Tony Gilman: Supporting HIE Success in Texas
Recently, the eHealth Initiative (eHI) invited me to participate in a national webinar and comment on the key findings of the 2013 Health Data Exchange Survey. eHI has tracked the growth and progress of data exchange efforts across the nation through their annual HIE survey for the past 10 years. As I reviewed the progress, key findings and obstacles identified through the survey, I found myself reflecting on our progress in Texas and the role that THSA has and will continue to play in addressing these challenges as we support local HIE advances.
According to the eHI survey, most HIE organizations took one or more years to achieve eHI Stage 5 status and become operational with data being transmitted between health care stakeholders. This is consistent with the progress of our local HIEs in Texas.
In order to participate in the state’s Local HIE Grant Program, an HIE must attain eHI Stage 3 (an organization that transfers vision, goals and objectives to tactics and business plan). Of the state’s 12 HIEs, nine were at Stage 3 and three were at either Stage 5 or 6 when they were launched in 2011.
Now, in 2013, two HIEs are at eHI Stage 7, which means the HIE has a sustainable business model and expanded their organization to encompass a broader coalition of stakeholders than was identified in their initial operational model. Four HIEs are either at Stage 5 or 6 (fully operational, transmitting data and have a sustainable business model), and another four HIEs are at eHI Stage 4 (well underway with implementation — technical, financial and legal), with three of the four HIEs very close to moving into Stage 5. By the end of 2013 or early 2014, 10 of our 12 HIEs will be at eHI Stage 5 or higher.
As the survey reflected, the costs and complexities of developing thousands of interfaces to connect to different technology platforms remain a formidable challenge for local HIEs. Alleviating the challenges of interoperability for local HIEs is one of the primary reasons Texas is supporting a network-of-networks model. Through HIETexas, THSA will develop and implement statewide infrastructure that will enable HIE-to-HIE connectivity between HIEs in Texas, and connectivity with other states and federal agencies through the national eHealth Exchange. In addition, HIETexas will support HIE connectivity to state health data sources, including the Department State Health Services.
Through its state-level shared services approach, HIETexas will reduce costs to HIEs for interfacing with each other and enable connectivity to state and federal data sources with the single interface to HIETexas rather than multiple interfaces. In other words, rather than building tens of thousands of interfaces to allow Texas physicians to electronically report information to the state’s immunization registry, Texas will support about 12 HIE interfaces to HIETexas to support this connectivity.
Overcoming interoperability challenges between electronic health record (EHR) vendors and HIE vendors is a significant issue that HIE participants grapple with across the country. This challenge is reflected in the limited vendor bandwidth, which is causing protracted delays in implementation. Because the technology platforms are not “plug-and-play,” greater transparency in pricing and types of interfaces currently supported or already available will better enable HIEs to identify resources to enhance the development of their local networks.
Increasing Data Sharing Between Competing Organizations
In addition to interoperability challenges, trust remains a significant obstacle to increasing data sharing between competitors. Entities participating in an HIE must believe that their information is being used for the best interests of patient care and population health, and not as a means of marketing to a competitor’s patients. In Texas, this is generally accomplished through a data use/trust agreement, which helps to ensure that identifiable information is shared for limited purposes not to include marketing. With strong legal agreements in place, HIEs can ensure their participants that competitors will not poach their patients, or at least not without consequences.
Privacy and Patient Engagement
Patient consent is certainly an area in which law and policy are ahead of technical capabilities. Part of this is due to interoperability issues regarding standards for data and vocabulary. Until those become more universal, segmentation of records will be difficult. When language in records becomes more standardized, computers/technical systems will be better able to flag key words that identify sensitive information to which the patient may want to limit access.
For HIEs to succeed in improving health outcomes, patients must be involved. And as the survey found, providers are the key to patients knowing and understanding the medical data that is maintained on them. Providers have limited time to provide insight and direction to patients on how to use a patient portal, how to upload/download from their EHR, or what the value to the patient is of engaging in these activities. Additionally, some providers are skeptical about the accuracy of patient-provided data, which raises issues about whether patient-provided data should be flagged or differentiated from other information. THSA will continue to work with local HIEs and other stakeholder partners to navigate this complicated dynamic of HIE development and acceptance.
HIE Expansion in Texas
The overall findings of the eHI survey are consistent with what is occurring in Texas, and we are encouraged that our approach in Texas puts us in a strong position to overcome some of the significant challenges HIEs are facing. Interoperability and content standards will continue to be challenges for the foreseeable future. Patient engagement and consent management across HIEs and across the state will also be critical components to HIE success in Texas.
Through HIETexas, THSA will continue to help lead the way in the path to success for HIE expansion in Texas. By utilizing the HIETexas state-level shared services, local HIEs will be empowered to focus on developing sustainable business models that will allow them to meet the technology needs of the hospitals, providers and patients they serve.