1. Care Coordination and Interoperable Health IT Systems
Unit 8: Exchange of Health Information
Lecture b – Health Information Exchange Organizations
Welcome to Care Coordination and Interoperable Health IT Systems, Exchange of Health Information. This is Lecture b, Health Information Exchange Organizations.
This material (Comp 22 Unit 8) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0004.
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2. Exchange of Health Information Learning Objectives
Objective 1: List the quality problems in health care that the exchange of health information is intended to remediate (Lecture a)
Objective 2: Describe the nature of health information technology assets that the exchange of health information is designed to interconnect (Lecture a)
Objective 3: Explain the motivations, capabilities, and challenges of health information exchange organizations (HIEOs) (Lecture b)
Objective 4: Explain the motivations, capabilities, and challenges of using Meaningful Use and Direct to advance the exchange of health information (Lecture c)
Objective 5: Describe the future directions for the exchange of health information exchange (Lecture d)
The learning objectives for the health information exchange unit are: number one, to list the quality problems in health care that health information exchange is intended to remediate; two, describe the nature of health information exchange technology assets that health information exchange is designed to interconnect; number three, explain the motivations, capabilities, and challenges of health information exchange organizations; number four, explain the motivations, capabilities, and challenges of using Meaningful Use and Direct to advance health information exchange; and number five, describe the future directions for health information exchange.

3. Interconnecting hospitals and large provider organizations
Creating interconnections among hospitals and other large provider organizations was an appealing way to advance health information exchange (HIE)
Such organizations provide a lot of care. Therefore, they have an extensive amount of data on large numbers of patients.
Interconnecting hospitals and large provider organizations was viewed as one approach to advance health information exchange. The idea here is that such organizations, these large organizations, provide a lot of care. They see a large number of patients and they have a lot of data on each of those patients.
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4. Challenges to interconnecting hospitals / large organizations
Leadership / organizational models
Who is responsible for getting this to happen?
What is the structure for governing and managing exchange?
Financial sustainability
What is the mechanism to pay for the technology and operations?
However, there are challenges with interconnecting these large organizations. One of these challenges is leadership and organizational models. It’s unclear who should bear responsibility for getting large organizations in a particular region to interconnect and address all of the other challenges that exist with respect to this kind of interconnection. There needs to be a structure for governance and for management. Second is financial sustainability. Any kind of interconnection will have technical and operational costs and it’s not clear what the mechanism should be to pay for these expenses.
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5. Challenges to interconnecting hospitals / large organizations (Cont’d – 1)
Technology: data interfaces, networks
Privacy
Just because the data can move, should it?
How do the patient’s wishes fit in?
Patient matching
How do we know that the “Gilad J. Kuperman” who went to NYU Hospital for care is the same as “Gil Kuperman” who went to NewYork-Presbyterian Hospital for care?
Refer to component 24, unit 5 for more information about patient identification
Another challenge is the technology itself. There are data interfaces that need to be built and these may be complex data interfaces. There are data networks that need to be created and these need to be designed and developed. Another challenge is privacy and just because a technology can be developed to move a patient’s data around, does that mean that the patient’s data should be moved around? Does that patient want that to happen? Where do the patient’s wishes get involved? Do federal and state privacy laws fit in with developing visions of how the exchange of health information will take place? Another challenge is patient matching. So in the United States, we do not have a universal patient identifier. If I go to one facility and identify myself as “Gil Kuperman” and I go to another facility and I identify myself by my full name as “Gilad J. Kuperman”, how would one facility know with certainty that I am the same person that went to the other facility?
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6. Structuring / coding of the clinical data
Challenges to interconnecting hospitals / large organizations (Cont’d – 2)
Structuring / coding of the clinical data
Lots of data types: medications, problems, allergies, reports, etc.
Some standards are not mature
Refer to unit 5 for more information about standards for interoperable health IT
Competitive concerns
Do I want you to see my patients’ data or data about me as a provider?
Another challenge is the structure and the coding of the clinical data. If I want to intermingle data from two institutions, maybe laboratory results, but those data are represented differently in the databases of the two organizations, how would I be able to intermingle those data? The way the data are represented presents challenges for health information exchanges. In some instances, there are standards to represent particular data types, but those standards are not completely mature. They would not address this problem completely. Additionally, there may be competitive concerns among health care providers. A health care provider may be concerned that competitors would have the ability to understand the provider’s practice patterns and use that information in adverse ways. Similarly, a provider may be concerned that a competitor would have the ability to identify who the provider’s patients are and pursue those patients with marketing techniques. There are subtle, but real, concerns about competition among provider organizations as health information exchange networks are developed.
