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Why ODs Must Embrace Health Information Exchange


To be a part of the new emerging outcomes-based medical model and the changes in reimbursement that will result, optometrists must embrace the ability to electronically share and use secure, encrypted patient data.

Built on a foundation of electronic health records, this interoperability is one of the steps toward transforming health care.

One way to achieve interoperability is through Health information Exchanges (HIEs), which enable providers to securely and efficiently share and use patient data among caregivers.

‘No More Clipboards’
“Health information exchange is both an action and an organization,” said Scott Jens, OD, CEO of RevolutionEHR, whose optometry-focused EHR software offers the Revolution Personal Health Record that he describes as a consumer-based health information exchange. The “action” would be the actual exchange of information, while the “organization” would be the entity in which information is exchanged by practitioners who both provide and access the patient data it contains.

“No more clipboards,” said Jens, referring to the fact that the objective of health information exchange is to now be able to obtain patient data electronically rather than through a form completed each time the patient sees a new doctor. “If we don’t participate and we rely on 1990s faxing, there’s going to be a point where we will be left behind,” said Jens.

Three Types of HIEs
CMS defines three types of health information exchange:

1. Directed Exchange – (provider to provider) the ability to send and receive secure information electronically between care providers to support coordinated care.

2. Query-based Exchange – (one entity asking another entity for information) the ability for providers to find and/or request information on a patient from other providers, often used for unplanned care.

3. Consumer Mediated Exchange – ability for patients to aggregate and control the use of their health information among providers (emerging and yet to be accomplished).

While not the most efficient, communicating directly from provider to provider is currently the most prevalent and the best established. Query-based exchange requires using one of the state-based HIE platforms, which have gotten off to a rocky start, and consumer-mediated exchanges are still emerging.

Using the standardized electronic language established by the Direct Project enables disparate EHRs to share secure encrypted patient data directly from one provider to another. Launched in March 2010 as a part of the Nationwide Health Information Network, the Direct Project was created to specify a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the internet. When used to transport and share qualifying clinical content, the combination of content and Direct-Project-specified transport standards may satisfy some Stage 1 Meaningful Use requirements (see “Comparing and Understanding the Stages of Meaningful Use”).

In the new world of health care, optometrists are one integrated element of a broader, complex system, in which they will be required to exchange and analyze patient data.

Query-Based HIEs
However, even though the Direct protocol enables disparate software to share data, communicating directly from one provider to another requires that they have the necessary contact information for communicating with each other’s EHR system.

A more efficient model is a Health Information Exchange in which providers securely share their patients’ encrypted health data that can then be accessed (via a query) by other authorized practitioners also caring for a particular patient who has given them permission to access that information.

Eduardo Martinez, development manager of EHR software provider, MyVision Express, provided an analogy that helps illustrate why HIEs that allow for query-based exchanges are more efficient than sharing information directly from provider to provider. He compared one provider communicating directly with another as being similar to texting, which requires you to know the number of the person you are contacting.

He then compared being a part of a trusted HISP (Health Information Service Provider) serving as an HIE in which patient data is shared and accessed by multiple providers as being similar to using Skype. As long as the provider knows the name of the person whose information they would like to access, they are able to find that information within the HIE. They don’t need to know the contact information for communicating directly with another provider. Instead, they can simply query the HIE to request that particular patient’s data.

To help facilitate the formation of HIEs in every state throughout the country, the Health Information Technology for Economic and Clinical Health Act (HITECH), as part of the American Recovery and Reinvestment Act of 2009, budgeted over $540 million to be allocated among all 50 states so they could each establish their own health information exchange for the sharing of patient data.

(To clarify, these health information exchanges differ from the health insurance exchanges established to sell health insurance to individuals in each state as a result of the Patient Protection and Affordable Care Act of 2010, both of which differ from private exchanges established by independent companies to also sell health insurance to individuals.)

Establishing HIEs in each state turned out to be easier said than done, however. “The problem was that they didn’t use the concept of standards first but gave out the money and told each state to put together an HIE with no specific guidelines,” said Jim Grue, EyeCare Registry director of analytics. “Some states created 10 or 11, some did one, and some did 15 to 20 HIEs to cover their whole state, but there was no interoperability plan that was consistent throughout the whole country. Every state, every HIE, made their own decisions, which didn’t result in their ability to share information between the different ones.”

By 2014, with all the money spent by mandate, some HIEs survived while others floundered and failed. Grue suggests that it is those that incorporated self-funding that remain sustainable.

