Right now,  healthcare organizations have to go through some pretty tricky maneuvers to link patient data across varied systems and settings.  It’s possible to connect patient info electronically through database hacks, but more often than not, matching patients to clinical data gets done by hand.

Given the insane complexity of the existing system, would it make sense to create a national patient identification number for every U.S. patient?  The question is worth revisiting, given the immense level of error and wasted time generated by the existing system. After all, not only would putting an NPI in place make it easier to track patients within a hospital or health system, it would simplify the rollout of HIEs dramatically, wouldn’t it?

Dr. Robert Rowley of EMR vendor Practice Fusion notes that the biggest enemies of establishing a National Patient Identifier are privacy advocates who feel that an NPI would expose patients to greater risk of breaches or misuse of data.

But is that a realistic concern? Probably not. I agree with Dr. Rowley, who asserts that it’s hard to imagine that PHI would be at greater risk simply because of how it’s indexed.  As he notes, PHI breaches are nearly always often haphazard affairs in which a laptop is stolen than Big Government or corporate conspiracies. (If you’re afraid the government is covertly siphoning your health data off to study it, not having an NPI won’t protect you, anyway.)

No, the real barrier to this kind of administrative simplification measure is time, money and resources, the same barriers that hold back any other proposed HIT project.  It’s hard to imagine the resources that would be involved in instituting such a system — the idea makes my head hurt — and I have to assume it’d be several years before it was anything like mature.

Still, it’s good to bear in mind that at least some members of the public are afraid that creating an NPI would compromise their privacy. If the only barrier to improving patient matching in our EMRs is technical, that’s one thing — but if it’s patient fears, that’s another thing entirely. Sometimes, it’s good to remember that most of the world doesn’t think like a health IT exec.

I recently saw a tweet to the National Conference of State Legislatures (NCLS) list of “Top 12 Legislative Issues of 2012.” It’s an interesting look into issues that state legislatures will be dealing with in 2012. Plus, it makes an interesting observation at the outset that state budgets have been cut so much in past years that lawmakers won’t have to focus all of their initial energy on budget shortfalls.

Most of the list is not surprising with managing the state budget and jobs are at the top of the list. However, there are a couple healthcare and health IT related sections in their list of top government issues as well.

One of the issues is Medicaid: Efficiencies and quality. It talks about how the tough economy is making the Medicaid budgets in states a real challenge and many are looking for cost containing actions. Plus, it points to ACO type reimbursement based on patients’ health outcomes, medical homes and streamlining services. The ACO part was quite interesting to me. I wonder how much of an effect lack of Medicaid budget will push forward a new model of healthcare.

The disturbing part of the report comes in the “Health: Reform in the states, health care exchanges, technology and benefits. Here’s the section on health IT, the EHR incentive money and HIEs.

HEALTH INFORMATION EXCHANGE: One focus for state legislatures in 2012 will be how to move health care providers, especially those participating in the Medicaid program, toward the adoption of certified electronic health records (EHRs). Essentially, instead of having a different health record at each doctor or provider you visit, an EHR will serve as one file that all of your doctors can see. EHRs, once fully implemented, are expected to provide doctors and health professionals with easier access to patient histories and data, resulting in cost-savings and better health outcomes by removing costly errors and duplications in services.

I love how this basically assumes that by having widespread adoption of EHR software, that we’ll then have one patient record that each doctor you visit can see instead of having a different health record at every doctor. Of course, those of us in the EHR world know that this is a far cry from the reality of EHR software today. In most cases you can’t even share a patient record with someone using the same EHR software as you let alone sharing a patient record with a doctor who is using a different EHR.

The sad part is that whoever wrote these legislative issues must have realized that there was some issue with EHR software exchanging information, because then they wrote the following about the state HIE initiatives.

In addition, states are responsible for building and implementing health information exchanges (HIEs) where those EHRs can be accessed by health care providers. HIEs function like an online file cabinet where your medical record is securely stored, and can be accessed by any doctor or health care professional you visit. By mid-year 2012, every state should have Medicaid EHR Incentive programs in place and will be working toward building an HIE by late 2014 or early 2015 as required by deadlines attached to federal cooperative agreements.

