Electronic Health Records


Solutions for Addressing Health Information Exchange Challenges

Health information exchange is essential to achieving true interoperability, but solutions are necessary for addressing challenges to information sharing.

Source: Thinkstock

“Hospitals and physicians are now exchanging more electronic health information than ever before,” the Office of the National Coordinator for Health Information Technology told Congress in an annual report from early November.

It is a statement of fact backed up by rather positive statistics.

“In 2008, 41 percent of all hospitals electronically exchanged health information with outside health care providers,” the report continues. “These rates have since doubled. In 2015, more than eight in ten (82 percent) non-federal acute care hospitals electronically exchanged laboratory results, radiology reports, clinical summaries or medication lists.”

The ONC report then includes this impressive finding.

“Moreover, of the hospitals that electronically send, receive, find, and integrate information, approximately nine out of ten report that they routinely had clinical information needed from outside sources or health care providers available at the point of care, which is about double the national average,” it states.

According to ONC, an increased flow of health information is happening. However, these statistics paint an incomplete and rather complicated picture of health information exchange across the country and beg a few questions to be asked.

What does health information exchange mean? Is all information sharing the same? What is the relationship between the exchange of health data and health IT interoperability?


ONC compiles data from numerous sources to track the health data exchange by hospitals and physicians, namely the National Center for Health Statistics and the American Hospital Association.

Absent from this year’s report to Congress pertaining to the increased flow of health information was any mention of the health information exchange statistics for office-based physicians, which was the case with the 2015 annual report.

This information is buried in the latest report in an appendix although there is no direct corollary to the 82 percent of hospitals that electronically exchanged laboratory results, radiology reports, clinical summaries or medication lists.

The data from the NCHS 2015 National Electronic Health Record Survey breaks down physician health information exchange into four categories: sending, receiving, finding, and integrating and using.

Here’s how hospitals and physicians stack up against each other in sending health data:

Source: ONC

There’s no contest. Office-based physicians lag significantly behind in every category. Likewise, few baselines exist to measure the progress of the former over the past seven years.

The same can be said of the juxtaposition of the percentage of physicians and hospitals with the ability to receive and find patient information.

Source: ONC

Lastly, there’s the comparison of each provider group’s ability to integrate and use health data from external sources. Again, physicians are worse off. However, more hospitals are likelier to struggle with integrating external health data.

Source: ONC

Recall that statistic from earlier — “approximately nine out of ten report that they routinely had clinical information needed from outside sources or health care providers available at the point of care, which is about double the national average.” That figure is drawn from a much smaller pool of hospitals considering that  46 percent of hospitals in the ONC and AHA data reporting this capability.

More recently, ONC has taken to the practice of measuring interoperability among providers rather than health information exchange, but even here variation is commonplace. This year, the federal agency publish two briefs on interoperability among non-federal acute care hospitals in 2015.

The first provided several key takeaways. For one, 26 percent of hospitals could conduct all four domains measuring four health data exchange capabilities — the aforementioned find, send, receive, and use or integrate. Second, 47 percent of hospitals reported that their providers rarely, never, or may not have access to external health data when treating patients. And finally, the leading reasons among all hospitals in the data for not using patient health information received electronically from outside providers were: information not available in the EHR as part of clinicians’ workflows (53%), difficult to integrate information in EHR (45%), and information not always available when needed (40%).

A second ONC data brief published in July 2016 highlighted variation in interoperability among the same set of hospitals. According to one of the findings, hospitals relied on numerous methods for sending and receiving summary of care records (which happens to be a core requirement of the EHR Incentive Programs).

Beyond the fact that most hospitals rely on EHR secure messaging to complete these tasks, the data also show that these providers have access to a variety of means for doing so, either via solutions in their own technology or through external networks — health information exchange as an organization. The most important finding, however, concerned variation in hospital interoperability by hospital type, which raises doubts about the national average.

Source: ONC

Small, critical access, and rural hospitals find themselves in a much different predicament than their counterparts, in some cases trailing by more than 50 percent (e.g., rural hospitals demonstrating all four domains).

A comprehensive view of all these figures makes clear that provider-to-provider information sharing is dependent on multiple factors and highly variable. As such, limited health information exchange likely means that either patients are responsible for moving health data between providers or additional testing is necessary to fill the information gap.

