Jan

10

HIE versus RHIOs and the Like

There is a lot of talk about HIEs at the state and national level these days. Everyone wants to get into the act of tapping into the new HIT dollar supply and “setting an HIE.” As indicated, the new HIE gold rush seems to be driven by the significant influx of stimulus funding that will be short lived (in comparison to the time it has will likely continue to take to move the HIT agenda forward and establish widespread electronic exchange of meaningful patient data). The federal government, states and entities are waiting in line to “set up that HIE” and quickly advance the vast flow of patient information from one provider to another to “increase the quality and efficiency of health care.” I think it is important we are clear on what HIE means and not to forget about the recent past (and present) as all embark on the HIE/HIT train.

I think it is important to clarify what I believe I (and others) consider is and is not electronic health information exchange (HIE) in the sense that it relates to communication across health care entities. I can use a number of different health care entities from hospitals with clinics to health care delivery systems to HMOs as examples to illustrate what I do not consider an HIE (which doesn’t mean that entity is not involved in developing or soon implementing a platform to facilitate HIE).

As an example, a large multi-state health care organization in the US installed the same electronic health record (EHR) across the country. When the EHR was implemented in different regions of the country, it was configured differently and has created interoperability issues within the health care organization. As an example, without the implementation of an EHR translator, this health care organization’s operations in the NW part of the US cannot “talk” to the health care operation’s NE part of the US.

When a translator is implemented that allows different internal applications (in this case the same application configured different ways), to communicate, I would not consider that HIE in the sense being discussed as part of a number of states’ HIT strategic plans. It is a health care organization connecting applications to allow internal communication of health care information about that health care organization’s patients. I would stress internal – it is not an exchange fostering the sharing of patient information across organizations but addressing an internal interoperability issue.

Any efforts to internally establish communication between, say, a hospital’s EHR and the hospital’s clinical EHR is not, in and of itself, HIE as is envisioned at the national level. Just like the preceding example, it is point-to-point communication and a streamlining of the communication of patient information internally. Wherever the same situation existed within any health care organization where internal applications do not communicate but efforts are underway to facilitate that internal communication of patient information, I would make the same statement about those health care organizations – such efforts do not constitute HIE.

As another example a number of independent physicians associations (IPA) across different states have elected to purchase an EHR as a service to members and allow members to subscribe to what amounts to each physician’s own EHR, albeit a “slice” of the larger application. I would also not consider this HIE if the physician only has access to his or her own patient’s medical records versus all IPA member patient records. If the IPA worked with the community and its members to create a true regional health information organization (RHIO) or health information organization (HIO) that facilitates HIE – allowing communication across a network of health care professionals or providers – I would consider the information exchange falls within the category of HIE.

To provide a bit of additional clarification, during the national Health Information Security and Privacy Collaboration project (HISPC), there was a distinction made between RHIOs, HIOs or health information exchange organizations (HIEO) and electronic health information exchange (HIE). RHIOs, HIOs and HIEOs were considered nouns and HIE was considered a verb – the act of the exchange versus an entity or organization facilitating the exchange. This is to a great extent supported by the adoption of a national definition of RHIOs and by the language in the American Recovery and Reinvestment Act (ARRA), Division A, Title XIII (also called the HITECH Act), Subpart D. RHIOs, HIOs and HIEOs will be categorized as business associate entities of covered entities effective February 17, 2010.

Also, the National Alliance for Health Information Technology provided clear definitions for HIE, RHIO, HIO, etc. Many of these definitions have been adopted nationally and, as an example, if you review HISPC Phase III glossaries of terms, the California state HIT related project definitions, the Wisconsin state HIT related project definitions, etc., you will find they are fairly consistent. HIE is the act of sharing information while RHIOs, HIEOs and HIOs are the organizations that facilitate or manage HIE. Statements have been made that there is “no common definition of HIE” which, in its own way, is true in that there are different organizational and exchange models that have evolved over the past few years. The basic definition of HIE, RHIO, etc., though, is relatively consistent.

States and regions will adopt their own flavor of one or many RHIOs, HIOs and/or HIEOs that work for the state or region but I would recommend viewing state or regional efforts as how to expand HIE through one or many RHIOs, HIOs, etc. (which can be individual hospitals, independent non-profits, health plans, state government, etc.). You can check out the National Alliance for Health Information Technology’s report to the Office of the National Coordinator for Health Information Technology (ONC) regarding the definitions I referenced at http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS0107418481330018/102hit_terms.pdf.

As we move forward, I think it is important that, as much as feasible, we build on the quality work of the Health Information Security and Privacy Collaboration (HISPC) project, the work of the National Institute for Health Information Technology, the work of the Health Information Technology Standards Panel (HITSP) and others to make the best use of the significant amount of HIT related funding that will be short lived rather than start from scratch. I also think it is important to be clear regarding what we are talking about and what we state to be true. Many have said, “look how many HIEs we have,” when in actuality we may have entities involved in facilitating HIE and in other cases what I would call point-to-point communication only (not necessarily a bad thing and what can be a good place to start).

We will not develop a vast interconnection of networks exchanging significant amounts of patient data over the next two years. We can, given intelligent moves, make significant strides towards that end but to think we can do what we have yet to be able to fully accomplish over the last several years overnight is not realistic. Let’s make the best use of our money and build the foundation that recognizes the plan needs to include short term objectives and some results with mid-range and long term objectives that can be realized. Such an approach is realistic if such are the plans of the federal government and states as HIT strategic plans evolve and are funded from the now available HIT stimulus dollars.