So, wait. If EHR software has created one file where any doctor can access our patient record, then why do we need “an online file cabinet” for our medical records? We know the answer is that we need the online filing cabinet because EHR software isn’t connected and there isn’t one patient record. Each doctor maintains their own patient record and that’s not going to change any time soon.

The above quote also implies that every state is working towards an HIE program per the federal program. I must admit that I haven’t gone through every state, but is every state working on an HIE? I certainly know there are a lot of states working on some sort of HIE project, but I didn’t think that every state had funding for HIE. I guess maybe the question is whether there is any state that doesn’t have some sort of HIE program in the works.

Reading issues described like this, you can understand how government passes legislation with limited understanding. Based on this resource, EHR software creates one patient record. Wouldn’t that be nice if it were the case?

In my ongoing series of Major EHR Developments from John Halamka (see my previous EHR In The Cloud and Modular EHR Software posts), his third major EHR development from the Technology Review article is: A Network of Networks.

Halamka basically says:
-Most people think doctors and hospitals exchange healthcare information (they don’t)
-New standards are being integrated with EHR that will make it happen
-There won’t be one large database of health records
-Many regional data exchanges are happening
-There will be multiple Health Information Service Providers (HISPs)

I agree with most of these ideas. Although, I think it still faces two major challenges.

The first challenge is the standards challenge. Sure we have CCD. Oh wait, we have CCR. Oh wait, they merged, kind of. Oh wait, now CCD has multiple flavors. Oh wait, what kind of standard is it if there are multiple standards of the standard? I think you see my point.

The second challenge is whether HISPs and the other regional data exchanges have a viable future. I’ve talked to a lot of people about these exchanges and I have yet to hear someone clearly articulate a viable model for these exchanges. My favorite was the HIE expert who told me they’d figured out the model for HIE. So, I asked what it was and they gave me some convoluted answer that made no sense to me. Maybe I’ve just missed it, but I’d love to hear someone try to describe a viable HIE model.

I do predict we’ll see Fax slowly phase out over time. Although, I think it will more likely be replaced with a fax like service on the internet (Direct Project?) as opposed to some other sort of Data Exchange. It will probably best be described as Fax 2.0.

There seem to be three big acronyms when it comes to healthcare IT and interoperability – EMR (electronic medical record), HIE (health information exchange) and ACO (accountable care organization). Implementing one does not always necessarily lead to the implementation of another. I’m sure everyone will agree, however, that an EMR most likely leads to connectivity to a HIE, which increases the likelihood of participating in an ACO or coordinated care program. I consider these technologies and concepts to be the interoperability triumvirate, if you will.

Of these three, the HIE seems to have seen its day in the sun. Enthusiasm for the concept and its surrounding technologies – at a fever pitch at tradeshows and in the media last year, in my opinion – seems to have been eclipsed by Meaningful Use incentive payments for EMRs and the general consternation related to ACOs. Which is why my interest was piqued when I came across news from a company called NexJ and its new Health Exchange solution.

In order to learn more about the product, touted by the company as one that “brings together the numerous electronic health records systems and applications that exist within healthcare organizations – many of them old, out-dated legacy systems – into one place so that healthcare providers can deliver better, safer, more comprehensive care,” I reached out to Oz Huner, Vice President of Health Solutions at NexJ Systems.

JD: What type of healthcare facility would be the typical customer for your new HIE solution?
OH: “The NexJ Health Exchange solution facilitates the sharing of patient information between healthcare organizations such as hospitals and healthcare providers, ACOs, HIEs, and public health and government agencies.

“Our customers are choosing our solution because it enables them to move from paper-based workflows to electronic workflows and gain such benefits as complete access to accurate information, improved quality of care and patient empowerment.”

Can you give me a specific example of how this HIE can potentially (or has already) improve patient outcomes at a client facility?
“In a current project we’re working on, NexJ is helping meet the challenges emergency department physicians and staff face by providing timely access to the patients’ primary care provider records when they arrive at the hospital admitting department. The NexJ Health Exchange solution connects the patient’s medical record directly with the emergency department systems, improving information sharing between community health providers and the hospital, and improving patient safety.”