Given the high levels of certified EHR adoption among hospitals and physicians, how can this be?

Dig Deeper:

Most Providers Still Lacking Effective EHR Interoperability
Lack of EHR Interoperability Holding Back Enterprise Imaging
Electronic Health Data Exchange Eludes Small, Rural Hospitals


Heretofore, the term health information exchange has referred to the act of exchanging health data rather than the organizations with the primary task of facilitating this exchange. The previous section focused on the act itself which proves to be a hard figure to calculate precisely.

The history of health information exchanges — be it a regional health information organization (RHIO), health information network (HIN), or health information organization (HIO) — provides insight into the challenges currently facing the healthcare industry in its quest toward true (or semantic) interoperability.

Earlier this year, a study by  Alder-Milstein et al. found that the number of operational state and community HIOs is on the decline, from 119 in 2012 to 106 in 2014. Not only is the number of operational health information exchanges decreasing, but the number of organizations planning to stand up an HIO is also dwindling — the first decline of its kind since 2006.

The leading cause of the decline based on the findings? A lack of sustainable business models — followed limitations of current interface standards, a lack of resources to implement them, and competition from health IT vendors offering HIE solutions.

"Together, these factors suggest that HIE efforts may need to offer value beyond facilitating the transmission of clinical data—which, although clinically important, is not something provider or payer organizations have been willing to pay for at a meaningful level," the researchers claimed. "Instead, HIE efforts will likely need to generate value from that data, perhaps through analytics, decision support, and patient engagement."

The study echoed the findings of another piece of important HIE literature published early this year — that is, an evaluation of the State HIE Cooperative Agreement Program by researchers at NORC at the University of Chicago. With funding provided by the Health Information Technology for Economic and Clinical Health Act (HITECH), ONC was tasked with using $564 million in grants to develop health information exchange services in all 56 states and territories.

While the report contains much more information than can be covered here, one particular finding is germane to a discussion of enabling the sharing of health information. “Sustainability was a persistent concern among grantees,” stated the report.

According to NORC researchers, successful HIEs tended to make use of pre-existing health IT infrastructure and resources and built their services around business cases voiced by their constituencies of health systems, hospitals, physician practices, and payers.

“Our evaluation findings demonstrate that there is no one-size-fits-all solution with HIE; instead, development and use of HIE is predicated on the state and local environments within which it exists,” they wrote.

Of paradoxical importance was demonstrating value for HIE participants.

“The usefulness of HIE depends on broad-based adoption of HIE-supportive technology and expansion of HIE networks. Expansion must occur within states, across state lines, and nationally. The paradox of HIE activities is that they need participants but will struggle for participants until the activities demonstrate value,” NORC researchers concluded.

White the program as a whole proved beneficial in advancing the healthcare industry “toward greater data liquidity for both exchange and interoperability” according to researchers, its benefits for understanding health data exchange challenges and identifying solutions  to them are equally important.

Dig Deeper:

• Value Remains a Problem for Health Information Exchanges
• How Behavioral Health Complicates Health Data Exchange
• Should a Health Information Exchange Be Opt-In or Opt-Out?

Source: Thinkstock


For the healthcare industry to achieve true interoperability, it must learn from its past and take a bottom-up approach to enabling the exchange of health data. While this target still remains a way off, numerous healthcare organizations — standards development organizations, health IT vendors, public-private partnerships, trade associations, and providers — have made headway by improving health data exchange in myriad ways.

In its most recent annual report to Congress, ONC found there to be 3 actions critical to advancing healthcare interoperability — promoting accepted health IT standards, building the business case for interoperability, and changing the culture around access to information.

As it turns out, there are examples aplenty of each critical action, starting with health IT standards.

One major achievement this year was the operationalizing of The Sequoia Project’s Carequality Interoperability Framework by EHR vendors athenahealth, Epic Systems, eClinicalWorks, and Next Gen and HIE networks Surescripts and HIETexas.

The integration of the framework went live this summer and meant that more than 3,000 clinics and 200 hospitals could exchange health information with their current technology as of August. Providing agreed-upon rules of the road, the framework enables connectivity between different EHR systems as well as incorporates a record locator service.

