The potential advantages offered by health information exchanges (HIEs) are well-known. They’ll be vital spokes of the proposed Nationwide Health Information Network (NHIN) architecture initiative, streamlining patient care and records and providing accurate, nearly immediate test results to practitioners anywhere. The potential is promising, but the reality is no Field of Dreams scenario: If you build an HIE, subscribers will not necessarily come.

A study published in the January 2010 issue of the Journal of the American Medical Informatics Association captures the gist of the problem. In the study, more than 1,000 family practice and specialist physicians were asked whether they thought HIEs would drive down costs, improve patient care, free up their time and preserve patient confidentiality. They also were asked whether they would be willing to pay a monthly fee to use an HIE.

The study found that 86 percent of those surveyed said HIEs would improve the quality of care, and 70 percent thought it would cut costs. A full 75 percent indicated it also would save time. However, 16 percent said they were “very concerned” about potential privacy breaches, while 55 percent said they were “somewhat concerned.” In addition, physicians said they wouldn’t support a suggested $150 monthly fee. Nearly half were unwilling to pay anything.

Privacy and financial concerns are only two of the obstacles that healthcare facilities and practitioners face when they embark on launching or joining an HIE. CMIO asked several early HIE implementers what advice they have for organizations that are building or planning to join an information exchange. Following are some of their comments.

Develop a financial plan that will work

“A number of large HIEs around the country have failed because the financial sustainability model was never put together properly,” says Steve O’Neill, CIO of Hartford Healthcare Corp. Hartford Healthcare is rolling out an HIE, developed using Misys Open Source Solutions (MOSS)  software, to three hospitals in the Hartford, Conn., area, and will demonstrate its exchange statewide under the auspices of eHealthCT, for the Connecticut  Department of Social Services, later this year.

“We agreed—with the support of our CEOs and CFOs—to develop a shared-cost funding model for the HIE that would make it sustainable.” The HIE will be funded primarily by the hospitals, he says, and fees will likely be based on usage. “For instance, Hartford Hospital is the second-largest hospital in the state, so we would bear a larger share of the total operating cost than the smaller hospitals,” says O’Neill. “We also expect to charge physicians for use of the system, but that might be a membership fee or a one-time access fee.” 

“Sustainability is a really important issue,” agrees David Cochran, MD, president and CEO of Vermont Information Technology Leaders (VITL), the non-profit organization charged with deploying a statewide HIE. VITL is developing its HIE under contract with GE Healthcare in Burlington, Vt. The HIE will be funded through the state’s health information technology (HIT) fund through 2015, says Cochran. The HIT fund is supported by commercial medical claims and contributions from the Medicaid program. “It’s a very small percentage, something under 0.2 percent of medical claims, but that provides the foundation for VITL’s work,” he says.

There are 14 hospitals in Vermont. Eight of them currently use one or more VITL services. About 90 physicians in 19 practices are currently participating in the HIE, Cochran says. By 2015, “we will build out the HIE … and be able to demonstrate the value in such a way that we will be able to use fees that are to be determined, probably some form of subscriber fees,” says Cochran. The VITL HIE enables healthcare providers to view and share radiology and lab results, medication histories and other critical patient data.

“It’s not the technology, it’s always the finances that hold up the strategic plan when you’re in a health information exchange,” says Dana Gibson, MPH, vice president of WNC Data Link, an HIE implemented in the Western North Carolina Health Network, a network of 16 non-profit hospitals. “People [have to be] willing to invest in it. And there is not always a lot of money to build and expand.”

WNC developed Data Link using a grant from the Health Resources and Services Administration. A second grant from the Duke Endowment enabled it to go live. “We were able to manage because the WNC hospitals are willing to pay the maintenance fees to keep the HIE running,” Gibson says. WNC Data Link uses Medseek’s Clinical Web Portal software as the foundation for its HIE. Data repository duties are handled by Peak 10 Data Center, in Charlotte, N.C.

A grant also helped get the Mississippi Coastal Health Information Exchange (MISCHIE) up and running. “We had a fairly large grant to start this project, we have developed governance structures, and we’ve developed a plan for sustainability,” says James McIlwain, MD, a family practice physician in Ridgeland, Miss., and CEO of Information & Quality Healthcare, the organization that launched the MISCHIE. The MISCHIE initiative focuses on six coastal counties in the state, but also is working toward statewide adoption and possible collaboration with neighboring states, including Alabama, McIlwain says.

