Dispatch from HIMSS17: One National Model for HIE?

"Our job is not complete until all patient information is shared nationwide to support treatment, population health, and public health. But we have the unique opportunity and challenge every day to make that happen." - John Kansky, MSE, MBA, CPHIMS, FHIMSS

I was fortunate to attend the 2017 HIMSS health IT conference, a one-of-a-kind event that gathers over 45,000 health care providers and professionals from all over the USA and internationally. Breathing in health IT-related topics and networking for a week was exhilarating and exhausting, but I brought back a great deal of information and ideas from the experience. One session in particular that I attended was part revelation, part frustration and 100 percent relevant to the work that VITL does every day. The session title was "Health Information Exchange: Can There be One National Model?"

The session description:

The nation's "current state" of the exchange of health information is that there are several competing approaches playing out, which are often conflicting and most definitely confusing. Industry professionals who are responsible for making decisions about "if" and "how" their organizations will interoperate often aren't equipped with the information they need to know the difference between Health Information Exchange (HIE) (the noun and verb), CareQuality, Commonwell, and the eHealth Exchange. The industry could do a better job of providing a cohesive story to explain these different approaches. This session aims to help tell that story by explaining the differences in these approaches and how they work, and sometimes compete, with each other. Our talk will acknowledge the current state, explain the differences and present a cohesive approach for national interoperability.

Indiana Health Information Exchange CEO John Kansky and their Vice President of Solution Delivery Keith Kelley delivered an excellent analysis of the various current approaches to HIE in the span of one hour, just enough to cover the surface of a subject that is complex and often confusing for providers, patients and health IT professionals.

I outlined the session's major themes in this post, but heads up that readers may not be happy with the conclusions.

The problem:

  • There has been little progress on interoperability from a patient outcome perspective.
  • The HIT industry is wasting time and resources in the process.
  • There is no clear understanding of the various national approaches.
  • There is an unsupported belief that one approach is the correct one.

The current interoperability approaches:

  • eHealth Exchange -  evolved from the federal government's NwHIN as the public-private national network of networks. The Sequoia Project is the legal entity. VITL uses the Sequoia Project standards for HIE to HIE connections.
  • Carequality -  created by The Sequoia Project, in part to accommodate needs of EHR vendors ineligible for eHealth Exchange. The Sequoia Project is the legal entity.
  • CommonWell -  created by a group of EHR vendors led by Cerner, Athena and others (not Epic). Partially motivated as a market response to Care Everywhere. Overseen by a board of directors.
  • Epic-Care Everywhere - initially developed as part of the Epic EHR product a decade ago. Epic and the governing body made up of customers are in charge.
  • Health Information Exchange (HIE) - the oldest HIEs date back to the 1990's. Many state-run exchanges emerged from the federal ARRA HITECH funding. Each HIE has its own management, board and governance.
  • Strategic Health Information Exchange Collaborative (SHIEC) - Patient-Centered Data Home -  a national association of more than 40 statewide, regional and community HIEs. SHIEC has a board of directors elected among their HIE members (not all HIEs are members).

John Kansky used the analogies of stitching a quilt or connecting dots (I appreciated his use of the famous Seurat painting A Sunday Afternoon On The Island Of La Grande Jatte, where the artist used the technique of pointillism, or painting in dots, to fill in the picture), to compare how various systems are connecting, and their coverage. The eHealth Exchange and HIE connections are located in the west, midwest, southwest and mid-Atlantic regions of the US and New York state, and comprise quilt patches. Along with SHIEC's 48 member organization Patient-Centered Data Home approach, the expanding "quilt" of data homes equals half of the United States population.

HIE coverage

The Seurat "connected dots" analogy was used for the CommonWell, Carequality, and Care Everywhere implementations and to represent coverage across the United States. I believe the point of these comparisons was not only to visualize the connections, but to illustrate the variability in defining interoperability. It seems that there isn't a standard definition.

Comparison of Seurat to health care interoperability coverage

Whether we are talking about quilts or dots, interoperability within a hospital or across state lines, it means different things depending on what the need is:

  • Interoperability is not ONE thing.
  • There are several different interoperability approaches.
  • No one approach will work for all interoperability use cases.
  • Different types of organizations have different interoperability needs.
  • The best approach depends on key characteristics of your organization’s market.
  • Today, there is a general industry belief that a single interoperability approach should be capable of meeting all your needs.

Examples of different use cases for interoperability include:

  • Immunization, syndromic surveillance and public health
  • Electronic prescribing and refill information
  • Claims transactions/electronic eligibility information
  • Clinical decision support
  • Disease or chronic care management
  • Quality improvement reporting for clinicians
  • Clinical results delivery
  • Medication history
  • Ambulatory order entry
  • ADT notification
  • Population health management
  • Research support

The list of use cases is long and growing. Refer to the presentation PowerPoint for a series of tables that illustrates, depending on the use case, what type of interoperability solution would match a health care organization's needs.

What was the presenters' answer to the question, "Can There Be ONE National Model?" The answer was NO, and it was not popular among many audience members. A question about replicating the ATM banking network for health care systems was asked: not possible currently was the answer. One reason is that there are too many data integration challenges in health care. The answer lies in using multiple interoperability approaches.

The presenters' solution recognizes that using multiple interoperability approaches is difficult. However health care organizations should understand the different interoperability approaches, realize that the best solution is a combination of them, and then create a Living Interoperability Plan:

  1. STEP 1: Identify internal clinical value opportunities (use cases) and prioritize.
    1. Address workflow and adoption!
    2. Be prepared for clinician apathy or resistance (think pre-EMR days).
    3. Look beyond point of care (CCD query) use cases.
  2. STEP 2: Identify environmental factors that currently (or soon will) affect your interoperability needs.
    1. Government programs (ACO, MACRA, CJR).
    2. Business relationships.
  3. STEP 3: Assess interoperability approaches (IA) capabilities for YOUR organization BY USE CASE.
    1. Determine how data will integrate into your internal systems.
    2. Engage the IA initiatives in your planning efforts.
    3. Seek collaboration among IAs (e.g. HIE and Carequality/CommonWell).
  4. STEP 4: Align with organizational strategy and other IT initiatives.
    1. What are the interoperability needs of my organization’s strategic initiatives?
    2. Given finite financial resources, how do interoperability projects stack up against internal IT initiatives?

Many people in the audience did not agree with the presenters' answers or solutions. Several people were in favor of a federal, one model solution, but others were not. I took away a lot of new knowledge from a one hour session that compressed the complexities of interoperability and health information exchange and what health care organizations can do about it now. I also learned more about SHIEC (VITL is a member organization) and the Patient-Centered Data Home framework as a future means for HIEs to connect nationwide, realizing the goal of Americans being able to travel from state to state with their digital health information available when and where they need it.


President and CEO
Indiana Health Information Exchange

Keith Kelley
Vice President, Solution Delivery
Indiana Health Information Exchange