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7. Health Information Exchange (HIE) Organizations
In 2005, to address the challenges in getting large provider organizations to exchange data, the Office of the National Coordinator advanced the idea of health information exchange (HIE) organizations
Premise: A new kind of organization is needed to address the challenges of health information exchange (HIE)
Such organizations would be most effective at the regional or state level
Some health information exchange (HIE) organizations are known as “regional health information organizations” (RHIOs). Still others are known as “state – level HIEs”
To address all of these challenges, to interconnect large provider organizations, a concept emerged in the mid-2000s called a health information exchange organization. This concept was advanced by the Office of the National Coordinator for Health Information Technology, which was established as a division of the U.S. Department of Health and Human Services in the mid-2000s. The premise of an health information exchange organization is that a new kind of organization is needed to encourage health care providers to work together to address the challenges to the exchange of health information, for example, the technology challenges, the privacy challenges, and financial challenges, the governance and other challenges. Further, the Office of the National Coordinator encouraged these activities at the state or regional level because most patient movement occurs within those boundaries and so the benefits would accrue within those geographies and so the health information exchange organization’s efforts should be organized within those geographies. Some health information exchange organizations are known as “regional health information organizations” or RHIOs. Some other health information exchange organizations are known as “state level health information exchanges”.
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8. Health Information Exchange (HIE) Organizations (Cont’d – 1)
Indianapolis region was a successful example
Indiana Network for Patient Care (which became the Indiana Health Information Exchange, or IHIE) had been developed over approximately 15 years
Some funding was available
AHRQ (demonstration projects), local governments, state governments, etc.
Idea caught on: as of 2010, ~200 health information exchange (HIE) organizations nationwide
Especially prevalent in NY State
$400 million in state funding over eight years
In Indianapolis, there was a successful example of an health information exchange organization. In the Indianapolis area, there was the Indiana Network for Patient Care, which became the Indiana Health Information Exchange, or IHIE. This had been developed over approximately 15 years, beginning in the early 1990s. In addition, in the mid-2000s, there was some funding available to advance health information exchange organizations. The Agency for Healthcare Research and Quality and local and state governments provided funding for demonstration projects. The concept of health information exchange organization caught on and by 2010, there were approximately 200 such organizations nationwide. The concept of health information exchange organization was especially and strongly adopted in New York State, where the term RHIO was commonly used. New York State provided more funding than any other state for health information exchange organizations. In particular, there was 400 million dollars of funding over an 8- year period to advance health information exchange and healthcare programs, for example, patient centered medical homes, that would be enabled by a modern health information exchange infrastructure.
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9. SHIN – NY: State Health Information Network – New York
The funding that New York State provided was used across the state. Initially, close to 20 health information exchange organizations, also known as RHIOs, were established. However, over time, there have been several consolidations and mergers. Currently, there are eight RHIOs in New York State. There is one in the Buffalo region, the Rochester region, Syracuse region, Albany and northern New York State region, Hudson Valley, and downstate or metropolitan area of New York State, where half of the state’s population lives. In this area, there are three separate regional health information organizations. Several other states across the country have had state-led initiatives to advance the exchange of health information among health care providers, however New York State is notable in that it has invested far more in these activities than any other state.
8.4 Figure (Healthix, 2015)

10. Healthix overview Healthix serves the New York City metropolitan area
5 boroughs of New York City and two counties on Long Island
Over 165 participants providing care at over 550 facilities
Hospitals and health systems
Long term care
Community – based organizations
Behavioral health organizations
Physician practices
Health plans
One of the regional health information organizations in New York State is known as Healthix. Healthix is a non-profit organization, the mission of which is to provide health information exchange services to health care providers in the New York City metropolitan area. We’ll describe Healthix in some detail to give you a sense of what these regional health information organizations are like. The geographic area that Healthix serves is the New York City metro area, including the five boroughs and two counties on Long Island. Healthix has over 165 participating organizations that are providing care at over 550 facilities. Examples of the kinds of members or participating organizations that Healthix has, are hospitals and healthcare systems, long-term care facilities, community based organizations, behavioral health organizations, physician practices, and health plans. Several health care provider organizations are members of Healthix and participate in health information exchange.
