals and other sponsors from many different

RUJDQL]DWLRQV�VHDUFKLQJ�IRU�WKH�PRVW�HI¿FLHQW�ZD\V�WR�RUJDQL]H�DQ�+,(�DQG�hold it together.

Any of the four categories of exchanges will also fall into two general types of

organizations:

1. Proprietary, which means the HIE was started and is controlled by a

single organization (e.g. an electronic health record vendor, or a large

hospital or hospital system, etc.)

2. Non-proprietary, which means the HIE was started and is controlled

E\�PXOWLSOH��FRRSHUDWLQJ�EXW�XQDI¿OLDWHG�RUJDQL]DWLRQV��H�J��D�QHWZRUN�consisting of public health agencies, state government, physician

SUDFWLFHV��KRVSLWDO�V\VWHPV��GLVHDVH�VSHFL¿F�UHVHDUFK�RUJDQL]DWLRQV��DQG�health insurance providers)

There are advantages and disadvantages to both types, but by far the most

‘workable’ type of exchange is proprietary. Since a proprietary exchange is

headed by a single organization or company, it has leadership, a funding

source, and provides clear value to the participants. However, a proprietary

exchange has limited access to patient data, because the stakeholders that

are entering information into the exchange database represent only a subset

of the entire scope of healthcare stakeholders that could exist for any given

SDWLHQW��2EYLRXVO\��WKLV�FRXOG�OHDYH�VLJQL¿FDQW�JDSV�LQ�WKH�SDWLHQW¶V�HOHFWURQLF�health record.

The non-proprietary exchanges have the potential to be all inclusive and

present a more complete picture of any given patient’s health status, because

they typically have access to the entire range of healthcare stakeholders.

However, it has one almost insurmountable obstacle, and that is a lack of

reliable long-term funding. Beyond the lack of money, the non-proprietary

exchanges also have serious technical challenges when it comes to

integrating so much data from so many sources. Although that challenge

can be overcome, it takes a lot more coordination and cooperation between

stakeholders to be successful.


p a g E 6 o f 1 0

State Level HIE projects2QH�RI�WKH�PRVW�VXFFHVVIXO�SURSULHWDU\�6WDWH�/HYHO�+,(V�LQ�WKH�FRXQWU\�LV�LQ�the state of Indiana. The Indiana Health Information Exchange focuses on

SURYLGLQJ�¿QDQFLDO�DQG�WHFKQLFDO�VXSSRUW�WR�H[LVWLQJ�ORFDO�H[FKDQJHV��7KH�PHPEHU�ORFDO�H[FKDQJHV�DUH�XVXDOO\�VPDOO�ZLWK�YHU\�VSHFL¿F�SDWLHQW�SURYLGHU�needs, but they have comprehensive coverage within a geographic area.

At a National eHealth Collaborative meeting earlier this year, John Kansky,

vice president of product management for the Indiana HIE (IHIE), said the

key to Indiana’s success is keeping their focus on providing clear value to

its customers. “We approach it and sustain it as a business,” he said. The

IHIE connects 90 Indiana hospitals, and 19,000 physicians use it. The IHIE’s

'2&6�'2&64 subscription service provides lab and radiology results to

physicians in a Web-based inbox. The IHIE also offers a service that enables

hospitals and physicians to electronically share clinical images.

The state of Maine started a non-proprietary state-level health information

exchange (SLHIE) in 2004 called the HealthInfoNet. This is a good example of

a state-wide HIE that stores all health information in a single shared database.

Where most states use a federated model of data storage in multiple locations,

which doesn’t always have standard formats; Maine preferred the centralized

PRGHO�WR�HOLPLQDWH�WKDW�LVVXH��³2QH�NH\�SUREOHP�ZLWK�WKH�IHGHUDWHG�PRGHO�LV�WKDW�WKH�GDWD�LV�QRW�VWDQGDUGL]HG�´�VDLG�'HY�&XOYHU��&(2�RI�+HDOWK,QIR1HW��“They can’t create a view of the patient. We put a lot of time into mapping all

that data to standards. In a federated model, that is impossible to do.”

It’s expected that all of Maine hospitals will be under contract to HealthInfoNet

by 2012 and will be connected by the end of 2013. The exchange is planning

for at least 80 percent of the state’s ambulatory and outpatient providers will be

connected by 2014.

