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We are at a time of dramatic change in health care. Not only is the question of health care finance on the table as a hot area of debate, but also the issue of health care delivery is (perhaps more quietly) undergoing big change. And the kinds of health Information Technology needed by the delivery system is evolving just as dramatically.
Perhaps the best way to describe the kinds of healthcare delivery system changes we are seeing is like this: we are witnessing health care emerge from a largely disaggregated cottage industry to one dominated by coordinated delivery networks. Yes, there have been very large “box store” integrated delivery networks (often centered around academic medical centers), but the majority of physicians have been in “mom and pop” small stores across the country. That is now changing.
What we are seeing is the emergence of local and regional delivery networks, which can take many forms. As part of the recently-upheld Affordable Care Act, CMS has encouraged the development of Accountable Care Organizations (ACOs) to manage Medicare patients in a coordinated way. In parallel, Patient Centered Medical Homes(PCMHs) are also emerging as a way of managing populations, centered around primary care.
These new forms of coordinated healthcare delivery attempt to tie together previously adversarial elements of the delivery system – physicians, hospitals, and health plans – and incentivize them to reduce the total cost of care for a given population. With proper data, the ability to generate quality measures visible to those who directly render care, prompts around best practices based on medical evidence, and rewards for actual performance and demonstrated value (rather than simply for volume of service delivered), these new forms of healthcare delivery require unprecedented access to data.
Data that connects hospitals, physicians in their offices, diagnostic services (such as labs), medication usage from pharmacies, and health plans is something that has historically been difficult to achieve all-in-one-place.
The evolution of HIEs
The initial way of addressing this need to share data between healthcare settings was through regional government grant-funded Health Information Exchanges (HIEs). Though this approach has gained some momentum (largely because of government grants), and all 50 states have identified a vendor partner for developing their regional HIE, it is based on a premise that all the competitive elements in the healthcare ecosystem will want to cooperate with data sharing.
Various models have been explored concerning HIE success as self-sustaining businesses, after the government subsidies run out. A recent paper examined the financial worth of HIE data sharing, and looked at three models for support: fixed-rate annual subscription, charge per visit, and charge per lookup. The fixed-rate approach was the most successful, and resulted in HIE usage to the level needed to result in savings from preventing unrequired hospitalizations, reducing duplicate tests, and avoiding emergency department visits.
However, growth in these kinds of HIEs has been slow. More importantly, the rise of private, local HIEs within delivery networks has been growing quickly. In fact, a survey of vendors of HIE-supporting software (a whole market segment outside Electronic Health Records) shows that private HIEs are the fastest-growing segment in this market.
This is not a surprising observation. Health care in the U.S. is competitive. There is not much incentive (other than governmental requirement) for competitors to exchange data with each other. However, as coordinated delivery networks mature, given significant momentum by ACOs, the need to develop HIE-type functionality within their network becomes critical.
Challenges within private HIEs
Technology that is needed for ACOs and similar organizations certainly has some technical challenges. Creating an “abstraction layer” over a collection of different systems, each with its own data structure, is a challenge. Surprisingly, the “standards” that all systems are supposed to support are not really that standard. The result is that hospitals, laboratories, and one or several ambulatory EHR systems may encode certain kinds of data differently.
Further, there is the technical challenge of creating an Enterprise Master Patient Index. Correctly identifying patient data, derived from various data sources, is one of the most complex aspects of health information exchange, and a sophisticated EMPI tool will promote accuracy while reducing PHI errors.
The kinds of things being asked of HIE technology within these new private networks is beyond simply transporting and connecting the dots. Health IT is being asked to roll up data (from all the component sources – hospitals, emergency departments, ambulatory doctors’ practices, laboratories, imaging centers, surgi-centers, etc.) and deliver actionable data. Quality measures; coordination of care between doctors, hospitals and home health agencies; payment methods that reward value, rather than simply volume (which means that “value” needs to be quantified) – all these things are what ACOs and similar coordinated delivery networks ask of modern health IT.
But that is not the hard part.
In talking with CIOs trying to support the emergence of these kinds of networks, most of their time is not spent on the technical aspects of HIE technology (though certainly, much of their budget is spent on this). What actually consumes most CIO time is managing the relationships. It is getting the various parties, who have traditionally seen each other as adversaries competing for their own slice of the pie, to want to cooperate. Data exchange can be built, technically, much more easily when the parties involved actually see the value and want to work together.
“Relationship management,” then, is the biggest challenge for HIEs. Even within a given coordinated network, moving beyond the competitive and possibly adversarial tradition (the local health care politics) is where much effort is being focused. If done right, the network (ACO, PCMH, IPA, or whatever form it takes) will be poised for success. Technology is a result of the relationships involved, though it can also facilitate the relationship moving forward.
This is also the biggest reason why regional and statewide government-supported HIEs, as envisioned in the 2009 ARRA legislation that gave rise to Meaningful Use, have experienced slow adoption. Why should competitive entities want to cooperate? They may do so reluctantly, if forced, but don’t have much motivation for doing so given their market incentives. What we have seen, on the other hand, is that ACOs and efforts like them are driving HIE technology within private networks – this is where the relationships issues are hammered out, and technology evolves. This is where the HIE-supporting vendor marketplace is growing.
In the next 1 or 2 years, we will likely see maturation of delivery networks, and the HIE technology needed by them. A “stage 2” issue will be the question of how (or even if) these internally-functioning and -efficient networks cooperate with each other. Will the regional HIEs, as envisioned by ARRA, be simply where ACOs/PCMHs/coordinated networks talk to each other? Will those technology needs be different (simpler) than what is needed within an ACO? We will only be able to answer that question well once we have built out experience with “stage 1” – creating coordinated delivery networks that use internal private HIE technology.
Robert Rowley is a practicing family physician and healthcare information technology consultant. From its inception through 2012, Dr. Rowley had been Practice Fusion’s Chief Medical Officer, having created the underlying technology in his own practice, and using that as the original foundation of the Practice Fusion web-based EHR. This article was originally published on his web site www.robertrowleymd.com.