Whether you take the public or the private route, experts say there are numerous benefits to participating in an HIE.

By Renee Diiulio

data_highway2First came digital information. Then came advances in the technologies that supported it, allowing the transmission and storage of that information. Next came the electronic health record (EHR), followed by more technological advances. And then came Meaningful Use.

Defined by the Centers for Medicaid and Medicare Services (CMS), the initiative was intended to make sure that the technology did more than become a massive digital file cabinet. Ultimately, the goal became to promote the spread of EHRs to improve healthcare in the United States.

Such an undertaking takes time and resources, and it’s no secret that the medical community is already strapped for both. New processes and culture change don’t help to speed evolution either. So CMS set a timetable, and as we start 2014, the earliest healthcare providers will become eligible for Meaningful Use Stage 2 incentives (the last will need to meet the first year requirements for Stage 1).

Enter the health information exchange (HIE). The first stage of Meaningful Use focused on the EHR and data capture and sharing to the benefit of tracking, coordination, and reporting. With its completion, healthcare organizations become adept at sharing information within their confines. Stage 2 focuses on advancing clinical process through digital information sharing—outside of traditional borders. Via health information exchange, it is hoped that healthcare will become more efficient, productive, and, most importantly, effective.

The Office of the National Coordinator for Health Information Technology (ONC) of the US Department of Health and Human Services summarizes the four major requirements of Stage 2 Meaningful Use as more rigorous health information exchange, increased requirements for e-prescribing and incorporating lab results, electronic transmission of patient care summaries, and more patient-controlled data. CMS breaks these down further into specific objectives, pending whether the organization is a provider or hospital.

For either, participation in an HIE can help to achieve some of these criteria. For radiology providers, long used to sharing data, the exchange of information can also grow through HIEs, becoming both more expansive and easier to complete.

Radiology as HIE Champion

In fact, radiology is often used as a prime example to support the benefits of broader information exchange. Defined in its simplest form, a health information exchange permits the sharing of patient data across the boundaries of an individual health system or practice. It is not generally the repository for that information but merely a means by which the data (taken from other databases) can be transferred.

As more data is exchanged, more benefits can be realized. Sean Kennedy, director of Health Information Exchange for the Massachusetts eHealth Institute (MeHI) in Boston cites just a few: the streamlining of care coordination, reduction of medical errors, improvements in patient safety, a decrease in duplicate diagnostic procedures and corresponding reduction in waste, public reporting and analytics, and a foundation for accountable care organizations and the value-based healthcare model.

Hamid Tabatabaie, CEO, lifeIMAGE

Hamid Tabatabaie, CEO, lifeIMAGE

“Image sharing is one of the easier described benefits of participating in an HIE because imaging exams are often a first step in the diagnosis and detection of disease today and are certainly part of every surgical event,” said Hamid Tabatabaie, chief executive officer of lifeIMAGE, based in Newton, Mass.

In addition, radiology exams are expensive, and some involve radiation exposure for the patient. “You can avoid the risks and costs of duplication if you have access to images from the last provider,” said Tabatabaie. Studies support this view, such as one by Cook et al that found that more than 80% of repeat scanning in pediatric trauma patients was potentially preventable.1

The ABCs of HIEs

Determining which benefits that can be gained from HIE use can help a healthcare organization decide in which exchanges it should participate. Does a facility want to complete public health transactions or facilitate information exchange with a partnering skilled nursing facility? Which departments will be involved? What are the costs?

There are two major forms of HIE: public and private. “The biggest difference between the two surrounds funding and governance,” Kennedy said. Public HIEs are governed by and receive the majority of funding from government dollars; private HIEs work with private funding and governance.

“Private HIEs are used by a particular health system or provider to connect to their own referral base and/or the other providers they interact with to share information more efficiently. The proposition is very straightforward because they are not being asked to share information with competing organizations but with those they already work with,” Tabatabaie said. The infrastructure has often been created by the user or, more frequently, a vendor, and funds are typically generated via user fees or service contract agreements.

Public HIEs often have their infrastructure developed with public funding. The infrastructure of the Massachusetts Health Information Highway (The HIway) was built with funds through government grants, both regionally (through the Executive Office of Health and Human Services [EOHHS] of Massachusetts) and nationally (via the ONC and CMS). Moving forward, enrollment and subscriber fees, kept to a minimum, will be used to cover upgrades and maintenance.

Building On-Ramps

Every state now has a public HIE program in place, although some have a longer history and more recorded success. Some require provider participation; some do not have such regulations in place. But, of course, the more organizations that participate, the greater the value of the information exchange.

In Massachusetts, connection to The HIway is currently voluntary, but state law requires all medical providers to connect by 2017 to support their phased goals for the entire project. The first stage is direct connectivity of healthcare providers; subsequent phases will address the analysis of protected health information (PHI) to better manage the quality and cost of care delivered, as well as the query and retrieval of information across the healthcare community to achieve the best possible care coordination for Massachusetts residents. Providers who connect will have an easier time building patient histories and, ideally, delivering patient care, but there are some challenges before this data-sharing utopia can be achieved.