Is there a limit to the number of EMRs and applications that can be connected within the NexJ health exchange?
“No, there is no limit to the number of EMRs and applications that can be connected using NexJ Health Exchange. It is highly scalable and can address the needs of the even largest healthcare organizations.”

Does it work with some EMRs better than others?
“No. NexJ Health Exchange provides open, standards-based integration to any EMR system. Its secure, Web-based portal and flexible architecture enables connectivity with legacy and proprietary systems, support for global messaging standards (HL7v2.x and HL7v3.x), exchanging of clinical document formats (CCR and CCD), and support for multiple standardized clinical terminologies (SNOMED, LOINC).

Based on your interactions with providers, do you feel that more and more are finally coming around to the idea of adopting EMRs and eventually HIEs? Or do you find that many providers still think they aren’t worth the expense?
“It is our opinion that EMRs have historically been of great value to healthcare organizations, but since they’re often siloed, such information technology has not been ubiquitously adopted. As an element of a HIE, however, we believe there will be greater EMR adoption as government incentives and programs encourage healthcare providers across the country make the switch to EMRs. As more physicians move to EMRs and become net receivers of patient information, they will realize the benefits of access to accurate information, improved quality of care and patient empowerment.”

Are you working with any regional extension centers around the country to promote your EMR and HIE solutions?
“Indirectly, yes. Through our partnership with Open Health Tools, NexJ is a member of the Platform Implementation Project (PIP), which is working on an open HIE solution for state agencies. The focus is currently on southeast Texas, but is by no means limited to that region.”

NexJ will be at the Health 2.0 conference in San Francisco next week. If you plan on going, stop by their booth and let me and your fellow readers know what you think about this new health exchange solution. Is HIE the buzzword worth bringing back?

For several years, I’ve been watching health information exchanges struggle to birth themselves. Despite ongoing support from state and local governments, HIEs continue to fade away, few having found a business model that works. And no workable business model seems to be on the horizon yet, either, despite efforts by thousands of providers to keep their HIE afloat.

This week, I was sorry to read about the death of yet another HIE.  CareSpark, a Kingsport, TN-based network which has been in existence for six years, announced on July 11th that it would be ceasing operations.  CareSpark, whose age makes it almost a young adult in HIE years, holds records for 1.28 million patients.

According to a piece in FierceHealthIT, CareSpark was forced to close because it couldn’t come up with a viable plan to sustain itself.  The group’s leaders had hoped to move from a grant-supported non-profit to one-funded by payments from subscribers, but apparently, they just couldn’t attract enough cash to survive.

The group began its final descent in March, when Health Information Partnership of Tennessee pulled federal funding from CareSpark.  The closing leaves 38 participating healthcare organizations in the lurch.

Given you don’t have a mature EMR if you can share health information freely — at least according to HIMSS Analytics — you’d think that providers would finally be ready to dish out enough money to support their local HIE.  But apparently, they aren’t.

The question is, why?  Do hospitals and medical practices think of HIEs as “nice to have” rather than “need to have”?  Do providers only kick in money when they can control the whole exchange (such as linking up hospitals within a single chain)? Have any of them done a cost/benefit analysis which suggests HIEs *aren’t* a good investment?

All I know is that if 38 providers spend six years building up trust, it doesn’t make much sense to cheap out now, especially if it shuts down critical linkages between their EMRs. I’d really like to know why they don’t want to pay for this. Don’t you? After all, it’s about time we figure out what kind of HIE model does work.

Anyone who knows me has probably heard me take a few potshots at the AMA, which isn’t exactly known for its progressive positions on health policy issues.  But this time, I must admit, the AMA has done the industry a good turn by shining a spotlight on an issue that deserves a closer look.

The group’s House of Delegates has just adopted a policy asking the AMA to study the issue of who owns — and can use — data sent back and forth across an HIE network.

The author of the policy, a New Mexico-based nephrologist, noted that as health plans acquire HIE technology vendors, it’s become unclear who will control patient data.