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11. Healthix technology 8.5 Figure (Kuperman, G. 2016)
Healthix uses two technologies to enable health information exchange. One is the master patient index. The master patient index is a solution to the patient matching problem. Since there is no consistent identifier across the multiple Healthix members, each Healthix member contributes its registration file to Healthix. Healthix can then look across these registration files and using data elements, such as the patient’s name, date of birth, address, etc. they can identify with high probability, who is likely to be the same patient across facilities. The other technology that Healthix uses is to actually retrieve the data. The way this is done is that each participant takes data from its core system and places them on an edge server. This edge server is accessible to the Healthix interface engine. When a clinician requests data using the Healthix browser, first the master patient index identifies which of the Healthix members that patient has been to previously, and subsequent of that, the Healthix interface engine goes to the edge servers at each of the participants and retrieves data from the participant, aggregates that data, and then displays that data to the clinician who has requested the data.
8.5 Figure (Kuperman, G. 2016)
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12. Healthix screenshot 8.6 Figure (Healthix, 2015)
Healthix displays the data in a results review application. This results review application is not very different than the kinds of results review applications that are available in electronic health records. The Healthix results review application displays data elements such as encounters, allergies, vaccinations, diagnoses, lab results, radiology reports, etc. The only difference between a Healthix results review application and that in an electronic health record is that Healthix displays data across multiple organizations.
8.6 Figure (Healthix, 2015)
*Note that this screenshot is of a fake patient and data.

13. Health Information Exchange (HIE) Organizations: Issues
Burdensome privacy policy
In New York State, a provider can only access the health information exchange (HIE) organization if the provider has obtained the patient’s written consent
Difficult to operationalize
Fitting the use of the health information exchange (HIE) organization technology into the workflow
Yet another application for the clinician
Healthix is an example of an health information exchange organization and there has been a lot of progress with these kinds of organizations over the last several years. However, there are issues and challenges that health information exchange organizations face. One challenge is that health information exchange organizations may have a burdensome privacy policy. For example, in New York State, health care providers can access data from a RHIO only if the provider’s organization has obtained the patient’s written consent. Getting the patient’s consent can be difficult to operationalize because it requires having someone explain the ramifications of allowing the provider to access the patient’s data from the RHIO, getting the patient’s signature on a form, and putting the form into the medical record. Using this approach to obtain the consent adds one additional step to the process of registering patients when they arrive for their health care encounter, which frequently is already a hectic process. In New York State, the patient’s consent is durable, which means that it only needs to be collected once, not at every encounter. An additional challenge is fitting the use of the use of the health information exchange organization’s technology into the workflow. In the example of Healthix, the health information exchange organization’s technology is the Healthix portal. To use the Healthix portal, the provider has to access an application other than the EHR. Switching applications can create a hurdle to the use of the health information exchange organization’s technology.
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14. Health Information Exchange (HIE) Organizations: Status
Because of implementation challenges, adoption has varied across states and regions
For example, adoption of health information exchange is greater in upstate New York than in downstate New York
In general, use of health information exchange (HIE) organizations as part of care is not yet widespread
The adoption of HIEO technology has varied across various states and regions. For example, in New York State, there has been more adoption upstate than in the downstate region, which includes the New York City metropolitan area. In general, nationally, the use of technology provided by health information exchange organizations is not yet widespread.
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15. Do health information exchange (HIE) organizations make a difference?
21 studies on use of HIE
Thirteen organizations (six in NY), generally used in less than 10% of encounters
12 studies of impact on resource use
Low quality evidence of decreased resource utilization and emergency department (ED) costs
17 studies of sustainability
25% of organizations felt to be sustainable
In 2014, a literature review was performed of studies of the impact of health information exchange on a variety of parameters. Some of the results are as follows. The review found that there are 21 studies on the use of health information exchange. In these 21 studies, there were 13 organizations represented, of which six are in New York. Those studies found that the health information exchange capabilities were generally used in less than 10% of encounters, where health information exchange was available. This may be reasonable because not every encounter requires the use of health information exchange. There were 12 studies on the impact of health information exchange on resource use and there was low quality evidence that the use of health information exchange led to decreased utilization – for example, less imaging – and also lower emergency department costs, such as tests ordered in an emergency department encounter. There were 17 studies of sustainability and only 25% of health information exchange organizations felt to be sustainable.
