Thursday, October 06, 2011

Health Information Exchange Where Are the Roadblocks. The Scene Is As Hard In Australia. We Now Have Some Late Breaking PCEHR Standards News!

The following useful review of the barriers to Health Information Exchange appeared a few days ago.

The Top 5 roadblocks HIEs face

September 28, 2011 | GHIT Staff
Just as young businesses of most any sort must circumvent myriad challenges to succeed, health providers are encountering multiple roadblocks in the implementation of HIEs. At the core of those: financial sustainability. The root of many, perhaps, money is neither the only problem, nor the most trying.
“The most important obstacles facing HIEs depend on the perspective of who is looking at them – the patients, the providers, etc. So as we move forward, we have to make sure to address all these stakeholders,” said Benjamin Stein, MD, president and CEO of HIE Long Island Patient Information eXchange (LIPIX). “There is no one-size-fits-all answer to the problems of HIEs.”
Indeed, many healthcare professionals have raised doubts about HIEs living up to their potential. A survey of healthcare providers, vendors and experts found five issues that constitute the top concerns.
1. Data sharing
The groundwork already in place, with federal incentives for EHRs, HIEs, telemedicine, and related projects available, the goals of HIEs are straightforward: Reduce administrative costs associated with manual data and paper-based systems, reduce costs related to improved information access by decreasing redundant testing, avoidance of unnecessary hospitalizations due to missing information, more efficient visits, improving co-ordination of patient care with timely and accurate information across providers, and more effective medication reconciliation.
That all comes down to actually exchanging health data.
As HIEs now stand, however, much of their operations still occur in narrow sets of silos. Data exchange between EHRs and exchanges through organized state and regional HIEs is decidedly uneven in delivery. Electronic reporting for public and population health measurement is lacking.
2. Patient consent
Patient authorization and consent is often cited as one of the first challenges to HIEs, because authorization is a true test of the ability of EMR systems to work across healthcare and technology platforms as data is exchanged.
At Geisinger Health System, a Danville, Pa.-headquartered provider, Jim Younkin is program director of IT, leading development of the Keystone Health Information Exchange (KeyHIE), a regional HIE.
“Our legal counsel reminds us of the risks, and to make sure we don’t share information with anyone unless we have patient authorization allowing it to be shared,” Younkin said. “So we have increased our efforts in obtaining authorization, but that’s not easy.”
KeyHIE includes 12 hospitals, more than 90 clinics, skilled care, long-term care, and home health organizations. More than 385,000 patients have signed authorizations, allowing their information to be shared for treatment purposes through this exchange. Nonetheless, Yonkin says patient authorization and consent remain a hurdle to further development of HIEs.
“Because we have a large footprint,” Younkin adds, “a lot of doctors see patients who have records from other hospitals, where in some cases the information comes back in faxes. That’s been a difficult issue for us.”
Having started an EMR system in 1996, Geisinger is a seasoned user of technology platforms to facilitate date exchange, and is continuing its search for best practices in patient authorization, Younkin added
Likewise, Patty Dodgen, CEO of Tampa, Fla.-based Hielix, which provides HIE implementation services, sees difficulties in adopting patient authorization on the large scale contemplated by HIEs.
“There is a maze of EHR vendors touting, not an HIE system, but an interface. You have to have functionality that includes a mechanism for verifying and authenticating individuals and a record location service,” Dodgen explained. “You have to build an HIE that includes functionality that can go into a variety of settings and pull information back into the user.”
3. Standards
LIPIX CEO Stein believes HIEs need to bring in as many stakeholders – doctors, providers, patients – as possible from the very beginning, particularly to settle differences of healthcare standards that might prevent integration.
“The complexity of the healthcare IT market creates a challenge in relation to standards. All the vendors have their own standards,” Stein explained. “I think we can overcome that but it’s going to take a focus on development of core standards, some key standards.”
Lots more here:
There is little doubt that after getting a properly functional EHR in place the next step for most health care providers is to be able to gather information regarding the patient in front of them from all the useful information sources that can be accessed. This may be in the form of test result information, specialist and hospital record information or whatever else can be safely and reliably located.
Actually organising a then managing such exchange is no trivial task, but with some effort and co-operation is certainly possible.
The issues of what actual information is shared, how consent is managed, what standards are used, how complexity is kept as low as possible and so on are all vitally important as is the critical issue of how the exchange can be sustained in the longer term (i.e. who pays for what etc.).
With all this activity in the US it is important to recognise that Australia has developed a pretty effective health information exchange infrastructure based on a small charge being paid for the practitioner for connectivity (and some state-wide arrangements).
The figures for adoption and use are actually pretty impressive. As an example Medical Objects now has about 17,000 health practitioners connected with secure clinical messaging.
See here:
There are a range of other providers (e.g. Argus, HealthLink proMedicus etc. with varying capabilities and functionality) and between these providers most GPs have access to such health information exchange if they desire (and most do).
A point to note here is that all this activity and success has been had despite rather than because of NEHTA’s efforts. To date adoption of NEHTA’s offering in the secure messaging area has been very low indeed.
According to the NEHTA Secure Messaging Site this effort has been underway since 2006
To date it is not clear - after 5 years - just how many sites are using it compared with the providers mentioned above but I doubt it would be 1% of those using other systems.
The software compliance list to NEHTA Standards does not seem to have been updated since March 2010 and it is by no means clear what has happened here either. I would love to hear from active users out there to get a handle for all of us as to just where all this is up to!
After this was written - and just in the last day we have these 2 files become available:
and here:
These two documents are the analysis that supported the earlier reported NEHTA standards choices for the PCEHR and the until quite recently unavailable Direckt Report on what the available choices were.
Those cleverer than I can analyse in detail but it does rather look that there are at least some changes of direction in some areas with other areas still going with approaches that are unproven and unimplemented in Australia. This will keep the developers busy!
The big question is, of course, how all these proposals fit with the infrastructure Medical Objects, Argus, HealthLink and others have in place. Replacement of what already is in place is a multi-year and expensive activity at best and total lunacy at worst! Comments on that issue welcome.

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