HIEs Need Cultural “MegaChange” to Flourish

The alchemy involved in developing and executing successful health information exchange (HIE) is complex.  Technology, policy and specific organizational situations are core components embedded in the success/failure equation that can either help or hinder the creation of a thriving clinical data-sharing network, whether in a hospital, IDN or region.  Because HIE, by definition, requires the cooperation and coordination of multiple groups factions and individuals within an organization, it is important that the various agendas of these groups be identified and addressed.

A recent White Paper published by the Brookings Institution on the governance of HIEs finds that implementation challenges and barriers to successful HIEs are similar to the challenges found in setting up government programs because of the density and complexities intrinsically found in both. “Mission ambiguity, problems of organizational coordination, resource and organizational capacity restraints, political interference, as well as lack of clarity and consensus, limit the ability of policy makers to achieve the desired goals.”[1] Institutional and regional HIEs face these same issues, which are also further complicated by a heavy dose of technology which is at the heart of HIE and what makes it possible.

States and organizations that have implemented HIE are well aware of these challenges and all are in different stages of the throes of wrestling them to the ground to either start-up or improve the distribution and sharing of patient data. For example, Tennessee, an early adopter of HIE, has chosen to build an HIE network on the foundation of former RHIOs (regional health information organizations). This approach has the advantage of embedding interoperability into an existing structure between organizations. The state leverages a “network of networks”[2] methodology of using already accessible networks at the local and regional levels to provide a universal layer of connectivity.

This approach has worked very well for Tennessee, whose HIE is a public-private partnership comprised of physicians, nurses, pharmacists, hospitals, insurers and patients. Other states have had similar, as well as a host of other issues, to deal with.  Among them are 1) governance mechanisms which have a huge effect on implementation. These players typically include hospitals, medical societies, government health departments, universities, physicians and public officials. Others often include payers and unions. The number of players, all with varying agendas, makes implementation a tremendous challenge; 2) consensus on the path forward. With many aspects of healthcare reform being contentious, tensions inevitably arise between local, regional and state organizations which further slow down implementation; 3) the role of the federal government which includes the Direct Program designed to effect simple and secure clinical messaging. While Direct’s goal is to connect many physicians and hospitals, many claim that the program undermines efforts to connect at broader levels.  And demand for Direct protocols, thus far, has been weak. 3) privacy and security continues to complicate HIE performance since data exchange requires permission and consent.  Uncertainty about privacy can greatly impede, if not kill, an exchange network unless sufficient guidance is made explicit. And finally, 4) the elephant in the room is sustainability. With HITECH funding not being eternal, HIEs must plan for ongoing self-sufficiency.  This inevitability is complicated by the current weak economy with states still cutting budgets. Options being considered are membership or subscription fees along with a small “claims tax” which will enable sustainability.

In short, HIEs, while in many ways the clear answer to the kind of connectivity that will ultimately reduce healthcare costs and improve outcomes over the long haul, face daunting challenges. These challenges, taken as a whole, are probably best addressed through a cultural shift, or MegaChange in attitudes that will enable the tackling of these issues broadly in order to get us where we want and need to be: the transformation of healthcare delivery in the U.S.


[1] Kent Weaver, “But Will It Work?: Implementation Analysis to Improve Government Performance,” Issues in Governance Studies, February, 2010, pp. 3-8.

[2]  Darrell M. West and Allan Friedman, “Health Information Exchanges and Megachange”, Governance Studies at Brookings, February 8, 2012, pp 20-21.

  1. While HIEs aren’t all about money, helping manage health care costs is certainly a front and center issue in the argument for HIEs.

    So who benefits most, if the HIEs of our happiest visions become functional?

    Answer: the current funders of health care who are most at risk for inefficiencies caused by lack of coordination and poor hand-offs between providers. That’s Medicaid, Medicare esp. for patients with multiple concurrent conditions (and many providers), and safety net providers who care for uninsured patients who enter the system when they’re too sick to be turned away.

    The commercially insured segment of the market isn’t perfect, but there most patients have a primary care physician, and there’s already processes in place to attempt to better coordinate care.

    Since Medicare, Medicaid, and state support for the uninsured collectively provide 60-70% of health care funding, AND disproportionately should benefit more from the savings HIEs should provide, clearly the public sector should be paying for … i.e. investing in … this technology. That’s where the majority of the benefit will be realized. It benefits the tax-payers who pay those bills.

    The common thought that HIEs should be funded by what is essentially a transaction tax on participating providers is critically flawed, in the health care system of the future these things are necessary public infrastructure for the common good, like highways and schools.

    And because of this fundamental mis-recognition, the people creating HIEs spend half their time worrying over the “sustainability of the business model”, i.e., funding, rather than concentrating on the technical and political aspects of pulling working HIEs together, which are certainly tricky enough.

    Govt. money SHOULD be the start-up AND sustaining long-term source of funding for HIEs. Anything else is a dysfunctional forced subsidization of one part of the health care “system” by another, with the ensuing perverse incentives we’ve experienced all too often.

  2. Douglas, There are three basic principles that I disagree with in your argument:

    1. We have many clients throughout the country who have several different sustainability models. However, the one thing we discovered early on is that those providers without sufficient skin in the game are reluctant players in HIE initiatives. This is especially true with clients that received government funded start-up money and where the first five years of funding and participation (actual use) of the in-place technology was abysmal, compared to the client who contributed its own funding from the very beginning. Asking the government to pay for technology infrastructure that is associated with optimizing business processes is like asking the government to fund transaction processing software for clearinghouses of banking transactions.

    2. As the reimbursement model changes, with accountable care on the horizon, healthcare must move away from episodic-based care to a more coordinated, patient-centered approach. This shift must occur whether the current government-based ACO model comes to fruition or not. To accomplish this, the healthcare system as a whole must begin developing ways to share information, communicating across the continuum of care and managing patients as patients moves from ambulatory to acute, from acute to sub-acute, from sub-acute to rehabilitation, from rehabilitation to home care, etc. This change requires a re-tooling of not only the technology infrastructure but also of clinical care management. Only through wholesale changes in how we care for patients, will we shift into a paradigm of care that truly is able to decrease costs while increasing the quality of care.

    3. And lastly, patients deserve to be the center of their own care and have the same capability to manage aspects of their care as they do their own finances and other aspects of their lives. If there is not an infrastructure that is market-driven rather than government driven – we will end up with the same type of customer service within healthcare as we have at the Department of Motor Vehicles or the Internal Revenue. Personally, I’d rather healthcare systems, communities and states figure this out without the help of the federal government. No offense but I’ve had the government show up to “help” me and it is my experience that saying thanks but no thanks doesn’t work at that point.

    The healthcare system shouldn’t be exempt from re-tooling itself to meet a changing financial, customer service and quality environment. I remember when government price freezes, DRGs and pay-for-performance initiatives where going to solve the problems of healthcare. I believe that healthcare, like all other struggling businesses, must show leadership and change from within, rather than relying on the government to tell them what to do and how to do it because the change is being funded with federal dollars.

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