Is Lack of EHR the Real HIE Problem?
HIE (Health Information Exchange) is a really interesting thing. It’s something we all know we want to have happen and so far millions and millions of dollars later no one has been able to crack the code on how to make an HIE a reality.
The benefits of having an HIE are real and apparent. I’ve never heard anyone argue about whether an HIE would bring benefits to healthcare. It’s simple to see that having all of your health information available to a doctor at the point of care is valuable and useful. We don’t need a study to show that. We know it’s the case. Having the information could be the difference between life or death.
We all know that if a doctor can get the lab or radiology information from the HIE, then they don’t have to order another duplicate lab or x-ray. They might still order another one (for a bunch of perverse and maybe some legitimate reasons), but in many cases they wouldn’t have to order one since they’d already have the info they need.
Why then isn’t HIE a reality today?
For the longest time I’ve argued that there are two main barriers to HIE: governance and funding. By governance I mean, “How are we going to make sure that the right people get the right information and that the wrong people don’t get the information they shouldn’t have?” Funding is really about finding a sustainable revenue model for an HIE.
While I still think that both of these issues are real challenges for HIE, I recently started to wonder if the real challenge for an HIE is that not enough doctors and hospitals are using EHR. We want HIE’s to be successful, but can an HIE be really successful for doctors and hospitals that don’t have an EHR?
The lack of EHR adoption might be the biggest impediment to HIE.
I think you are on to something here. The lack of EHRs, or even agreement on what an EHR does is a real issue. It is easier to blame governance and funding.
I think the lack of interoperability is the next level problem. What I named my lab tests is probably different than what you named yours. Very few organizations have implemented standards like LOINC. So, the HIE can ask for all of your lab results, but my EHR can’t intelligently look for the order I am thinking of placing. There is no way the doc is going to sort through the history manually, so they place a duplicate order.
HIEs that truly join EHRs is a decade away. The best we can do today is to replace the fax machine with something with a wired connection.
Excellent insight as always Will. It’s not just an EHR, but an EHR with some standards for exchange. Although, considering many of the crosswalks and translations I’ve seen done in other IT systems, I think that problem could be overcome if the data was at least stored electronically. You’d still have to tread lightly in many cases, but it would be a step in the right direction.
A decade sadly seems right.
Great point made here. The lack of adoption of the EHR definitely hinders the nationwide acceptance of an HIE. Another thought to consider is why have some European countries been able to adopt these methods, yet not the US? Size difference could play a factor.
Just imagine the administrative and reporting costs that could cut if all records were kept in the cloud in a HIE….
Thanks John for the interesting topic!
I work for an HIE system vendor, ICA. One of the challenges we see our HIE’s face is FUD (Fear, Uncertainty and Doubt) around sharing patient data. The fear arises in sharing data with other participants that are direct competitors. The competition between participants can lead some participants to refuse to share “their” patient data with other participants, creating complex sharing rules based on these relationships, and meaning that the view of a patient’s record will change depending on what facility you happen to be in. This results in the patient’s medical record not being complete. The patient, meanwhile, is not aware of these nuances and is not aware that their record is incomplete due to these competitive issues. I can’t say we have an answer as to how to solve this, but it’s definitely a potentially large roadblock, larger I think that EMR adoption itself.
I would say in response to these issues:
* The EMR determines what data is shared, so you (as a customer of the EMR) should have some control over what exactly is shared and when
* The HIE will not by any means have a “complete dump’ of your database; the EMR sends out a limited amount of data about the patient or the encounter
* The interoperability standards are set up to keep participants from attempting what I call “patient surfing,” keeping the availability of data to those patients for which you have an established relationship. This means that your competition cannot simply download every one of your patient records, as they have no access to a means to query for all your patients.
* Auditing and regulatory measures ensure that attempts to access records for purposes other than direct patient care are caught and properly sanctioned.
I would say that the utilization of an EHR is the number one barrier to the adoption of a HIE. The implementation of a HIE requires that an EHR already be in place. We can worry about governance and interoperability later, first lets get everyone up to speed so there is a chance for all to participate.
And from a technical standpoint, interoperability is not such a huge feat to accomplish. It will mainly require adoption of a standard, the code and interfaces will be the easy part.
Lots of good points made by the author and in the comments. But there’s more. I’m on Long Island, where from what I can tell we have 2 competing HIE’s – that as far as I can tell don’t talk to each other. One big hospital in one HIE, nearly everyone else in the other. On top of that, the patient portal in the one is a very well kept secret and access to it requires that paper forms be filled in and mailed; no way to tell if the other has one.
Lack of EHR’s is also a problem; the hospitals (not always including the ER) typically do have them, usually EPIC from what I’m told. Few doctors or labs do. The doctors are terrified about the cost and privacy issues, and seem so confused and unsure they just don’t know where to begin. There are far too many EHR products, too little info on which will meet their needs, costs are not typically published. And because it is extremely hard for new people (IT Pro’s and others) to break into the industry, there is not a lot of manpower available. And the incentives are not enough to overcome the fear.
I’ll write it again.
HIPAA and HIE are two ideas from different perspectives of health data.
They are diametrically opposed as difficult vs easy are opposed.
Great comments. I love your suggestions Tim. I’m probably going to republish them as a post on my other blog. Great stuff!
DocJim,
It’s true. How do we overcome it?
From a techie’s viewpoint (I’m at IT manager), it seems that a major barrier is a standard format for publishing data. I’m one of the last people to advocate government oversight but in this case that’s probably what will be needed.
For instance, why is it that you can connect your notebook PC to just about any wireless internet, assuming you have the password? It’s because there is a set of rules and requirements for manufacturers that build wireless routers, and they have to conform to those standards if they want to state that their equipment is “802.11g” or “802.11n” compliant.
The same thing will be needed for HIE; there will have to be a standard format that ALL health providers must comply with, or the resulting data will be almost impossible to use. In addition, participation will have to be mandatory (at least for those with EHRs) and information exchange will have to be in both directions. The mandatory participation requirement will hopefully prevent some providers from simply ignoring available information and ordering all new tests (which translates to big $$$), and we must also hope that the free market will weed out those providers that try to be isolationists.
[...] response to my post about the Real HIE Problem, Tim Dunnington provided this powerful insight into a major challenge that are faced by HIEs. [...]