The Indiana Health Information Exchange (IHIE) has been building bridges among healthcare providers since 2004, and the state's history in clinical data sharing goes further back than that. Yet the nonprofit, among the nation's longest-running HIEs, has only recently added a critical piece of the healthcare community: long-term care and post-acute care facilities.

Three long-term care organizations signed contracts during 2010 to participate, and when the first of those groups went live on the exchange in February, IHIE became something of a frontrunner among HIEs.

"We've had a fairly robust health information functionality in a good chunk of the state for more than 10 years – for the most part almost completely without the involvement of long-term care," said John Kansky, vice president of business development at IHIE. "Suddenly, we've got long-term care organizations involved, signed and connected."

The recent uptick in long-term care participation may spark a new round of data sharing. But HIEs will first need to study the information requirements of their new neighbors.

"We've been trying to educate ourselves as an HIE on how to serve long-term care," Kansky said. "We have a lot of learning to do."
The Indiana exchange has plenty of company in that endeavor.

A Separate History

Long-term and post-acute care centers have been largely absent from HIEs, which have thus far concentrated for the most part on hospitals and ambulatory practices.

"As HIE activity evolved, the focus has been on connecting physicians and connecting hospitals," said Michelle Dougherty, director of practice leadership at the American Health Information Management Association.

Part of the problem, she said, is the perception that the long-term care sector has nothing of value to share. While HIEs haven't traditionally courted long-term care, nursing homes likewise haven't been clamoring to join HIEs.

 "A lot of facilities are not aware of this HIE initiative going on," Dougherty said.

Another obstacle: A lack of robust electronic health record use in the long-term care sector. Interoperable EHR systems are generally what plugs providers into an HIE. But long-term care facilities, assuming they have the money to invest, lack the options other providers enjoy.

"There is not a strong and vibrant EMR/EHR market for long-term care," said Greg DeBor, a partner in integrator CSC's Healthcare Group.

That some long-term care centers don't see themselves as healthcare facilities serves to limit automation, DeBor suggested. "A lot of people think of them as playing that role, but long-term care is often about tending to the activities of daily living," he said. "Healthcare is on an incident or emergency basis."

A Seat at the Table

Despite the history of disconnection, long-term care organizations are now edging into the HIE orbit. At the federal level, a recent set of state grants from the Office of the National Coordinator aims to get more long-term facilities into exchanges. Still, would-be integrators will need to address long-term care's automation challenges and workflow requirements.

Indeed, including long-term care within HIEs holds the promise to raise the level of care coordination. Transitions between hospitals and nursing homes can misfire, putting patients at risk. Injecting timely patient information into the process would smooth the handoff, reduce medication lapses and cut back on hospital readmissions, advocates say.

 "I spend a lot of my time contacting organizations that have had ample opportunity to learn about HIE and get involved – I still have to work very hard to get them interested," Kansky said. "Long-term care seems to be exhibiting better initiative in this state than other sectors of healthcare."