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.”

LIPIX, an independent HIE in the New York metropolitan area, provides doctors in healthcare facilities across Long Island with secure access to more than 834,000 patient medical records.
Achieving buy-in from all the necessary parties, and soliciting feedback demands both focus and time, particularly since complex standards are involved. Key pieces of the collection: Continuity of Care Document (CCD); NwHIN (Nationwide Health Information Network) standards, services, and policies, including the Direct protocol for secure messaging and all that can be built on top of it; as well as XPS.D for healthcare payments.

“At the high level these are the answers,” Stein said, “but even with these, we need to get more specific.”

At Salt Lake City-based HIE vendor Medicity, president Brent Dover added that “healthcare standards need to come out of R&D and into the doctor’s office.”

Indeed, the further development of standards is essential in connecting the systems of diverse healthcare stakeholders, but “there are only so many resources, so much money for hospitals trying to address needs,” Dover said.

Geisinger’s Younkin said standards would be a catalyst toward building out HIEs. “Standards will absolutely help,” he said. Younkin cites IHE (Integrating the Healthcare Enterprise), a set of profiles for secure exchange of patient information across enterprises.

“IHE’s become a national standard for sharing healthcare information,” Younkin explained. “They’ve been very beneficial so we have been able to work with communities to share information. So that’s a barrier that’s gotten lower.”

4. Complexity Costs

The most cutting criticism of HIEs may be that they are just too complex. What sounds good as an ideal health system in practice often turns out to be too demanding for hospitals, doctors, and community health centers. All too often, the way to address complexity is to pay for new systems, with costs mounting in unison. As such, the wide variety of community, state, and regional HIEs are operating under different economies of scale.

“From a national perspective, we’re not proceeding in a rational fashion,” said Julia Adler-Milstein, one of the authors of a mid-summer Harvard Business School report that found many RHIOs are struggling to achieve financial sustainability. “States with five organizations will take a different approach than states with one.”
What will help push these differing organizations along toward harmonization is the meaningful use provisions that encourage best practices and offer financial incentives, she said.

In addition, the advance of technology that promises to reduce complexity and further integrate systems continues. David Hartzband, CTO of San Francisco-based Resilient Network Systems, a security and networking startup serving the healthcare industry, said some health exchanges use scores of software programs, each with its own service and pricing models. “You can imagine a healthcare provider struggling to implement this,” Hartzband said. “For a community health center, that’s pretty darn hard.”

Many health exchanges have responded by seeking other technologies, so-called “vendor churn,” he added. Despite this activity and spending, applications remain in silos, unavailable to others – when HIEs really need to be concentrating on the exchange of EMR data, the most basic function that must be performed.

5. Competition

Despite great efforts at technology fixes and government regulation to develop HIEs, competition among providers persists and only slows cooperation.

“The biggest challenge is that healthcare operates in a complex environment fundamentally based on the centrality of information,” LIPIX’s Stein said. Healthcare is a business and a right. Competition among providers is key. Organizations will continue to compete for patients, but they should not compete on sharing information.”

The Harvard Business School report found reluctance about sharing information to be a significant concern among healthcare providers such that it actually impeded HIE development, Julie Alder-Milstein said.

“Stakeholder concerns about the competitive nature of sharing information kept showing up in our surveys,” she continued. “Many see data as a resource that ties patients to their organizations. I don’t know that incentives offered by meaningful use will be enough to overcome those concerns.”

Looking Ahead

Despite challenges, the surveyed healthcare leaders were in unison expressing their belief that HIEs are destined to grow into key pieces of the country’s healthcare system – if not in a year or two, then perhaps in four or five.

“HIE’s are going to survive and thrive, but only through significant commitment to continued creation of efficiences and reduction of costs,” Stein said. “No one single technical solution addresses these issues. But I’m an idealist."

Sharing a rather similar attitude, Adler-Milstein holds out hope that HIEs will one day soon thrive to provide an efficient and modern means for exchanging health information.

“We’re not close yet to a nationwide HIE,” Adler-Milstein said. “I’m optimistic, but it’s harder than we and the public policymakers have acknowledged.”