Similar doings are going on concerning the development and use of Fast Healthcare Interoperability Resources (FHIR), the health IT standard and application programming interface that has gained much attention for having the potential to unlock and connect disparate health IT systems and services.

 As HL7 CEO Charles Jaffe, MD, PhD, told HealthITInteroperability.com in August, three initiatives are driving FHIR development — the Argonaut Project (the privately-funded project including Epic, Cerner, and athenahealth), Partners in Interoperability Program, a group of genomicists working on precision medicine — and will be proof that “the marketplace will decide the utility of FHIR.”

As for building the business case for interoperability, purposeful health data exchange holds the key.

DirectTrust recently attributed an uptick in the use of the Direct standard to a growing body of use cases for health data exchange.

“We’ve entered a new phase of growth for Direct exchange; one in which Meaningful Use (MU) is no longer the single major driver of adoption," President & CEO David Kibbe, MD, MBA said. "New and often innovative use-cases are springing up in which Direct replaces fax, phone, and/or mail in the workflows of healthcare-related organizations whose professionals don’t necessarily use EHRs and don’t directly benefit from the MU incentive bonuses."

By the close of the 2016 third quarter, healthcare organizations connected to DirectTrust health information service providers (HISPs) and using Direct exchange was up 62 percent over the previous year, an increase of 69,000 organizations. Meanwhile, the number of transactions grew by 64-percent to approximately 22 million over the same period.

Providers such as those at Reliant Medical Group are employing the Direct standard as a means of sharing clinical data with emergency departments when their patients present at an area hospital.

“Instead of getting notified that our patient is in the emergency room and then having to manually call the emergency room and fax something there,” Larry Garber, MD, explained, “we realized that we could get our electronic health record to automatically send the patient summary right to the emergency room using Direct messaging and have it load directly into their electronic health record, right into their EHR system, and make it available instantly for the emergency room physician to help improve the care that our patients get.”

At the state level, HIEs in Arkansas and South Carolina are playing an active role in connecting behavioral health providers — a provider population with much lower levels of EHR and health IT adoption — to other parts of the care continuum. State officials recognized a need and leveraged existing technology to meet it.

As for changing the culture around access to information, that will take a mixture of policy and education. The final rule for the Quality Payment Program and the Merit-based Incentive Payment System (the heir apparent to the EHR Incentive Programs, Physician Quality Reporting System, and the Physician Value-based Payment Modifier) puts in place a program for rewarding and penalizing eligible clinicians not fulfilling its annual requirements, which include health data exchange and interoperability components. Stage 3 Meaningful Use will have a similar effect on eligible hospitals.

While the Centers for Medicare & Medicaid Services (CMS) handles the policy around the Quality Payment Program, ONC is looking to take a more direct approach regarding its oversight of health IT certification. The federal agency will conduct direct reviews of certified EHR technology and health IT systems that fail to remain compliant following testing certification. Reviews could result in suspension or termination of certifications if clinicians and individuals cannot “use and exchange electronic health information safely and reliably.”

Additionally, National Coordinator Vindell Washington, MD, MHCM, has spearheaded the federal agency’s efforts to educate providers about misconceptions of information sharing under the Health Insurance Portability and Accountability Act (HIPAA).

“People insist that HIPAA makes it difficult, if not impossible, to move electronic health data when and where it is needed for patient care and health. I wish I could talk to every doc and patient in the country to tell them, ‘This just isn’t true.’ But unfortunately, this misconception is widespread,” he said last month.

“These misunderstandings of HIPAA and other business practices are inhibiting us from realizing the true potential for technology in supporting patients and clinicians,” Washington added. “Providing an individual with easy access to their health information empowers them, it helps put them in control of decisions regarding their health and well-being, and it helps them actively partner with their care teams as well.”

In the end, improving health information exchange comes down to make data actionable and available to providers. As use cases increase in number and are shared more widely, the usefulness of information sharing tools will prove their worth and true interoperability will begin to materialize.

Dig Deeper:

• How Epic Systems Is Advancing Healthcare Interoperability
Open APIs, Use Cases Driving Interoperability at Allscripts
Potential for Healthcare APIs to Revolutionize the Industry



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