Health Information Exchanges (HIEs), publicly or privately operated hubs of patient data intended to connect regional providers, have faced significant obstacles in recent years despite support from the ACA and state organizations. While some are technological, such as discrepancies in data classification among EHR systems, others involve deliberate data blocking or economic factors that aren’t as easily addressed. Even so, as the potential savings become realized, the future of HIEs and data sharing in general appears promising.
The theoretical benefits of HIEs have long been touted: fewer duplicate clinical tests, better care coordination, and easier access to patient information in critical settings such as emergency rooms. Federal and state funding helped set up many regional HIEs to further these goals, but their impact has been disputed, with most research finding minimal positive effects, though more providers are being connected each year. A new study, “ Reducing Medicare Spending Through Electronic Information Exchange: The Role of Incentives and Exchange Maturity,” estimates that the widespread utilization of HIEs could save Medicare up to $3 billion each year, but more importantly, it identifies some of the reasons why certain HIE deployments have proven successful.
The most successful HIEs, according to the study, offer value to all actors in healthcare delivery. While lower costs and better outcomes may seem inherently desirable to everyone, providers and insurers can have divergent priorities. Insurers welcome data sharing because more efficient care reduces the number of claims they have to pay, but a physician or hospital stands to lose out on revenue, both from lower procedure volume and possible patient migration, since multiple organizations can access a patient’s information and are equally prepared to offer treatment. As other analysts have pointed out, providers can have a disincentive to participate. The key to overcoming perverse incentives, and what the study concludes is most effective, is to introduce counteracting incentives through value-based and capitated reimbursement models. If providers receive a set payment for any service, redundant testing reduces potential profit and can even result in a loss. While fee-for-service reimbursement still dominates the healthcare market, the volume of value-based payments continues to increase each year among private and public payers, suggesting that HIEs will steadily become more important in the future. The necessity of HIEs will also help alleviate existing financial issues, as many HIEs are currently struggling to adopt viable operating models that don’t depend upon public support.
The study also suggests that the overall maturity of the HIE helps determine its success. Most HIEs start with modest goals, sharing a few types of data sets and gradually increasing the data volume as participants invest in their IT capabilities and grow accustomed to the system. Unfortunately, there is often substantial lead time before an HIE can be fully utilized. An incomplete patient record does little to discourage redundant utilization, and providers tend to struggle to adapt to new workflows, especially when the first few years of access to an HIE fail to provide any noticeable benefit. While the overall number of HIEs has declined recently, the number of covered areas continues to expand, suggesting that providers are still investing in exchange capability and are willing to work through the initial startup period.
A less prominent but potentially significant obstacle to HIEs is information blocking. A 2015 report from HHS concluded that deliberate attempts to interfere with the transfer of patient information posed a real problem, with most complaints directed towards HIT developers. Some providers claimed that their developer charged fees that made it cost-prohibitive to send or search for patient information. Others set high prices to establish connections with other healthcare organizations or impeded providers’ ability to install third-party add-on modules. HHS determined that not all of the pricing variability could be explained by standard cost-shifting practices, and some was likely due to anticompetitive strategies. Healthcare organizations were accused of blocking as well, often allegedly in order to restrict referrals to non-network physicians and maintain market dominance. The report states that ONC has few tools to directly address the problem, though it can endorse new governance and transparency regulations. Information blocking may be the most difficult problem to solve in the coming years, especially as it’s only documented through anecdotal evidence. Technological developments or unified standards may correct some of the issues, but legislative mandates would appear to be the only certain way to ensure providers have sufficient access to a defined set of data sharing capabilities.
Traditional HIEs may face another threat from EHR vendor platforms. The wide deployment of EHRs and the dominance of a few vendors has led some of them to create their own HIE systems. Epic, the most-widely deployed EHR, features the Care Everywhere platform, allowing easy exchange of records between all other facilities with an Epic system. In 2016, the system exchanged 250 million patient records. Vendor-specific systems may not have the same level of regional inclusiveness as established HIEs, but are spared the challenge of building a working operating model. Regardless of the method, it’s likely that exchanging patient information will be an increasingly important part of clinical care in future years.
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