________________

��,QGLDQD�KDV�OHYHUDJHG�WKHLU�FOLQLFDO�PHVVDJLQJ�VHUYLFH��'2&6�'2&6��WR�LPSURYH�the communication of information between public health agencies and health care pro-

YLGHUV��'2&6�'2&6��LV�D�V\VWHP�GHVLJQHG�DQG�GHYHORSHG�E\�WKH�5HJHQVWULHI�LQVWLWXWH�to deliver clinical results to physicians.


p a g E 7 o f 1 0

Tennessee is a good example of a regional HIE organization that did a mid-

course correction. In June of this year, the board of directors for the Health

Information Partnership for Tennessee (HIP TN) decided to shut down its

operations. The partnership was created in 2009 to help Tennessee create

D�QRQ�SURSULHWDU\�5+,2��+RZHYHU��WKH�WDVN�SURYHG�WR�EH�PRUH�FRPSOH[�DQG�ambitious for their level of readiness. The state wanted to offer enterprise

services, including links to an immunization registry, electronic lab results and

compiled patient medication histories, but was unable to create the exchange.

Instead of a Regional HIE organization, Tennessee decided to pursue a

simpler strategy that uses email messaging systems to communicate with

provides.

Tennessee may not be the only state that is changing direction. With limited

grant funding and many technical challenges, other states are also re-

evaluating their larger goals of creating a state-wide or regional infrastructure

that would allow searching of patient records from both hospitals and doctors’

RI¿FHV�

2QH�FKDOOHQJH�WKDW�SXEOLF�VHFWRU�+,(V�IDFH�LV�FRPSHWLWLRQ�IURP�SULYDWH�+,(V�being set up by independent health systems to support primary care and

home-healthcare organizations. In Connecticut, the three main hospital

systems are expanding rapidly by buying smaller hospitals and large physician

practices, and building out their own proprietary HIE architectures that are tied

WR�VSHFL¿F�HOHFWURQLF�KHDOWK�UHFRUG�YHQGRUV��

“That is changing the thought process about the role the state HIE will play,”

VDLG�'DYLG�*LOEHUWVRQ��&(2�RI�WKH�+HDOWK�,QIRUPDWLRQ�7HFKQRORJ\�([FKDQJH�RI�&RQQHFWLFXW��³:KDW�LV�WKH�LQFHQWLYH�IRU�SURYLGHUV�WR�FRQQHFW�WR�XV"�2QH�LV�WR�¿OO�WKH�JDSV�DQG�RIIHU�DFFHVV�WR�WKH�SURYLGHUV�WKDW�DUH�QRW�SDUW�RI�WKHVH�organizations,” he said. “Another is to provide access to public health and

Medicaid data. Those are the value propositions.”


p a g E 8 o f 1 0

HIE Technical architectureAs mentioned in the beginning of this whitepaper, the vision of any Health

Information Exchange is to improve healthcare across the board by

exchanging patient information. To share meaningful patient information,

securely, on a scale this large is a complex and multifaceted undertaking.

The only way to do it is with sophisticated technology. And, the only way

WHFKQRORJ\�ZLOO�ZRUN�LV�ZLWK�D�VFDODEOH�DQG�ÀH[LEOH�LQIUDVWUXFWXUH��+,(�WHFKQLFDO�architecture models fall into three categories: centralized, hybrid, and

federated. The diagram below explains the differences of each type:

HIEs: Technical Architecture Models (3 Types)

Centralized Hybrid Federated

1 Data is accumulated/managed in a single, centralized repository

1 State HIO has full control over data and ability to authenticate.

1 HIO is responsible for management of patient ID, data storage and privacy.

1 MPIs used to link patient records across databases.

1 Centralization or distribution is dependent &%�*'��!2��)�(,!)�$�%+*�

1 User interface connects patient information from various sources.

1 Multiple patient !��%+!2��+!&%�technologies: Master patient Indices and Record Locator Service (RLS)

1 Network permits users access only when needed.

1 Peet-to-peer architecture.

Each architecture has its pros and cons, but whichever architecture is chosen,

the hardware, software and IT personnel required to run the exchange plays a

key role in the success or failure of the HIE.

