Health Information Exchange Debate Gets Fiery

Even as the Office of the National Coordinator of Health IT (ONC) continues to promote health information exchanges, the debate over the viability and usefulness of the current generation of HIES is heating up.

"It's time to face the facts: Our nationwide network of Health Information Exchanges (HIEs) is an unmitigated disaster," declared William Yasnoff, MD, PhD, president of the Health Record Banking Alliance, in a recent article in NHINWatch. John Loonsk, MD, chief medical officer of CGI Federal and a former high-ranking ONC official, also raised questions about the feasibility of HIEs in a recent Healthcare IT News piece.

Even Michael Matthews, president and CEO of the MedVirginia HIE and president of Healtheway, the not-for-profit firm that runs the operations of the eHealth Exchange -- the private-sector successor to the NwHIN Exchange -- told InformationWeek Heathcare, "If an HIE says, 'I'm going to do tomorrow what I do today,' they're going to be out of business."

[ How is lack of a national health information exchange like Hurricane Sandy? Read National Health Information Exchange: Why The Delay? ]

What's going on here? Yasnoff pointed out that, three years after ONC began to invest over half a billion dollars in statewide HIEs, 90% of hospitals in 32 states have yet to exchange a single patient record. He cited a 2011 study showing that of 179 HIEs, only 13 were capable of helping providers meet Meaningful Use stage 1 criteria for interoperability. And he noted that most HIEs have yet to overcome the key obstacles of "privacy, stakeholder cooperation, and financial sustainability."

Naturally, Yasnoff favors a health record banking approach in which all records are aggregated in a regional database under patient control. The widespread federated HIE model, in which records are accessed from multiple databases when they're needed, but not stored centrally, is the biggest reason for the failure of interoperability, he maintains. Among the drawbacks of the federated model, he said, is that it's too complex and expensive, prone to error, insecure and unable to guarantee privacy, not financially sustainable, and unable to assure stakeholder participation, because HIE participation is voluntary.

Loonsk is just as downbeat about HIE progress to date. Noting that "there is a new degree of pessimism about when health IT interoperability will ever be achieved," he said, "recent, non-political Congressional testimony suggested interoperability is still another decade away." In fact, he argued that the proliferation of EHRs that can't communicate with one another is pushing the goal further into the future.

Loonsk also attributes the lack of HIE progress to these factors:

-- Too much emphasis on quality reporting, too little on interoperability in stage 1 of Meaningful Use.

-- Certifying only EHRs, not organizations, for interoperability.

-- Lack of a compelling reason for providers to communicate with each other online.

-- Lack of a standardized way of measuring progress on interoperability.

In his interview with InformationWeek Healthcare, Matthews did not deny that HIEs have fallen short of expectations. However, he said that there are "nimble, value-adding HIEs" that are changing in response to the current transition of the healthcare industry toward new care delivery models.

"I do see some serious progress around population health, best practices, clinical outcomes, accountable care and aligning incentives. And all of a sudden it may be worth that additional step it takes to access all the information on a patient, not just the information that's in my own medical chart. So that encourages me that we still have to work to do, but the economic drivers will start to support that."

The biggest barrier to making HIEs work, in Matthews' view, is not EHRs that can't easily exchange data, but physician workflow. "It still boils down to showing physicians that it's worthwhile to change workflows that currently work for them. Disrupting that flow for a patient here or there is not conducive to taking advantage of the information that's available through an HIE."

For example, he pointed out, if a physician has to sign out of an EHR and go to a patient portal to look for information on a patient or to use Direct messaging to send data to another doctor, he or she is unlikely to do that very often. Instead, the physician must be able to access that data and do all of his or her work within a single application or platform.

"When all of that gets integrated -- and I think that will get happen in the next two years -- that's where the curve goes straight up on being able to access and integrate information out of your core system," he said.

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