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 own private HIEs and also benefit from the connectivity of a statewide HIE."

NC HIE's strategy was created with representatives from all healthcare community players, Miller says. "We had a diverse board that looked at all the aspects of the exchange." While grants have served as venture capital, the organization's business model expects financial sustainability by mid-2013. At that time, revenues for operating costs should cover core services and the group will look to foundations and grants to help extend its capabilities.

The N.C. exchange works through qualified organizations, licensed distributors, to resell services to providers. "This presents a challenge, but that also means those organizations can consume our services and use us without fear of direct competition from the NC HIE."

The HIE's initial services are pretty straightforward, Miller says. It serves as connectivity fabric, offering participants the capability to receive updates, make queries and receive information, as well as a portal technology for those seeking a visual interface. The group currently is launching a data distribution service that can exchange lab orders and results through the HIE, which prevents the need for providers to build point-to-point interfaces for each of the lab companies with which they work. They also are working with the North Carolina Department of Health and Human Services to release a set of public health services.

The NC HIE also developed a partnership with Allscripts and Blue Cross Blue Shield of North Carolina to sponsor and provide 600 rural physicians and 40 free clinics with EMR hosting and HIE connection and services at 15 percent of cost for practices and 100 percent of cost for the free clinics for several years.

Buckeye state versatility

The public-private partnership marries the best of both worlds, says Dan Paoletti, CEO of CliniSync, Ohio's statewide HIE. "It allows an entity like ours to be more versatile, respond better to market needs, as well as to the needs of stakeholders than a public entity." The organization's structure, however, ensures that the public good is the key driver.  

The hybrid model was good for Ohio for several reasons, he says, not the least of which was a major budget crisis and the state's inability to sustain an HIE. The organization was treated as a start-up company with a goal of providing as many services as possible for free or at a very low cost. "There's a fine line between being able to provide a public utility model that still is sustainable," says Paoletti.

Healthcare is local and regional whether inside a state or a country, he says. As a result, some HIEs lend themselves to a public version because of their geographic make-up and demographics. A public model is more important in areas where a large percentage of people are covered by public payors, such as Medicare and Medicaid, says Paoletti. Conversely, Ohio has a large number of commercial payors.

In establishing CliniSync, every stakeholder had a voice, and contributes a fair share, says Paoletti. "Nobody pays a huge amount. We have spread the cost over a large number of participants." Grant money was initially used as venture capital to pay for implementation, set up and infrastructure. Now, participants pay ongoing subscription fees. It's much easier to get buy-in from the stakeholders on the front end, Paoletti says. "Allowing people to have ownership in the process has been the key to our success."

CliniSync has worked closely with the Office of the National Coordinator for Health IT on a phased-approach model, in which certain suggested milestones are met for each phase before moving to the next stage. "We built a strong business case around the capability to push information around, including alerts and notices of transition of care documents," Paoletti says. "The dollars that can be saved to create an efficient infrastructure appears to be enough to bring stakeholders their return on investment."

Phase 2, which begins in 2013, includes the HIE's capability to pull information through patient data queries. "We built a business case on the push piece, but the pull piece will add a whole value of services without a lot of cost. It's icing on the cake."

Future focus

Because healthcare is local, HIE becomes a manifestation of how healthcare operates, Cochran says. For example, "there are areas with strong private exchanges that connect provider systems. It doesn't make sense for a public network to try to replace them. But, information must be able to move between networks and state boundaries because patients do."

Going forward, the challenge is for all networks to establish and demonstrate what they add to the capabilities already in place, he says. Healthcare reform will drive the need for effective data exchange and local technologies will be developed. "The mix of public and private exchange is not possible to anticipate at this stage. We're going to see a mix that will work and we will not notice who is sitting behind it, public or private."

Private HIEs are here to stay, Garber says, and state HIEs will connect those private HIEs. "The state becomes the glue for all of the different pieces. That's where most states are going."

CliniSync wants to serve as a connectivity point for providers that don't need the HIE's whole suite of services, says Paoletti. Providing value and market competition will keep HIEs moving forward appropriately, he adds. "If we can't provide enough value, [providers] will do what's best for their patients and practices. That keeps us on our toes." Providers could pick someone else to work with, but Paoletti doesn't see this as a bad thing. "Competition keeps costs down, service level up and makes everything happen a lot quicker."

Technological advances may drive significant change for HIE. "At some point, technology will change enough that our role will drastically change," says Paoletti. "We will go more toward a utility model." He compares the evolution of HIEs to the internet: it is much cheaper to have an internet connection today than it was 15 years ago. If the same thing happens with HIE, that will alleviate much of today's cost concerns.

Garber compares the next stage of HIE to Facebook where one update automatically goes to everyone one patient has approved. "That's the evolution that's going to happen. There will be a much more automated flow of information."

While some of the future is up in the air, time will tell how the future of HIE will play out.