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16. 38 studies of attitudes, barriers, and facilitators
Do health information exchange (HIE) organizations make a difference? (Cont’d – 1)
38 studies of attitudes, barriers, and facilitators
HIE is felt to be valuable
Barriers are technical, workflow, cost, and privacy
Conclusion: Technology provided by health information exchange (HIE) organizations probably has some impact, but more research is needed
There were 38 studies of attitudes, barriers, and facilitators and it was felt that health information exchange was to be valuable to providers, but there are barriers such as technology, workflow, costs, and privacy. In conclusion, this lit review stated that health information exchange organizations have some impact on cost and quality of care, but more research is needed.
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17. Hurdles to scaling the health information exchange (HIE) organization model
Complex
Needs new privacy models, governance
Expensive
Complex technology
Need enough data to assure critical mass
Engage a lot of providers
Get a lot of data from each provider
Need approaches to handle a lot of data
Summarization
Consent
Fitting use into the workflow
There are several hurdles to scaling the health information exchange organization model. Number one, it is complex. There are privacy and governance models needed. The technology is complex and expensive. The expense comes from the cost of the data interfaces that are needed to be created from the member organizations to the health information exchange organization’s hub and from the master patient index. There needs to be enough data so there is a critical mass to engage a lot of providers and make sure you get a lot of data from each provider. In addition, since there would be a lot of data, there needs to be approaches to handling the volume of data. For example, summarization of extensive amounts of clinical data is needed. There are consent models for privacy and the RHIO needs to fit in the workflow. These are some of the challenges to scaling the RHIO model.
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18. Concerns about the health information exchange (HIE) organization model
Adler – Milstein et al. wrote an article in 2013: “Operational health information exchanges show substantial growth but long – term funding remains a concern”
“Findings suggest that despite progress, there is a substantial risk that many current efforts to promote health information exchange will fail when public funds supporting these initiatives are depleted”
There are additional concerns about the health information exchange organization model. Julia Adler-Milstein and her colleagues in an article in 2013 wrote that operational health information exchanges show substantial growth, but long-term funding for these exchanges is a problem. Also, “findings suggest that despite progress, there is substantial risk that many current efforts to promote health information exchange will fail when public funds supporting these initiatives are depleted.” Therefore, challenges for scaling the health information exchange organization model are exacerbated by the issue of sustainable funding.
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19. Unit 8: Exchange of Health Information, Summary – Lecture b, Health Information Exchange Organizations
Interconnecting large provider organizations is an appealing way to advance health information exchange (HIE); however, there are several challenges
The health information exchange (HIE) organization model was proposed in 2005 to overcome some of the challenges
New York State in particular invested heavily in the health information exchange (HIE) organization model
The health information exchange (HIE) organization model of HIE appears to have some benefit, but more research is needed
There are challenges to scaling the health information exchange (HIE) organization model
This concludes Lecture b of Exchange of Health Information, Health Information Exchange Organizations. In summary, interconnecting large provider organizations is an appealing way to advance health information exchange. However, there are several challenges. The health information exchange organization model was proposed in 2005 to overcome some of the challenges. New York State, in particular, invested heavily in the health information exchange organizations model, where health information exchange organizations were called RHIOs. The health information exchange organization model of health information exchange appears to have some benefit, but more research is needed. Finally, there are challenges to scaling the health information exchange organization model.

20. Exchange of Health Information References – Lecture b
Adler-Milstein, J., Bates, D.W., & Jha, A.K. (2013). Operational health information exchanges show substantial growth, but long-term funding remains a concern. Health Aff, 32(8),
Rudin, R.S., Motala, A., Goldzweig, C.L., & Shekelle, P.G. (2014). Usage and effect of health information exchange: a systematic review. Ann Intern Med, 161(11),
No audio.
Charts, Tables, Figures
8.4 Figure: Healthix. (2015). SHIN-NY: State Health Information Network – New York.
8.5 Figure: Kuperman, G. (2016). Healthix technology. Used with permission.
8.6 Figure: Healthix. (2015). Healthix screenshot.

21. Unit 8: Exchange of Health Information, Lecture b – Health Information Exchange Organizations
This material was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0004.
No audio.
End.