The prognosis for health information exchanges (HIEs) is anyone’s guess.

While some HIEs have managed to increase user participation through high-value services, others have struggled to link disparate systems and engage patients and physicians.

Many have questioned HIEs’ prospects for sustainability. In a 2013 poll of 1,550 providers using HIEs, 83 percent of hospitals and 70 percent of physicians said that publicly-funded HIEs are pursuing flawed business models and are not providing meaningful connectivity, according to Black Book.

In the meantime, 72 percent of respondents said there could be as few as 10 public HIEs once federal grant funding dries up, unless they find better business models, improve their processes and create ways to encourage participation. Nearly all healthcare organizations believe community and regional and private HIEs are better equipped to meet their needs.

Leaders at public and private HIEs are working hard to prove the naysayers wrong. But in their pursuit of that value proposition, success is not always guaranteed.

Data Integrity & Analytics

Many executives agree that quality data are essential to the success of any exchange.

Demographic and clinical data have to be accurately attributed to the right patient. “We spend a lot of time working on that,” says Bill Beighe, MD, CIO of the Santa Cruz HIE and member of Physicians Medical Group of Santa Cruz, Calif.—who  spoke at the 2014 AMDIS Physician-Computer Symposium.

The Santa Cruz HIE has found success—in part due to its history of sharing data going back to 1998, Beighe says. The HIE moves patient data, laboratory work, radiology imaging and connects “just about everyone”—from physicians and clinics to county health centers and mental health facilities.

The standardization of data is critical to this work. Santa Cruz HIE has evolved over the years from proprietary patient summaries to structured summaries utilizing Consolidated Clinical Document Architecture (C-CDA) to help facilitate exchange between all providers within the care continuum.

Also, the HIE has moved from proprietary secure messaging to Direct, for which it currently has 260 users. “Change is hard with a new system, but Direct messaging has the promise of sending messages to any physician within the whole country.” The HIE has been testing with Direct with six different sites nationwide.

“One lesson we’ve learned is that you can kill your user with too much data. We literally had to back off the concept of completeness, as it had no value,” says Devore Culver, executive director and CEO of HealthInfoNet, Maine’s HIE, speaking during a panel session at the iHT2 Health IT Summit in Boston. “The natural inclination is to dump everything on a user, but you shut people off.”

HealthInfoNet links every hospital in the state and 400 physician practices. About 90 percent of residents have data in the exchange. “The post office function of an HIE is not a sustainable model. If you are thinking about HIEs like a post office, you’re probably in the wrong business. It’s all about the data,” he says. 

Critical factors to achieving success include standardizing data to remove variability from data sources, and harnessing data for meaningful analytics. HealthInfoNet, which utilizes a data warehouse that stores and analyzes data in real time, currently is tapping the data to mine four predictors for key events, including risk of admission of the emergency room, probability of admission in six months, the most expensive asset in six months and who will return in 30 days, Culver says. All of this better informs care.

“Don’t underestimate the energy that goes into standardizing data in an HIE,” says Joe Hamdorf, director of Global VNA (Vendor Neutral Archive) Solutions for Perceptive Software—who also spoke at a panel session of the iHT2 Health IT Summit. “There is a lot of noise in the data that is not valuable and we’ve been working hard to get that noise out.”

Hamdorf stresses the importance of starting small. “We’re finding value in small things that can be aggregated, reported on and actionable” like issues around diabetes, weight loss and smoking, he says.

Governance for sustainability

Keystone Health Information Exchange (KeyHIE), founded in 2005, currently serves nearly 4 million patients in 53 counties in Pennsylvania. It originally began under the Geisinger Health System umbrella but later became its own separate nonprofit corporation. The exchange links 41 member organizations, including Geisinger, and represents 22 hospitals, 175 physician practices, 61 long-term care centers, one pharmacy and emergency medical services.

The HIE took off thanks to state and federal grants; Geisinger is among the recipients of the Beacon Community grants, and was funded with the express purpose of treating patients with chronic diseases, namely COPD. One functional requirement of the grant for the HIE was to connect to outside, disparate providers.

“The grant helped us get it launched, but has not helped us with sustainability,” says John M. Kravitz, associate vice president of IT at Geisinger Health System. Kravitz is also amongst the speakers at the AMDIS Fall Symposium in October in Boston.

Getting to stability requires a robust governance structure. That “makes or breaks” its success, he says and, fortunately, the participating HIE members are active. The majority of the HIE’s 41 members attend its meetings, which occur about eight times per year. The members participate in subgroups that tackle issues like standards, audits and security. Also, the members prioritize future HIE enhancements.

Add-on Services

HIEs have gotten creative in trying to prove their worth.

For example, Massachusetts-based Pioneer Valley Information Exchange (PVIE) is seeking to show value by providing portals layered onto its HIE platform for partners and providers, says Heather Nelson, senior director of enterprise clinical applications & IT operations at Baystate Health and senior director of IT at PVIE—who spoke at the iHT2 Health IT Summit.

“We’ll give you the portal and you can brand it and add on top of it, but it all comes back to the HIE. We’re generating a lot of energy and excitement in the community on this,” she says.

One way to prove that HIEs are “more than a fax machine,” is using the HIE as a way to help healthcare organizations with patient identification, says Culver of HealthInfoNet. “You can supply a single identifier with organizations that have multiplier identifiers.”

At KeyHIE, members benefit from a master patient index, which contains about 3.6 million patients, and a record locator service.

KeyHIE also uses a sophisticated notification service that fits in with members’ greater vision toward improved population health management. When a patient in the registry presents at the emergency department, notifications and alerts go out to physicians, and to care managers via mobile devices and email.

Proving Value

Add-ons are great, but what about ROI?

“We haven’t done ROI studies. Our proof of value is the usage of the system. If people aren’t using the system, there is no value or ROI,” says Beighe, adding that the number of transitions of care processed through the HIE grows every year.

In the process, value is being created through a more longitudinal record. Physicians can look up a patient’s full health history, anything from previous surgeries to sleep studies to EKGs. “Data drive usage and value. We are self-sustaining. To me, it’s all circular. If there are enough data to make it interesting to physicians, they’ll pay to use the system,” he says.

KeyHIE has 948 active users accessing the system. “Over time that number has grown significantly.” The HIE, with a $2 million budget, is nearing sustainability—but has gotten to that point by keeping a close tab on costs. “We cost $2.75 per patient, and we work hard to keep the costs down.”

In the meantime, the exchange has been successful reining in the costs of care delivery. Its image exchange has helped reduce duplicative procedures among members by 40 percent.

HIEs also provide value by helping providers achieve Meaningful Use (MU) Stage 2, especially with view, download and transmit requirements. Santa Cruz HIE is looking to implement an image exchange within its HIE, which would embed directly into the system, to help organizations meet one MU measure requiring 10 percent of imaging results to be available through certified EHR technology.

Looking to the Future

For Schneider, future investment should center less around health IT and more on patient engagement.

But for that to work, patients need a single data repository, he says. “That’s where all your data should go. Let’s market the heck out of Blue Button to seniors, students and workers. Let patients add, modify and delete their own data.”

“We need to be able to provide patients with information and allow them to tag information that’s true or not true. And we need to support physicians in use of these data… and make then easy to pull down data you don’t have.”

With so many moving parts in HIEs slowly  linking up throughout the country, giving patients the final say on the contents of their records may provide the data integrity needed to make them work. In the end, that translates to better care at lower costs.

 “As we move to value-based and accountable care, and pay-for-performance types of structures, we must break down silos and data must follow,” says Beighe.