How to get wired: The basics of health information exchange

Earning incentives for meaningful use requires your EMR system to communicate with other technology systems outside your office. But how do you make that happen?

By Pamela Lewis Dolan — Posted Sept. 6, 2010

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Many physicians are working to adopt an electronic medical record, or have recently done so. But if they plan to use the EMR to earn government financial incentive bonuses, they're going to need to make their EMRs talk to other EMRs and health information technology systems.

The key to earning incentive pay -- up to $44,000 per physician from Medicare or $64,000 from Medicaid -- is to become a "meaningful user" of your EMR. The government has made it clear that the key to meaningful use is your ability to participate in a health information exchange. In other words, your EMR must be able to connect with IT systems in other practices, hospitals, labs or other locations to send and receive data.

The movement or exchange of data can take on many forms, including exchanging clinical notes with other physicians and requesting and receiving a patient's entire medical history. The sophistication of data exchange will grow and develop over time, but right now experts say physicians should be prepared to take baby steps.

The first of those steps is installing an EMR capable of talking to other systems outside of your practice. Think of it as the difference between having a computer and having a computer that is connected to the Internet.

The large number of EMR systems on the market might make finding one capable of meeting the right technical criteria seem overwhelming. But the government has made it simpler to find a system that will handle the exchange of data required under meaningful use.

The Office of the National Coordinator for Health Information Technology has developed a set of technical requirements that EMR systems must meet to ensure that they are capable of exchanging data with other systems. The ONC is approving organizations that will test and certify EMRs for their ability to meet these requirements.

Even though the first two certifying bodies, the Certification Commission for Health Information Technology and the Drummond Group, were only approved in August, the criteria an EMR must meet to be certified has been in the hands of EMR vendors for several months. Most are offering a guarantee that their products will be certified so that physicians don't have to wait to make a purchase.

The next step is developing electronic communication with other entities outside your practice. It could be pharmacies, labs, other practices, insurers, a local hospital or other ancillary practices with whom you now communicate by mail, phone or fax.

Road to meaningful use

The term health information exchange describes the act of exchanging data between two or more health care organizations. But it also can refer to the network on which that information is exchanged. A regional health information organization is a more formal HIE run by a business entity and designed to coordinate the exchange of data between health care organizations across a predetermined geographical region, such as a state. The two terms, HIE and RHIO, often are used interchangeably.

There won't be many options in most areas in terms of which HIE or RHIO you participate with, experts say. Your local hospital (or hospitals) might connect with you and its affiliated physicians to create its own local HIE. Or, there might be a formal RHIO that any physician in that region can be a part of. Or there might be both.

Each RHIO or HIE is governed and managed in its own way. Each one exchanges different types of data and is capable of accomplishing different tasks. Each has its own business structure. One might allow you to request information on a particular patient, and if that information is there, you are charged for what you use, normally a few cents per transaction. The HIE also could be membership-based, requiring a monthly subscription fee, normally less than $100 per physician.

So how do you choose? Experts say you first should determine what information you would like to exchange or have access to.

The final rule for stage 1 of meaningful use requires physicians to have the ability to send prescriptions and hospital-based medication orders electronically, which are both on the list of 15 required objectives. There is another list of 10 objectives, from which physicians can choose five. They include tasks such as reporting electronically to state immunization registries and providing summary-of-care records to other physicians.

Experts say practices need to map out their own road to meaningful use and choose objectives from the ONC's list accordingly. The HIE you choose will need to accommodate the data exchange required under your chosen objectives.

Greg DeBor, partner in the health care division of the Falls Church, Va.-based consulting firm CSC, said the first thing physicians should consider when developing this plan are referral patterns and how they fit into their workflows.

He said referral patterns are important, because if there is one primary hospital to which a practice refers patients, the practice should focus on how it can exchange patient information with that hospital to make the referral process smoother.

"If, on the other hand, you practice across different entities or communities or across state lines, you have to consider either which HIE, or how many HIEs, you might need to participate in, in order to get the benefit that those HIEs will deliver in terms of supporting your workflow," DeBor said.

"The whole point of these health information exchanges is to provide each of the clinicians, both the physician who is treating the patient and the physician who previously treated the patient, with the best up-to-date information possible," said Barry Chaiken, MD, MPH, a fellow with the Healthcare Information and Management Systems Society and chief medical officer of Imprivata, a health IT software vendor based in Lexington, Mass. The goal is to go to the HIE that will be the best source of information, depending on who your patients are, and where else they may have been treated.

DeBor said practices should consider how they want to approach health system reform when deciding on their information-exchanging objectives.