“Eventually, sustainability comes down to whoever gets value from the exchange is going to have to pay for it. It’s like looking at a public utility like electricity—everybody wants it and everybody has it, but it costs money to use,” says McIlwain. Medicity provides the clinical interoperability platform and the end-user application infrastructure for MISCHIE, which is hosted by Perot Systems.

Kicking the tires It pays to partner with software developers that understand how important it is to keep costs down, says Gibson. “Know what your financials are, then look for a company that can give you everything. Look for a software developer that can help you with project management and have that be part of their fee.”

Reliability and longevity

“We wanted to be sure that we were working with an organization that could see us through this process,” says Carl Dirks, MD, CMIO of Saint Luke’s Health System in Kansas City, Mo. “We saw that things would evolve and we wanted a partner that would be in it for the long haul. We selected a vendor and technology platform that didn’t require internal pruning and maintaining, but would allow flexibility and extensibility to then connect outward.”

The not-for-profit system of 11 hospitals and multiple physician offices uses a software-as-a-service platform from RelayHealth (acquired in 2006 by McKesson). Services include e-prescribing, secure messaging, clinical results delivery and automated personal health records. The secure online service delivers authentication, data encryption and message integrity, allowing physicians to securely exchange information with patients or with other physicians. Results data can be delivered directly to a practice’s EMR or web browser.

Hartford Health looked at several potential software partners before deciding on MOSS, according to O’Neill. “Many CIOs are reluctant to consider open source as a solution for key applications,” he says. “I know, I was one of them! I got comfortable with open source because of the federal NHIN’s use of it, and because we would have a vendor to provide on-going development and software support. We joke here that open source is like getting a puppy as a present: it is free, but you have to pay to maintain it. Open source acquisition costs are low, but we expect to pay for ongoing support.”

Anyone looking at joining an exchange or connecting practices to one has to know not only what technologies are involved, but also what version of the technologies and what steps might be required to successfully hook up to the exchange, Cochran says. “As with any major technology initiative, good planning and a really clear understanding of this kind of issue can help a lot,” he adds.

In addition, “it’s important to acknowledge that the industry is going to a connected state,” says Dirks. “We feel like this is a situation where there is a first movers’ advantage. We want to provide that infrastructure, but at the same time, we have not chosen to build the walled garden. We have an open architecture by definition.” More than 300 physicians now use the Saint Luke’s HIE, he says.

Give the people what they want

HIE developers must know what participants expect to get from the exchange. “We started our exchange working with hospitals in the emergency departments,” says McIlwain. “[You know] how busy an ER can be. If you have to log onto the hospital system, then log onto another hospital and then wait—if it’s not speedy, then that can create some real problems.”

In the beginning, “we thought the main value to a physician would be to have a real-time medication history. It turns out lab and x-ray results and dictated hospital reports are just as important, so we added that feature to our exchange,” says McIlwain.

“When we began the project early on, we focused on looking at the e-prescribing needs of our physicians and their communication needs. As we got physicians and practices accustomed to those, as we added new features and functions, we leveraged that network effect in adding pieces to [the] HIE,” Dirks says. “I don’t know that we would be as successful as we are, had we tried to build an everything-for-all-people HIE in the beginning.”

Keep your eyes on the prize

Big HIE failures make news; successful HIEs usually don’t. More than 1,500 providers have signed up to use Data Link, and the HIE gets over 6,000 hits per month, according to Gibson. There are 440 users who are very active on Data Link every month—they use it “religiously” she says.

“When we’ve been able to show [the HIE] does improve quality and perhaps may reduce costs, [we] get pretty good buy-in,” McIlwain says. “Once this exchange is live, once people start hearing about it and physicians start using this, for the most part they fall in love with it and you just have to meet the demand. That’s what a lot of exchanges have found. Once it gets going and it shows good value, everyone wants to be on board. Nobody wants to be left out,” he says.

A final bit of advice? Don’t expect costs to drop once the HIE goes live. “Whenever you predict lower IT costs, you always end up being wrong,” O’Neill says.