This week I had the pleasure to be the keynote speaker at Orion Health’s HIE User Conference in the beautiful state of my youth, Colorado. In preparing for this conference I was struck again by just how quickly this market continues to evolve and just how messy evolution can be. By the time my slide deck was completed, I came to the conclusion that the health information exchange (HIE) industry is moving from HIE 1.0 to HIE 2.0. While no trend happens over night, certainly the release of Stage 2 meaningful use (MU) requirements had a significant impact.
HIE 1.0: All About the Message
Within the realm of HIE 1.0 the primary focus is on fairly simple, message-based, transactional processes. Large healthcare organizations (HCOs) adopted HIEs to facilitate orders and referrals with the hope that by making it easier for an ambulatory provider to place an order and receive timely access to lab results, that the provider would be more inclined to push business to that HCO, rather than a competing HCO in the community. It was all about physician alignment. Countless HCOs installed such HIEs, which are typically based on a lightweight, federated model. It was simple, inexpensive and relatively quick to deploy.
In the public sector, most HIE’s were meant to serve public health reporting functions and facilitate physician access to records to minimize duplicate tests and deliver better care. The objectives of public HIEs are far harder to reach, the value far harder to articulate and have contributed to a lack of sustainability and ultimately failure of may a public HIE. In a somewhat bizarre twist, last summer Health and Human Services (HHS) sent forth new mandates to all statewide HIEs to focus first and foremost on Direct Secure Messaging (DSM). DSM is little more than secure email, thus the original grand plans of public HIEs have been whittled down to much more modest goals.
With the release of Stage 2 meaningful use, which will require EHR vendors to embed DSM functionality within their EHR to become certified, messaging solutions provided by HIE vendors have now become commoditized. Messaging in the context of HIE is now passe.
HIE 2.0: All About Delivering Care
It has always been Chilmark Research’s opinion that the enterprise market will lead the public market in adoption and use of new, innovative HIE technology. With the move towards value-based contracting and associated reimbursement models, accountable delivery systems (ADS) (note: we don’t like to use the term ACO unless we are specifically talking about CMS), of all sizes are now looking to adopt an HIE platform and those that adopted a messaging-based HIE are looking to replace it. This will result in a high level of turnover in the HIE market, which we began seeing during middle half of last year.
The move to an ADS model requires a HCO to manage a given patient across all care settings. To meet these objectives, HIE 2.0 solutions will have such common attributes as data normalization services, patient disease registries, care management tools (care plans, templates and workflow) and some form of patient engagement capabilities. In adopting and deploying an HIE that goes beyond simple federated messaging, the HCO hopes to insure that appropriate care is delivered to a patient across all care settings and that all individuals (patient, loved one, case manager, nurse, doctor, etc.) that are a part of a given care team have the most current and relevant information associated with that patient, at their finger tips.
This is the goal of an HIE 2.0 but we are still quite a ways from getting there. Our latest end user research finds a market that is full of frustration. Despite all those Stage 1 certified EHRs that have been deployed, very few of them can actually create and/or parse a CCD. We are still in the land of simplistic and cumbersome HL 7 messaging. Some pretty big steps forward were made by the feds in Stage 2 to rectify this now well-known, but also fairly well-kept secret that HIEs today simply cannot readily support care management processes across care settings in a heterogeneous EHR environment. This week’s announcement to further push the envelop, via certification of HIE/EHR in conjunction with efforts that are being led by NYeHC are also a welcomed sign.
Ultimately, though, it will be market need that presses this issue forward, not the efforts of HHS, NYeHC and others. As HCOs continue their acquisition spree to build a robust ADS to serve their communities, these organizations will begin to have the marketing clout to force vendors to change their ways. For example, while Stage 2 may have had some impact on Epic’s decision to finally admit Care Elsewhere would forever be vaporware and have them strike a partnership with Surescripts, it is our belief that Epic’s customers were the ones that really forced Epic’s hand. Now if we could only apply similar clout to those ambulatory EHR vendors who hold their clients hostage with exorbitant interface fees – maybe this is where the feds can play their greatest role and Stage 2 is a strong step in the right direction.
How the growing portfolio of interoperability standards emerging from ONC’s Standards & Interoperability Framework is contributing to the disruption of HIE 1.0 is described by Jitin Asnaani here: http://news.avancehealth.com/2011/05/emerging-standards-and-disruption-of.html
One specific example is the collaborative, public-private sector effort to significantly reduce the existing $10-15,000 fees for creating LIS to EHR interfaces by utilizing the S&I Framework’s LRI/LOI/eDOS Initiative’s open source, end-to-end interoperability standard (http://wiki.siframework.org/Laboratory+Initiatives+Pilots).
Thanks for the links Bob. Another one of te tidbits of information I came back from my trip last week, this one from the Cerner conference is that there are some EHR companies basically hijacking HIE efforts with extortion fees. One HIE director told me they have seen quotes for the same interface requirements from various ambulatory EHR vendors (these are all certified under MU Stage 1) that range from $3000-$45,000. The sooner ONC (and those working on the S&I framework) can strip these EHR bandits of this capability, the better.
The 16 multi-stakeholder coalitions working to advance interoperability (1) together with the exponential growth in the number of EHR products available since the passage of ARRA/HITECH in February 2009 and suggest that disruptive health IT innovations are pushing the monolithic, “walled garden” health IT business model towards obsolescence.
In June 2011, there were 548 ambulatory and 274 inpatient EHRs listed when I began recording the number of EHRs on ONC’s Certified HIT Product List. (2). Today, of the total of 3,598 EHRs listed (a 4.4-fold increase), 2,708 are ambulatory and 890 inpatient. Of the ambulatory products, 1,356 are complete and 1,350 are modular products. Of the inpatient products, 257 are complete and 633 are modular.
Certainly not all of these EHR vendors will survive, but consumer-centered, value-based competition for those that do will advance both the adoption of interoperable HIE and the quality of their products.
Excellent overview of a rapidly evolving market! Can’t wait for customers to become more demanding!!!
While I agree that the intent of private HIEs was to facilitate lab orders and results, their success on the orders side has been extremely limited (see “Lab Orders and HIEs”, http://kenwillett.wordpress.com/2012/10/24/lab-orders-and-hies/).
Many of the DSM-based HIEs provide only the equivalent of a webmail client for sending and receiving messages. The requirement that EHRs support DSM directly will increase the convenience to providers of using DSM; but there are still significant policy and infrastructure requirements that the EHR vendors aren’t in a position to address (such as message routing, trust relationships, provider directories and certificate management). Someone has to to provide these services at a national scale, and the state-level and HCO level HIEs are unlikely to tackle this.
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