For example, UnitedHealth Group’s health IT consulting subsidiary Ingenix bought HIE technology provider Axolotl last year.  Another example of such consolidation comes from Aetna, which picked up HIE vendor Medicity last year, notes American Medical News.

At present, the AMA notes, it’s not clear whether payers who buy HIE technology vendors have the right to siphon out data on patients who aren’t members of their own plans.  (My guess is that health plans will be all too happy to do so, if they can get away with it, as it would help them screen out high-risk patients before they even consider applying for coverage.)

Now, I’m no legal expert, but I would have assumed that HIPAA regs would cover this situation.  But even if HIPAA does spell out what health plans may and may not do in this instance, this won’t be the last time the increasing consolidation of patient records will raise important privacy questions.

The truth is, as health data begins to become a public commodity — something that’s hard to avoid as it’s aggregated and shared with more parties — the notion of health data privacy will need to evolve.

Do we need a “son of HIPAA” law to protect consumers in this new era?  Not being an attorney, I’m not qualified to say.

But as HIEs begin to play a more important role in healthcare delivery, I do think we should pay close attention to what data ends up in whose hands.  Otherwise, we’re looking at loopholes you could drive a truck through.

In my naivete, I thought the following might be a serious milestone, or at least a thought-provoking read.  Consider the serious tone of this announcement:

The HIMSS Electronic Health Record Association (EHR Association), a collaboration of 46 EHR supplier companies, announced today the availability of a major new white paper “Supporting a Robust Health Information Exchange Strategy with a Pragmatic Transport Framework”.  The focused recommendations in the white paper, aimed at key health IT stakeholders, are based on proven standards and successful health information exchange (HIE) implementations around the world.

Then I took a few spoonfuls of my cereal, drank some coffee and my mind woke up. Oh yes, right, an announcement and a white paper will power the languishing HIE market into action. Right, and President Obama will show up next week and do my laundry.

Honestly, folks, I’m an analyst with health IT background, not a developer or CIO type — so I’m not qualified to say exactly what technologies will work. But I do know posturing when I see it, and that HIMSS press release is rife with quasi-visionary statements. More pointedly, the paper does little more than point to some successful projects and say “See, aren’t they great?”

In any event, I have little confidence in any announcement that proposes to offer the solution, or even the outline of the solution, to any of life’s big problems:  say, the national debt, the struggle for world peace or linking a bunch of fragmented, siloed regional clinical data-sharing projects into a workable whole.

Lest you think I’m a lone cynic, ponder this reaction from an EMR industry insider who preferred to remain anonymous:

“Just about all of this white paper beyond the Direct Project stage is pure B.S. Bits and pieces can be demonstrated at Connectathons, etc. but it will be impossible in the real world to have generalized usefulness with all this overly complicated garbage. It is almost as if the EHRA is conspiring to thwart real interoperability progress.

Look for the push methodologies/capabilities arising out of the initial Direct Project pilots to expand to provide the functionalities this report claims are not possible. This will happen and just supersede all this proposed nonsense because it will simply, incrementally work.”

Now *that* analysis makes tremendous sense to me. If The Direct Project — or other efforts to follow — can foster the growth of sensible data-sharing schemes, we might just get our national HIE. If not, well, don’t look to announcements like these for answers.

Today I bring you a couple of interesting clinical data stories from outside the U.S. One involves a cloud pilot and the other a national EHR; while U.S. providers are toying with the former, I doubt the latter will ever happen. Anyway, without further ado:

* Singapore Launches National EHR

Working with Accenture, the country of Singapore recently launched one of the world’s first national EHR systems. The system itself seems straightforward — it will capture medical data and patient demographics across clinic, acute care and community hospital settings — but its scale makes the project unique.

Obviously, the U.S. is nowhere near to creating such a network, and given our industry’s chaotic structure, I don’t see it happening anytime soon. Even centralized, nationally-controlled health systems are struggling to pull something like this off.

It certainly helps that Singapore has a population of just five million; the country plans to spend $144 million just to reach this relatively small group. It’s hard to imagine what it would cost to roll out such a network across the U.K., much less a giant country like the U.S.

