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?

In celebration of National Health Information Technology Week –  proclaimed by President Obama earlier this week in an effort to “urge all Americans to learn more about the benefits of Health IT by visiting HealthIT.gov, take action to increase adoption and meaningful use of Health IT, and utilize the information Health IT provides to improve the quality, safety, and cost effectiveness of health care in the United States – I’m hitting the road and heading to North Carolina.

Actually, it’s pure coincidence that my annual Fall road trip to Charlotte and Chapel Hill coincides with this newly official week of celebratory activities. (You can view a list of events here.) But it did prompt me to ponder the state of North Carolina’s EMR and overall healthcare IT utilization. My first stop was the HIMSS State HIT Dashboard, a handy resource that provides an overview of all 50 states’ utilization of healthcare IT.

According to HIMSS, as of September, 2011, North Carolina has six Health Information Exchanges (HIEs):

•  NC Healthcare Information and Communications Alliance Inc. (NCHICA)
•  Carolina HIE
•  Coastal Connect
•  Western NC Health Network (WNCHN Data Link)
•  Southern Piedmont Partnership for Public Health (SoPHIE)
•  Sandhills Community Care Network

The state’s regional extension center, which assists the state’s physicians with selecting and implementing EMRs, has at this point recruited 50% of the providers in its target group of 3,500 priority primary care providers, according to the NCHICA website. The NCHICA seems to be the main governing/advisory body over the state’s HIT activities. Its 239 member organizations will converge in just over a week at the Grove Park Inn in Asheville for its annual conference and exhibit. The lineup of sessions looks pretty interesting, especially “So You’ve Decided to Implement an EHR, Now What?” I’m sure conference attendees will have a great time at the Brews Cruise as well.

My next stop was Google, where a quick search yielded the fact that North Carolina, and the Duke Center for Health Informatics in particular, is home to MindLinc, an EMR for behavioral health. It is now the world’s largest codified behavioral health database, and provides information for research and benchmarking purposes.

My last stop was YouTube, where I found an interesting video created by Janet Apter, an RN and member of the faculty at the Duke School of Nursing, for Duke’s Doctor of Nursing Practice Program. Entitled “Electronic Health Record – a Promising Solution,” the video shares the perspective of one nurse/patient’s frustration with a lack of interoperability between facilities in the same health system, and makes a simple case for the need for a nationwide EHR system.

John’s recent post about ONC trained participants finding it difficult to find jobs struck a chord. A different post over at HIMSS had me thinking in overdrive.

Dr. Noam Arzt has a post on Meaningful Use and public health reporting. In it he discusses the problems faced by providers in submitting health information to public health bodies in ways that are also Meaningful Use Stage 1 compliant.

Health records in provider offices are sometimes stored in disparate silos that are cannot/do not communicate with one another. As Dr. Arzt explains with an immunization records example, there is no demonstrable Meaningful Use if an uncertified system makes the data submissions to public health.

Of course, adding additional functionality to the EHR system with a simultaneous revamping of uncertified system to provide Meaningful Use share data with one another is one (costly) solution. Getting the secondary data system certified is another one. A third approach, which Dr. Arzt touches on, is for Health Information Exchanges to act as/provide for certified intermediaries that bridge the data flow between an uncertified system and one that is Meaningful Use certified.

Here’s what HHS had to say about the subject a month ago:

If an intermediary performs a capability specified in an adopted certification criterion and a provider intends to use the capability the intermediary provides to satisfy a correlated meaningful use requirement (submission to public health according to adopted standards), the capability provided by the intermediary would need to be certified as an EHR Module

This intermediary need can be filled, especially by innovative software vendors or those looking to break into the EHR IT industry. From plain data conversions to web services, IT companies have plenty of tricks up their sleeve to assist HIEs. The technology is there, all we need are savvy techies (companies, people) to see the opportunity this presents and act on it.

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 any industry, there will be a certain percentage of those working in it who can’t move with the times.

New technologies, in particular, jolt people out of their usual ways of doing things, and leave those who don’t adapt in the dustbin. (Your classic “unemployed buggy-whip maker” comes to mind.)

The current narrative suggests that doctors who won’t buy in to the EMR movement are buggy-whip makers, too.  They’re, let me see now, uncooperative, stubborn, inflexible, timid, recalcitrant, defiant…got any more?  Clearly, any doctor who’s being dragged kicking and screaming into digital medicine is an old fogey or an arrogant type who deserves to be put into their place. Right?

Not so right.  The reality is, the shift from paper to EMR-based practice isn’t just a phase-in of a new technology, it’s a movement into a whole new world.  And it’s a place where the rules may turn out to be completely different than those doctors live with today.

While the post-EMR world may offer big clinical improvements, financial savings, improved safety and more, it’s likely to induce painful changes in the way doctors conduct their everyday work.

I’m not just talking about short-term workflow adjustments, I’m talking about introducing a new way of life, one which asks doctors to serve as clinical data analyst, sophisticated software user, expert on health data sharing and more in addition to providing direct care.

Ok, now you’re thinking that I’m exaggerating wildly — that most doctors will just need to go through an EMR training period, figure out where to click and get some practice doing it efficiently. Problem solved.

But I beg to differ. If that were all the government wanted doctors to get out of EMRs —- the ability to competently assemble an electronic patient record — I doubt the feds would be creating Meaningful Use standards and paying incentives. Doctors aren’t just being asked to use new systems, or even just to move from paper to software, they’re being asked to rethink the role they play in care delivery overall.

Let’s face it, we’re not just talking about switching from the typewriter to the computer.

We’re looking at a revolution which will, over time:

* Turn even single-physician practices into a node in a vast health information exchange
* Require doctors to pick up a wide variety of analytical/IT skills which may, on their surface, have little to do with traditional office-based medicine
* Permanently change the way doctors evaluate, diagnose, comunicate with, counsel and manage patients

Now, if the EMR revolution even comes close to meeting its patient safety, quality improvement and efficiency goals, I doubt doctors will regret the changes they had to make. After all, most doctors are incredibly dedicated, hardworking people who would be thrilled to find ways to improve their patients’ health.

In the mean time, though, I’d love to see critics tone tone down the anti-doctor rhetoric and think about what’s really going on here.  If we treat doctors like the intelligent adults they are, and collaborate with them, they’ll befriend health IT tools like the EMR in good time. If you treat doctors like they’re the problem, forget it.

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.