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Chapter 1
Essential Background Knowledge on HIE
In the 1990s, the idea of community health information networks, or CHINs, gained popularity, but with the exception of integrated delivery system formation, these initiatives generally struggled and failed because of their high costs, proprietary network formation and the inability to gain cooperation from competing providers.
While the notion of sharing data hasn’t faded, the lofty goals underpinning the CHIN era – the need to exchange patient information among providers to optimize care delivery – have evolved over the last 15 years. In addition, the stakes have been raised through the implementation of recent regulations regarding the meaningful use of electronic health records, which are likely to increasingly require the use of health information exchange (HIE) so providers can qualify for incentive fund payments.
While the meaningful use requirements regarding data exchange during Stage 1 of the incentive program are relatively simple, healthcare providers likely will need to increasingly make use of HIE in subsequent stages of the program. Additionally, reforms being discussed for the healthcare system will put a premium on improving communication between providers and with patients, and will necessitate data sharing capabilities to better coordinate care across the continuum. Proponents say that HIE holds great promise to expedite and improve care, increasing providers’ efficiency and saving costs throughout the system.
Legislative and Regulatory Background
The American Recovery and Reinvestment Act (ARRA) became law in 2009. One section of the law (Title XIII of Division A and Title IV of Division B) – the Health Information Technology for Economic and Clinical Health Act (HITECH Act) – provides incentives for the “meaningful use” of electronic health records, providing incentive funding to encourage providers to implement electronic health records and other electronic clinical systems in ways that improve the quality of care.
Through a formal rule-making process, the federal government through the Centers for Medicare & Medicaid Services established 24 objectives for eligible hospitals and critical access hospitals. Of those, 14 are required or core objectives that a provider must meet in order to qualify for stimulus funding; Stage 1 also includes a “menu set” of 10 objectives, five of which must be achieved to qualify for funding (a total of 19 of 24 objectives).
The final regulations establishing the meaningful use requirements set a core requirement for eligible providers and hospitals to achieve health information exchange. Specifically, this core requirement asks that eligible providers and hospitals have the capability to “exchange clinical information electronically with other providers and patient-authorized entities.” In setting this target for HIE, the rule-writers aimed to make achieving the objective as easy as possible, acknowledging in the final rules that “many areas of the country currently lack the infrastructure to support the electronic exchange of information.” To satisfy the objective, eligible providers, eligible hospitals and critical access hospitals “should attempt to identify one other entity with whom to conduct a test of the submission of electronic data. This test must include the transfer of either actual or ‘dummy’ data to the chosen other entity.” In addition, with the development of the Direct Project and supporting technologies, providers have another way to meet this objective.
The ability to exchange health information will be a key function for providers to achieve during Stage 1. An analysis of meaningful use objectives by the Healthcare Information and Management Systems Society (HIMSS) suggests that from six to 10 objectives, depending on individual providers’ circumstances imply “some form of HIE. Many of these are likely functions that are already handled electronically, or at least have some form of electronic exchange available (electronic claims, as an example). With that said, it is clear through comments in the Notice of Proposed Rulemaking (NPRM) that HIE is a national strategy. The NPRM clearly provides the impression that Stages 2 and 3 will have many more requirements that will rely on robust HIE availability in the country’s communities.” (HIE Implications in Meaningful Use Stage 1 Requirements, HIMSS, March 2010).
Additionally, a report this year by the President's Council on Science and Technology (PCAST) offers a variety of suggestions for accelerating and facilitating the exchange of healthcare information, and many of those are being considered for inclusion in future Stages, according to supporting comments from the National Coordinator for Healthcare IT, Dr. Farzad Mostashari. Coincidentally, the Office of the National Coordinator for Health Information Technology (ONC) has active efforts focused on defining the metadata associated with data exchange, as that data is used for routing and location services by and among electronic health records. Several of the provisions in the Advanced Notice for Proposed Rule Making on metadata, released on August 9, are likely to become federal rules, necessitating electronic health records (EHRs) and exchange service harmonization to ensure agnostic health data exchanges on the eventual national health information network.
State-based Approach
Because HIE activities are just getting under way in most areas of the country, the federal government is hoping to jump-start HIE development by offering grants through the State Health Information Exchange Cooperative Agreement Program, funded by ONC. The program “promotes innovative approaches to the secure exchange of health information within and across states and ensures that health care providers and hospitals meet national standards and meaningful use requirements.” See online.
In 2010, ONC awarded 56 grants totaling $548 million to help states (including territories) develop and advance resources to facilitate the exchange of health information. The awards were made to states, or organizations designated by states (known as state designated entities, or SDEs). In their four-year performance periods, “awardees are responsible for increasing connectivity and enabling patient-centric information flow to improve the quality and efficiency of care. Key to this is the continual evolution and advancement of necessary governance, policies, technical services, business operations, and financing mechanisms for HIE.” See online.
As providers seek to understand the development of HIE capabilities in their states, these grant recipients are their primary points of contact. A states or its state-designated entity may not be the organization that implements or operates the technical services for HIE, but it must serve as the governance entity that ensures that the capability for HIE in each state will be appropriately developed. The state or its designated entity must have a plan in place that makes it likely that, by 2015, HIE requirements for meaningful use will be achievable by hospitals.
As a result of the role the states or their designated entities are required to play in building HIE capabilities within a state, they are key resources for hospital executives seeking to meet HIE requirements to achieve meaningful use. A list of key contacts for each state can be found at http://www.ciostatenet.org established by CHIME in 2010. CHIME CIO StateNet is a state-by-state network of coordinators who gather and communicate relevant in-state health IT developments. State CIO Coordinators, representing all 50 states and the District of Columbia, are engaged in identifying key developments, communicating them on this website and sharing best practices within and across states in preparation for demonstrating meaningful use of EHRs to improve health and healthcare. Coordinators for CIO StateNet are gathering and updating information on their state’s HIE plan, strategic and operational plans for HIE infrastructure; links to ONC-approved state plans; and other related documents. Registration, which is free, is required to access CIO StateNet information.
Another source for assessing existing or developing organizations seeking to provide health information exchange is the annual report by the eHealth Initiative, released in July 2011 during eHI’s annual National Forum on Health Information Exchange. The most recent eHI report identified 255 active HIE initiatives across the country.
Some states also are collaborating to create critical mass on the approaches, standards and services necessary to support HIE. For example, the state HIE leaders in California, Colorado, Maine, Massachusetts, New York and Oregon have been collaborating; these states represent 30 percent of the U.S. population.
Resources
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CHIME CIO StateNet: As a result of the role the states or their designated entities are required to play in building HIE capabilities within a state, they are key resources for HIE executives seeking to meet HIE requirements to achieve meaningful use. A list of key contacts for each state can be found on the CIO StateNet website, established by CHIME in 2010. CIO StateNet is a state-by-state network of coordinators for purposes of gathering and communicating relevant in-state health IT developments. State CIO Coordinators, representing all 50 states and the District of Columbia, are engaged in identifying key developments for input into this website and sharing best practices within and across states in preparation for demonstrating meaningful use of EHRs to improve health and healthcare. State CIO coordinators for CIO StateNet are gathering and updating information on their state’s HIE plan, strategic and operational plans for HIE infrastructure; links to ONC-approved state plans; and other related documents. Registration, which is free, is required to access CIO StateNet information.
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eHealth Initiative Annual Report on Health Information Exchange: released in mid-July, this report is a source for assessing existing or developing health information organizations (HIOs). This report identified 255 active health information exchange initiatives across the country.
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