For example, a practice wanting to become a patient-centered medical home will want to find an HIE that allows the exchange of data such as patient summary charts and problem lists between various physicians on a patient's care team, he said. If a practice wants to be part of an accountable care organization, it probably would need an HIE with the ability to send and receive data to and from public health sites.

Many HIEs also are serving as the regional extension centers charged with helping physicians meet meaningful use. So even if sophisticated data exchange isn't in the short-term goals for a practice right now, many HIE activities are geared toward helping physicians meet meaningful use. That reason alone might make it worth a physician's time to get involved with one, experts say.

Meeting physician needs

Physicians can help the HIEs' development in ways that will benefit them best. Experts say the key to any HIE's success is to create value for the physicians it is trying to attract, which is why many are still evolving. Chances are, if a practice finds that the local HIE or RHIO is not offering the exchange capabilities it needs, others will find them inadequate as well.

Christina Galanis, executive director of Southern Tier HealthLink, a RHIO in New York, said physicians have been a great influence in the way her exchange has evolved.

"One of the most appreciated [aspects of the HIE] in our community is for the health information exchange to move its electronic referral data to a recipient who has an EMR," she said. "That is perceived to be of great value to physicians."

Without that ability, it has to fax information to the referred physician, which would cost up to $15,000 per doctor per year because of photocopying, faxing and keying in information from a chart, she said. This transfer capability is one the organization decided to add due to physician demand.

Deb Bass, interim executive director of the Nebraska Health Information Initiative, said her organization has been named by the state as a regional extension center to help doctors achieve meaningful use. That has been its greatest selling point, she said. In addition to HIE services, NeHII offers a complete package with an EMR.

Bass said some physicians might need to take things one piece at a time and not take advantage of everything an HIE offers right away.

Stephan Thome, MD, an oncologist in Omaha, Neb., said the most important thing for him was e-prescribing, a function of the NeHII system.

Dr. Thome hasn't implemented an EMR yet, but he said he found the benefits of having e-prescribing and medication lists for his patients far more important than meeting the meaningful use criteria starting next year. He plans to apply for the meaningful use bonus later so he can take his time adopting a system.

Whether or not a physician should wait to take advantage of all the local HIE has to offer is a difficult decision, experts say. Though the actual participation in a data exchange is limited to only a few functions for stage 1 meaningful use, stage 2 will make more demands.

"If those HIE activities, whether they are hospital-sponsored or community- or state-sponsored, aren't mapping themselves to HIE and don't have an answer for how they'll help physicians receive their meaningful use incentives, they will be out of business in the next year," DeBor said. "You can kind of safely assume there's a strong effort under way to align those things."

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Benefits for physicians

The most recent eHealth Initiative survey of active health information exchanges in the U.S. finds that many organizations are adding capabilities that will help physician practices meet the first stage of meaningful use requirements. The survey included the responses from 199 active health information exchange initiatives in the U.S., 73 of which are in operation.

Services provided 2009 2010
Connectivity to EMRs 38 67
Results delivery 44 50
Health summaries for continuity of care n/a 49
Electronic prescribing 26 37
Drug-to-drug alerts to prescribers n/a 35
Drug-to-allergy alerts to prescribers n/a 31
Disease or chronic care management 19 27
Clinical decision support 19 26
Quality improvement reporting for clinicians 10 21
Reminders 16 24
Immunization registry n/a 20
Medication reconciliation n/a 19
Patient-physician clinical data exchange 6 11
Public health: electronic lab reporting 6 11
Public health: syndromic surveillance reporting 13 8

Source: "The State of Health Information Exchange in 2010: Connecting the Nation to Achieve Meaningful Use," eHealth Initiative, July (link)

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Checking on HIEs

The federal government is investing in getting primary care physicians, particularly those in small practices in rural areas, hooked up to health information exchanges.

The government's regional extension centers can walk physicians through meaningful use requirements. Staff at the centers can point physicians to local health information exchanges that physicians can evaluate. A list of centers can be found on the Office of the National Coordinator for Health Information Technology website.

Greg DeBor, partner in the health care division of the Falls Church, Va.-based consulting firm CSC, said some physicians will have, in addition to a state-designated HIE, health exchanges that are set up by local hospitals. Physicians should check with local hospitals to see if they have data exchanges. If they don't, physicians can ask the facilities about their involvement with specific exchanges.

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External links

"The State of Health Information Exchange in 2010: Connecting the Nation to Achieve Meaningful Use," eHealth Initiative, July (link)

List of regional extension centers from the Office of the National Coordinator for Health Information Technology (link)

"Profiles of Progress 4: State Health IT Initiatives 2010," National Assn. of State Chief Information Officers, July (link)

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