Health information exchange in US hospitals: The current landscape and a path to improved information sharing

(4) What Governance Entity Defines the “Rules” of Exchange?

When more than 1 provider organization shares patient-identified data, a governance entity must specify the framework that governs the exchange. While the specifics of HIE governance vary, there are 3 predominant types of HIE networks, based on the type of organization that governs exchange: enterprise HIE networks, EHR vendor HIE networks or community HIE networks.

Enterprise HIE networks exist when 1 or more provider organizations electronically share clinical information to support patient care with some restriction, beyond geography, that dictates which organizations are involved. Typically, restrictions are driven by strategic, proprietary interests.^22,23 Although broad-based information access across settings would be in the best interest of the patient, provider organizations are sensitive to the competitive implications of sharing data and may pursue such sharing in a strategic way.²⁴ A common scenario is when hospitals choose to strategically affiliate with select ambulatory providers and exclusively exchange information with them. This should facilitate better care coordination for patients shared by the hospital and those providers but can also benefit the hospital by increasing the referrals from those providers. While there is little direct evidence quantifying the extent to which this type of strategic sharing takes place, there have been anecdotal reports as well as indirect findings that for-profit hospitals in competitive markets are less likely to share patient data.^19,25

EHR vendor HIE networks exist when exchange occurs within a community of provider organizations that use an EHR from the same vendor. A subset of EHR vendors have made this capability available; EPIC’s CareEverywhere solution²⁷ is the best-known example. Providers with an EPIC EHR are able to query for and retrieve summary of care records and other documents from any provider organization with EPIC that has activated this functionality. There are also multivendor efforts, such as CommonWell²⁷ and the Sequoia Project’s Carequality collaborative,²⁸ which are initiatives that seek to provide a common interoperability framework across a diverse set of stakeholders, including provider organizations with different EHR systems, in a similar fashion to HIE modules like CareEverywhere. To date, growth in these cross-vendor collaborations has been slow, and they have limited participation. While HIE networks that involve EHR vendors are likely to grow, it is difficult to predict how quickly because they are still in an early phase of development, and face nontechnical barriers such as patient consent policies that vary between providers and across states.

Community HIE networks—also referred to as health information organizations (HIOs) or regional health information organizations (RHIOs)—exist when provider organizations in a community, frequently state-level organizations that were funded through HITECH grants,¹⁴ set up the technical infrastructure and governance approach to engage in HIE to improve patient care. In contrast to enterprise or vendor HIE networks that have pursued HIE in ways that appear strategically beneficial, the only restriction on participation in community and state HIE networks is usually geography because they view information exchange as a public good. Seventy­one percent of hospital service areas (HSAs) are covered by at least 1 of the 106 operational HIOs, with 309,793 clinicians (licensed prescribers) participating in those exchange networks. Even with early infusions of public and other grant-funding, community HIE networks have experienced significant challenges to sustained operation, and many have ceased operating.²⁹

Thus, for any given provider organization, available HIE networks are primarily shaped by 3 factors:

1. Geographic location, which determines the available community and state HIE networks (as well as other basic information technology and connectivity infrastructure); providers located outside the service areas covered by an operational HIE have little incentive to participate because they do not connect them to providers with whom they share patients. Providers in rural areas may simply not have the needed infrastructure to pursue HIE.

2. Type of organization to which they belong, which determines the available enterprise HIE networks; providers who are not members of large health systems may be excluded from participation in these types of networks.

3. EHR vendor, which determines whether they have access to an EHR vendor HIE network.

Despite agreement about the substantial potential of HIE to reduce costs and increase the quality of care delivered across a broad range of providers, HIE progress has been slow. While HITECH has successfully increased EHR adoption in hospitals and ambulatory practices,³⁰ HIE has lagged. This is largely because many complex, intertwined barriers must be addressed for HIE to be widespread.

Lack of a Defined Goal

The cost and complexity associated with the exchange of a single type of data (eg, medications) is substantially less than the cost and complexity of sharing complete patient records. There has been little industry consensus on the target goal—do we need to enable sharing of complete patient records across all providers, or will summary of care records suffice? If the latter, as is the focus of the current MU criteria, what types of information should be included in a summary of care record, and should content and/or structure vary depending on the type of care transition? While the MU criteria require the exchange of a summary of care record with defined data fields, it remains unclear whether this is the end state or whether we should continue to push towards broad-based sharing of all patient data as structured elements. Without a clear picture of the ideal end state, there has been significant heterogeneity in the development of HIE capabilities across providers and vendors, and difficulty coordinating efforts to continue to advance towards a nationwide approach. Addressing this issue also requires progress to define HIE usability, that is, how information from external organizations should be presented and integrated into clinical workflow and clinical decisions. Currently, where HIE is occurring and clinicians are receiving summary of care records, they find them long, cluttered, and difficult to locate key information.