Not surprisingly, Accenture worked with many vendors to make the rollout work, including Oracle, Orion Health, IBM and HP.  The partners completed the first stage of the rollout in 10 months (pretty impressive, if you ask me!)

*  National Health Service Pilots Cloud-Based Health Data Services

Next month, London’s Chelsea and Westminster Hospitals plan to begin storing all patient data in in the cloud. The effort, known as E-Health Cloud, is a National Health Service pilot test. The system will offer fine-grained access controls, allowing patients to decide exactly which clinicians, friends and family members can access their records.  According to a report in Engadget, security is tight; users will have to verify their ID multiple times to access their medical data.

As you may know, a small number of U.S. hospitals are experimenting with storing data in private and public clouds. But I’d wager that this effort, backed by a national entity that can roll things out when it pleases, is likely to move far more quickly than U.S. healthcare cloud deployments.

So, progress in Singapore and the U.K.  Somehow, knowing what can be done, the state of regional HIEs and cloud projects in the U.S. seems a little bit depressing, doesn’t it?

Today I got a rather interesting response to a question I’d posted on question and answer site Quora.com.  I’d originally asked whether anyone thought giant EMR vendor Epic would go public anytime soon, but the conversation has veered a bit.

The comment that caught my eye:

“Unless HIE standards are adopted quickly over the next 5 years, interoperability of health records will at some point require a single, strong player.  Outside of claims data from the top 4 insurers, Epic is the only EHR company that has large enough stake to play this role.”

The poster, one Akshay Kapur, doesn’t say whether he’s an Epic employee, competitor or health IT end user, so I’m not sure what prejudices he brings to the table in making such a statement. That being said, his assertions are worth a thought or two.

To date, the growth of HIEs has been terribly stunted, in part because each has to essentially reinvent the wheel when they launch. Sure, they may be doing similar work but not necessarily interoperable work, so they’re far from achieving the kind of universal data sharing everyone dreams about today. (Their pricing models have been very dodgy as well, but that’s another story.)

So, would it help the HIE market coalesce if a big player like Epic laid down the tracks? Almost certainly. The HIE model has nowhere to go but up.

But would it be a good thing?  I suppose that depends on where you sit. My guess is that one-vendor domination of the HIE market could be very helpful at first but would ultimately impose a choke collar on the industry. Talk about vendor lock-in: if a whole HIE and its users was tied to any single technology, imagine how hard it would be to shift gears.

From where I stand, I’d rather see HIEs struggle their way into a viable model rather than relying on any single company. But hey, maybe that’s just me.

For several years, I’ve been citing dismal statistics on the growth of health information exchange networks. Perhaps, back then, I was too hard on them. After all, fledgling, starry-eyed HIE groups were facing tough odds, given how few physicians and hospitals were even wired enough to support their efforts.

Fast forward to today, and it seems little has changed. Though hospitals and medical practices are going online in large numbers, the HIE business model still seems to be shaky.  The latest evidence of this comes from a study from the Harvard Business School, which concluded that — surprise, surprise — that most HIEs still aren’t financially viable.

The study, which collected survey results from 165 HIE groups, concluded that just 75 of these organizations were actually up and running. Those 75 groups are probably working very hard, but still only reach 14 percent of U.S. hospitals and three percent of smaller medical practices. And get this: only three of the 75 groups offer a data exchange model which supports Meaningful Use standards. Wow.

Not only that, most of the HIEs studied don’t seem to have a sustainable business model. Two-thirds of the operating HIEs ended up in poor financial shape once they burned through initial hospital and physician funding, the study’s authors found.

Now, it’s worth noting that the study’s authors collected their data in late 2009 and early 2010, and heaven knows EMR penetration, interoperability and health data exchange are moving targets. If HIEs were just starting out now they might have had more momentum.

The unfortunate truth is, however, that HIEs have faced a nasty chicken-and-egg problem; if they wait for providers to get up to speed they’dllnever get rolling, but they’re having trouble making it without enough provider support.

At some point, the provider community’s going to have to decide how serious it is about data sharing, and whether leaders are willing to invest in this model over the long term.  Waffling, posturing and playing chicken (i.e. “let’s see if anyone else is willing to spend money on this”) obviously aren’t going to work.