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Is Health Information Exchange Headed in the Wrong Direction?

Recent studies on health information exchange highlights trends potentially detrimental to advancing health IT interoperability.

By Kyle Murphy, PhD

- Factors impacting health information exchanges and HIE use are the subject of two studies published in the most recent issue of Health Affairs.

Health information exchange struggles

The first could signal the beginning of the end for many standalone health information exchanges and their role in clinical data exchange while the second could provide the insight necessary to understand the role of EHR vendors in information blocking.

According to Alder-Milstein et al., the number of operational sate and community health information organizations (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 team of researchers conducted a national survey on operational health information exchanges. The researchers found the number of planning efforts to have declined by 60 percent between 2012 and 2014.

"For the first time since our survey began in 2006, we observed a decrease in the number of operational HIE efforts and a much larger decline in the number of efforts in the planning stage. This likely signals the beginning of a transformation, as federal funding is diminishing and new competitors to state and community HIE efforts are growing in number and size in the market," wrote Adler-Milstein et al.

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What's more, those organizations still engaged in supporting health information exchange are facing "major" challenges. First among them is remaining viable. Of the 94 health information exchanges responding to the survey's questions on financial viability, 49 (52%) reported being able to cover operating costs with revenue from HIE participants.

"This percentage is significantly higher than the 24 percent of operational efforts that met this definition of financial viability in 2012 (28 of 119 efforts)," the researchers noted. "An additional 9 percent of the efforts in 2014 were able to cover 75–99 percent of operating costs with revenue from participants; 10 percent of the efforts were able to cover 50–74 percent of costs; 6 percent were able to cover 25–49 percent of costs; 12 percent were able to cover 1–24 percent of costs; and 12 percent were unable to cover any operating costs with revenue from participants."

Viability among state-level HIE efforts — that is, those funded by HITECH Cooperative Agreement Program — was less commonplace. Only one-third of state-level efforts responded that they were "definitely sustainable," with community-level efforts reporting far less optimism — a mere 5 percent:

As context, 64 percent of community HIE efforts reported being 'very or moderately involved” with their state-level effort, while 23 percent reported being “slightly or not at all involved” (data not shown). In addition, 30 percent of community efforts reported that the state-level effort slowed their progress, 41 percent said that the state-level effort sped their progress, and 29 percent reported that the state-level effort had no impact.

By and large, respondents reported the development of a sustainable business model as the most widespread barrier to progress — 38 percent 2012 and 33 percent in 2014. Next on the list was a lack of funding, which has forced many a health information exchange to take a more aggressive approach to securing a user base of paying participants.

Barriers to health information exchange in the US.

Rounding out the list of barriers were limitations of current interface standards, a lack of resources to implement them, and competition from health IT vendors offering HIE solutions.

The solution for these state and community health information exchanges? Go back to the drawing board.

"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."

And for Congress as well as state and federal officials, the solution is a reconsidered approach to health data exchange policy-making.

"A policy approach that ensures the existence of options for provider organizations to connect with others with which they share patients should be a high priority, and this should be facilitated by actions that strengthen demand and reduce barriers. Without such actions, broad-based clinical data exchange—a critical element of improving the quality and efficiency of our health care system—will be far more difficult to achieve," Adler-Milstein et al. concluded.

EHR and health IT vendors in the HIE marketplace

As noted the aforementioned research, EHR and health IT vendors are expanding their role in health information exchange with consequences for standalone HIOs.

According to another piece of research from Jordan Everson and Julia Alder-Milstein, the presence of EHR and health IT vendors in the HIE marketplace has a direct effect on hospital HIE use.

Based on national data, the duo found that hospitals using hospital EHR systems by dominant vendor were 45-percent more likely to participate in health data exchange activities than hospitals not using the dominant EHR vendor. The same, however, proved to be true in circumstances where the dominant EHR vendor had less hospital penetration — for example, 20 percent — but hospitals using its EHR were 59-percent more likely to complete HIE activities.

The dominant EHR vendor in question? Epic Systems. Epic and its Epic EHR technology maintained the largest market share across 93 local hospital markets, dubbed hospital referral regions (HRRs), at 51.6 percent on average. Cerner, MEDITECH, McKesson, Allscripts, and Siemens rounded out the list:

We suspect that the reason why hospitals that use the dominant vendor engage in more HIE than hospitals that do not is because the former institutions likely face fewer technical obstacles in implementing HIE, and a given vendor may see strategic advantages to facilitating HIE among multiple hospitals that all use its systems. In addition, dominant vendors might facilitate the collaboration needed for successful HIE across hospitals by providing a technical strategy to create interoperability between systems and by mediating a collaborative solution between competitive health care providers.

However, HIE market dominance by any one EHR vendor does not mean hospitals are less likely to invest in and perform health data exchange activities.

"Greater EHR vendor market dominance may encourage greater HIE among hospitals that do not use the dominant vendor because the presence of a dominant vendor may make a hospital’s investment in HIE more attractive," wrote Everson & Adler-Milstein. "Specifically, higher market share for a single vendor likely reduces the cost for other hospitals to invest in HIE capabilities because the cost and complexity of interfacing with that single vendor’s system are less than those of interfacing with multiple different vendor systems."

The exception to the rule appears to be a uniquely Epic effect on hospital HIE use.

"The fact that when Epic was the dominant vendor we saw a different pattern—in which increasing dominance was not associated with greater HIE among hospitals that did not use Epic—may reflect the fact that Epic clients can readily exchange data with other Epic clients, and as a result, doing so with providers that are not Epic clients may appear prohibitively costly and complex," the researchers continued.

Epic Systems effect on hospital health information exchange

According to the researchers, policy aimed at reducing information blocking needs to look first at markets where EHR vendor competition is highest to "help facilitate broader-based electronic health information sharing than has been achieved through current HIE activity."

Image Credits: Health Affairs

Dig Deeper:

How EHR Technology Definitions Influence EHR Use Statistics
Return on Investment Remains a Problem for Meaningful Use



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