Public vs. Private? Say Hello to Hybrid HIE

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Health information exchange (HIE) is growing and expanding—the proposed rule for Stage 2 meaningful use draws heavily on open exchange of patient information and research indicates that more and more communities are launching their own exchanges. From 2010 to 2011, the number of active public HIEs rose from 37 to 67, while the number of active private HIEs more than tripled from 52 to 161 during that same time period, according to a July 2011 KLAS report.

Whether public or private, an HIE needs three components, says Larry Garber, MD, medical director for informatics at Reliant Medical Group, a multi-specialty practice based in Worcester, Mass., and vice chair of the Massachusetts eHealth Collaborative. Those components are: value for each stakeholder, fit into real-world workflow and trust in each other and the HIE. "Stakeholders have to trust that their competitors aren't going to steal data and patients, and those data won't get lost or find their way to the front page of the Boston Globe," he says.

Pros and cons

Public and private HIEs have different capabilities to accomplish these three components, says Garber. For example, a private HIE is local, so it can better understand and meet the community's specific needs. Also, private HIE probably can establish more sophisticated connectivity.

SAFEHealth, the HIE written by and for Reliant, includes an automated referral processing mechanism. "In our connections, we monitor the moments when patients are admitted or discharged," Garber explains. Providers receive those messages instantly, and they receive the patient's lab results via SMS text messaging while the patient is in the hospital. If a test result comes back after a patient is discharged, it goes directly to the primary care provider in any format. "While we can ensure those results go to a specific provider, you may not be able to do this in large, statewide projects."

On the other hand, state exchanges are better at creating a provider directory and establishing connectivity for public health and quality reporting. State projects also provide a directory for advanced directives. In this model, there is only one place to look up any patient's desired plans. Also, because there are independent physicians who don't want to be part of a hospital network, especially solo practitioners in rural areas, a state HIE offers them the opportunity to stay connected.

However, a private, community HIE has the upper hand when it comes to useability and trust, Garber says. "If you're trying to make something useable, it needs to be integrated into the EHR. A hospital-based HIE can provide that EHR to give much tighter integration." A state can't say that everyone in its exchange should use one vendor but a private HIE can and will do that. When trust is local, it's "easier for a community to build trust," says Garber.

Past successes, future funding

Vermont has a strong history in building trust for its HIE. Established in 2006, Vermont Information Technology Leaders (VITL) operates the state's independent, public HIE which connects small, private HIEs and provides exchange where there is none, says David Cochran, MD, president and CEO. Early on, the HIE was designed to demonstrate the capability to move lab data and care summary documents. It also worked with the state's medical home initiative to provide information for a registry. Now, the exchange has expanded to the point that by the end of this month, 12 of the  14 state hospitals will be putting data into the exchange and close to 100 practices will be sending information to the registry.

"One of the challenges with all of the health IT work is managing requests, as everyone wishes we would do it better, cheaper and faster," Cochran says. "The work is, at the policy level, interesting and engaging. At the delivery level, it's technically challenging." Rather than plug and play, he says connecting EHRs to an exchange and having information flow through is "more plug and struggle."

As for future HIE sustainability, Cochran says a state health IT fund designed to support infrastructure and other costs sunsets in 2016. After that, funding options may include tacking on provider fees or operating the HIE as a public utility.

Best of both worlds

Merging both models, several states are creating a hybrid HIE. North Carolina went live with its public-private HIE in March, says CEO Jeff Miller. In this state-designated mixed model, "organizations can still benefit from their