Kennedy believes the biggest challenge is change management. “In healthcare, we are very good at managing the release of information in the paper world, but to move to an automated approach with predesigned workflows requires some significant consideration and thought,” he said.

Subsequently, it’s also important to get providers’ buy-in. That process should begin early if the organization’s intent is to have them directly participate. “You want to avoid a big gap between when you connect and when you send your first transaction,” Kennedy said.

For instance, a referral that used to be faxed must be turned into a digital data set, then standardized and made secure for electronic transmission, then received and actually read, meaning the workflow changes from beginning to end. Providers must be prepared for the new processes.

The technology also must be able to support the effort, and, in the short term, will require IT involvement. “The biggest question for any provider to ask is whether their vendor is ready to connect. If not, it will mean a lot more work for the organization,” Kennedy said.

Often, there is more than one option to connect to an existing HIE. The Mass HIway offers four: webmail, EHR direct (through an EHR vendor), LAND (a pre-configured Direct-compliant gateway), and Direct (via an organization-developed gateway). But successful transmission also requires that the data is compatible between systems.

Standards have been developed, primarily by HL7 (Health Level Seven International, Ann Arbor, Mich), and are being refined as HIEs are developed and harnessed. Participants must meet these standards for successful participation, although they may not be required to supply every bit of information that an HIE can hold. For instance, few will likely populate all 175 data fields in the continuity of care document (CCD), suggests Kennedy, but they may choose 10 of the data sets to fill for their referral form.

Security is generally not an issue. “If best practices to minimize security risks were adhered to, then the system is probably more secure than manual brick-and-mortar records,” Tabatabaie said, but qualifies that there are always risks with online information.

Highways and Byways

For imaging providers, these risks have already been absorbed. Radiology has led the way in file sharing through technologies that allow remote reading and sharing of patient images, with standards like DICOM already well established.

One of the industry’s biggest challenges has been file size, and as a result, imaging has been a later addition to existing HIEs. But in an age when people can watch movies on their phones, it is no longer an issue without a technical solution, notes Tabatabaie.

In fact, those solutions have already been routinely employed with success. “Reaching out to the medical community, we discovered that some imaging vendors already had private HIEs, but that their systems were complementary to ours so there was still value in information exchange between the two,” Kennedy said.

Few in radiology question the value in sharing image data. The exams are expensive and radiation exposure is a concern, particularly for patients under disease management programs. Previously, patients were charged with keeping their image records, at first on film and later on CD. While many were happy to have this control, files got lost and forgotten—or simply couldn’t be read.

Having access to these files through an HIE eliminates a lot of these issues. In addition, that HIE can be accessible to the patient, permitting individual engagement and control.

Patient involvement is at the core of the RSNA Image Share network, a pilot project that allows radiologists to share images with patients via personal health records (PHRs). “We had two facets for development: one was that patients controlled the information, and the second was the use of standards that eliminated proprietary systems,” said David S. Mendelson, MD, FACR, Professor of Radiology; director, Radiology Information Systems Pulmonary Radiology; and senior associate, Clinical Informatics, The Mount Sinai Medical Center (MSMC), New York; and co-chair, Integrating the Healthcare Enterprise (IHE).

By using IHE XDS (Cross-Enterprise Document Sharing) standards, the Image Share network encourages compatibility across vendors, systems, and state borders. “For some patients, it’s great to have ownership of their records; for others, it may not work. But the use of these standards to build an infrastructure highway can leverage existing technologies to increase adoption of HIEs at a reasonable cost,” Mendelson said.

Taking the Driver’s Seat

Greater patient engagement is a goal of both stages 2 and 3 of Meaningful Use, and again, HIEs can help to meet these criteria. As more people connect and more information can be shared, decisions can be made more quickly and efficiencies realized. Data can speed along the information superhighway to be delivered when, where, and how it is needed.

“We don’t believe that one size fits all,” Mendelson said. For some, a private HIE will be best; for others, a public option may work; some may wish to focus on patient-centered control; and some (more likely most) will want some combination that best serves their patient and provider populations.

Tabatabaie expects that over the course of the next few years—perhaps as few as 3 to 5—a minimum standard of expectation for exchanging some subset of records will exist. “For instance, I believe data such as lab results, prescription history, imaging files, discharge summaries, allergies, and immunization records will be expected information that your doctor is able to access and reference from anywhere. As technology improves, adoption will increase at a faster pace,” he said.

Health information exchanges may not yet be fully up to speed. But according to experts, they will be soon, and they are here to stay.


Renee Diiulio is a contributing writer for Axis Imaging News.



(1) Cook SH, Fielding JR, Philips JD. Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure. J Pediatr Surg. 2010:45(10):2019-2024.