Additionally, because the infrastructure has to be secure, the HIE must to be

hosted in a HIPAA compliant environment that can meet the administrative,

technical and physical requirements of a structure containing patient

information. The trail of security extends to a variety of entities, such as the

hospitals, physicians, various vendors that are entrusted with data storage, the

systems performing the transmission of patient data over networks, as well as

those who are responsible for the physical security of the building housing the

HTXLSPHQW��2QH�ZHDN�OLQN�FDQ�OHDG�WR�D�GDWD�EUHDFK�DQG�H[SRVH�WKRXVDQGV�RI�medical records to the public or to someone trying to hack into the system.


p a g E 9 o f 1 0

There are two options for hosting an HIE architecture: 1) it can be hosted

internally by one of the participating stakeholders, or 2) it can be hosted by a

third-party managed hosting provider. Either way, the technical and logistical

requirements of the HIE architecture will be the same. The question to answer

is – which of the two options will do the best job and stay within the budget?

Before moving ahead with plans to create a Health Information Exchange, it is

advisable to decide how the hardware and software should be hosted and who

should provide the hosting environment. The option to utilize an independent

hosting provider and have the HIE hosted in a private cloud is one that should

EH�VHULRXVO\�HYDOXDWHG��7KLV�RSWLRQ�KDV�D�QXPEHU�RI�SRWHQWLDO�EHQH¿WV�OLNH�ORZHU�FRVW��VXSSRUW��FRQWLQXDO�PRQLWRULQJ�RI�V\VWHP��DQG�D�VROLG�GLVDVWHU�recovery plan. A third party provider will also build the technical platform and

dedicate the necessary resources to the HIE to insure that it performs at an

optimal level. This approach is opposed to an in-house provider that might

VLPSO\�µ¿W¶�WKH�+,(�HQYLURQPHQW�LQWR�WKHLU�H[LVWLQJ�DUFKLWHFWXUH��$GGLWLRQDOO\��most enterprise level hosting providers are compliant with all federal and state

regulations governing data security.

A cloud environment, such as those hosted by Secure-24, can facilitate any

of the typical HIE architectures (centralized, hybrid, or federated). Whatever

architecture is best for the HIE business processes can be designed, tested,

and deployed in a virtual cloud production environment in less time than using

a typical in-house environment. From rapid deployment to tighter security, from

better integration with diverse systems to higher performance, a cloud solution

is an excellent option for hosting Health Information Exchanges.

The diagram on the next page illustrates that patient information is collected

from various sources (top) and can be compiled and integrated in a cloud

(center) so that it can be understood by various constituencies (bottom).

ConclusionThe challenges to provide meaningful and secure patient information

electronically online are substantial and the jury is out on how to build the best

W\SH�RI�+HDOWK�,QIRUPDWLRQ�([FKDQJH��2YHU�WKH�\HDUV�D�QXPEHU�RI�GHVLJQV�DQG�PRGHOV�KDYH�EHHQ�WULHG��EXW�D�GH¿QLWLYH�DSSURDFK�KDV�QRW�HPHUJHG��7KHUH�DUH�FOHDU�EHQH¿WV�WR�DOO�SDWLHQWV�LI�D�VXVWDLQDEOH�+,(�PRGHO�FDQ�EH�IRXQG��EXW�WKHUH�will be more trial and error as the various approaches are vetted.


p a g E 1 0 o f 1 0

To learn more about how

outsourcing your applications and

infrastructure to Secure-24 can

help your organization achieve its

business goals, contact us at:

Phone: 800.332.0076

Info: [email protected]

Sales: [email protected]

www.secure-24.com

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HIE Core Services — Conceptual Model

As can been seen throughout this whitepaper, there are serious technical,

logistical and funding challenges facing all Health Information Exchanges.

However, each exchange can deal with their unique challenges in creative

ZD\V��ZKLFK�XOWLPDWHO\�ZLOO�KHOS�DOO�H[FKDQJHV�¿QG�WKH�EHVW�PRGHO�WR�XVH��7KH�)HGHUDO�JRYHUQPHQW�LV�SURYLGLQJ�VRPH�JXLGDQFH�DQG�¿QDQFLDO�DVVLVWDQFH�LQ�the early stages of designing and building a HIE, but the success or failure of

an exchange will come down to how much value the HIE provides and how

broadly supported it is by the stakeholders.

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health information exchanges: improving patient outcomes ...€¦ · health information exchange:...

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