Brett M. Paepke, OD, of First View Eye Care Associates in Plattsburgh, N.Y., agreed: “For HIEs to be self-sustaining continues to be important. HIEs were assisted in the beginning by federal funding/grants designed to get them on solid footing and establish revenue streams to help them survive. The ones who failed to do that have ceased to exist.”

Still, there remains “a fledgling number of emerging state HIEs in the market, but each of those state HIEs stands as a silo in and of itself that doesn’t share data across state borders with other HIEs,” said Jens. This resulted in unconnected islands of data with no connection to each other.

Data Islands
“HIEs are controlled at the state level, and each state has implemented theirs somewhat differently, which makes it difficult for patients, especially if they are moving across state lines,” said Brian Thorell, CIO of software provider, ManagementPlus.

Because establishing a standardized electronic language was not a priority, sometimes information is only available within that HIE, where it remains stranded on a data island unable to connect with other HIEs in other states.

David M. Anderson, OD, of Miamisburg Vision Care in Miamisburg, OH, and trustee of the Ohio Optometric Association, described why he believes HIEs have stalled: “A good start has somewhat slowed due to barriers, real or perceived. They require ECPs and other providers to cooperate and work together, and this has stalled some of the progress. The concept of HIEs and integration of all EHRs seems like many different cities with different laws, different structures and different people, but no way to connect to each other. We are all still waiting on the highways, but each still believes what we have and need in our own isolated city is either better or unique. The providers, in general, still see the short view of helping that patient that day, not the long view of helping all providers help those patients for their lifetimes.”

Despite significant progress in establishing standards and services to support health information exchange and interoperability, it is not the norm that electronic health information is shared beyond groups of health care providers who subscribe to specific services or organizations. This frequently means that patients’ electronic health information is not shared across organizational, vendor and geographic boundaries. Electronic health information is also not sufficiently standardized to allow seamless interoperability, as it is still inconsistently expressed with vocabulary, structure, and format, thereby limiting the potential uses of the information to improve health and care.

Will a National Standard Result?
There is talk that a national standard will eventually be established to enable state and other HIEs to communicate. The HHS on its website does allude to a national standard: “We must learn from the important lessons and local successes of previous and current health information exchange infrastructure to improve interoperability in support of nationwide exchange and use of health information across the public and private sector.”

In fact, on Jan. 30, 2015, the HHS Office of the National Coordinator for Health Information Technology (ONC) released “ Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Version 1.0,” a “draft roadmap” to deliver better care and result in healthier people through the safe and secure exchange and use of electronic health information.

The development of clear standards for the secure electronic exchange of patient information remains a roadblock that HHS hopes to correct with a recently released ‘Roadmap.’
The document outlines steps “that will enable a majority of individuals and providers across the care continuum to send, receive, find and use a common set of electronic clinical information at the nationwide level by the end of 2017.”

The draft Roadmap identifies critical actions to achieve success in sharing information and interoperability and outlines a timeframe for implementation. It builds on the vision paper, “ Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure,” issued in June 2014. Months of comment and feedback from hundreds of health and health IT experts from across the nation through ONC advisory group feedback, listening sessions and an online forum aided in the development of the Roadmap.

HHS Secretary Sylvia M. Burwell, said, “Great progress has been made to digitize the care experience, and now it’s time to free up this data so patients and providers can securely access their health information when and where they need it. A successful learning system relies on an interoperable health IT system where information can be collected, shared, and used to improve health, facilitate research, and inform clinical outcomes. This Roadmap explains what we can do over the next three years to get there.”

The draft Roadmap calls for ONC to identify the best available technical standards for core interoperability functions, delivering on this action with the release of the Draft 2015 Interoperability Advisory. This “Standards Advisory” represents ONC’s assessment of the best available standards and implementation specifications for clinical health information interoperability as of December 2014.

The public comment period for the draft Roadmap closes April 3, 2015. The public comment period for the Standards Advisory closes May 1, 2015.

With a national standard, HIEs will be able to communicate with other HIEs and across state lines. As Steve Baker, president of technology provider, Eyefinity, put it: “Each new piece of information can connect with the other pieces of information, so local roads can meet up with regional roads and eventually all the national roads.”

In some cases, this is already happening, according to Lee Stevens, director of state health information exchange policy for the ONC. “States are starting to exchange data, across state lines, in California and Oregon, Florida and Alabama, and other states, states have been fantastic partners in all of this,” he said.

Anderson said, “I see roads slowly being built, some challenges with data integration ahead, but big benefits to patient care. I see this again like cities. The water systems in both areas are in place. The cities chose different sized pipes, now we just need to adapt them to each other, and the water will flow. It will require some give and take, but once we begin to recognize the true value of our own EHR, we will soon fully recognize the value of all EHRs, and of course, interoperability will be the end result.”