HIEs: Getting to the Data

Medicine is moving from an art to an information science, and as such it is critically dependent on accurate, complete and timely data.  The discussion first centered on the role of HIEs in capturing clinical data and making data available at the point of care and for secondary uses such as analytics. Two distinct HIE models are evolving somewhat independently, according to Robert Fassett, MD, CMIO of Oracle, although they typically have common underlying technologies and standards. "There are inter-organizational HIEs, called community HIEs, and there are intra-organizational HIEs, called enterprise HIEs.  While many community HIEs have struggled to develop sustainable business models, enterprise HIEs have taken off like wildfire because getting a handle on the enterprise's data is one of the first steps in moving toward demonstrating meaningful use and accountable care."  

Community HIEs are continuing to evolve, with new interoperability approaches beginning to emerge.  The Office of the National Coordinator for Health IT (ONC) has "not bet the farm on the HIE as a state or regional entity," says David Cochran, MD, president and CEO of Vermont Information Technology Leaders, a nonprofit charged with deploying a statewide HIE. "ONC has invested heavily in developing the Direct Project, which is a vehicle that allows organizations to exchange information without having a fully functional identity." However, he adds that the federal government is supporting various paths, so regional entities or statewide entities are only one of the potential options.

As health systems become accountable for the quality of care that extends beyond their "four walls," community HIEs may yet find a financial "raison d'être," says Justin V. Graham, MD, CMIO at NorthBay Health System in Fairfield, Calif. Regarding the growing connection between HIEs and ACOs, he notes, "HIEs potentially have a role within healthcare reform as we try to coordinate care among multiple providers, whether in an ACO model or otherwise. While the national certification process promoting EHRs supports HIE development, it also supports HIE models that provide services to small facilities that are implementing EHRs while simultaneously seeking to implement ACOs."

Patient Engagement & HIT

While many providers are participating in HIEs, "the wild card still seems to be the patients," says Michael S. Blum, MD, CMIO at the University of California, San Francisco. The panel members agreed that patient engagement is crucial to achieving better outcomes and to health systems prospering in the accountable care era.  That said, the panelists also commented on the current lack of patient understanding of the cost/benefit trade-offs in becoming more involved in their care.

"Physicians must explain to their patients the value of participating in a medical home—a foundational component for the ACO," notes Graham. "The patient has legitimate concerns about exposure of his or her personal health information, but these concerns can be addressed in a discussion about how an ACO could improve his or her care, as well as part of the consent process."

Fassett says that a variety of approaches have been proposed to entice patients to get more involved, including a recent proposal to extend the shared Medicare savings to the patient themselves (N Engl J Med 2011;364:2085-2086). A number of medical home and early accountable care efforts have used reduced co-pays or premium payments as patient incentives.  

While Fassett sees technology as central to patient engagement, he identifies a fundamental change that must occur first. "In addition to better patient engagement, you need a culture change within the provider setting."

While many health systems have deployed patient portals for appointment scheduling and monitoring lab results, the panelists suggested that true engagement will require providers to embrace patients as a vital member of the team.  As evidence of a paradigm shift, the deployment of PHRs should extend well beyond today's patient portals, and the panelists agreed they have struggled to gain momentum.  Despite their potential, Blum points out, "we will need to see a lot more cultural change before achieving the intended goals with PHRs."

Healthcare IT will have an important role in facilitating provider-patient collaboration. "One of the strengths of EHRs in practice has been the ability to track trends over time and to show when we're improving patient outcomes. It's a great communication vehicle," Conchran says.  

"While we need to use these tools for communication, we also need to avoid data overload," Graham warns. "More information does not necessarily equate to better information. We run the risk of overwhelming providers with too much data—and not much more usable information."

As Graham notes, there's more data and then there's more meaningful data.  Problem lists are illustrative of this "making data meaningful" issue. "In the acute care setting, we have difficulty getting our providers to engage with the problem list," he adds. "It doesn't add anything to their documentation because some [components] were integrated into their workflow. In the outpatient setting, the process is better."  Without an accurate view of the patient's problems it's challenging to provide analytics that inform point of care interventions and to monitor outcomes.  

Fassett points out that "clinical decision support, outcomes reporting, comparative effectiveness research, and the like, all hinge on an accurate problem list." 

Role of Clinical Analytics

Once meaningful clinical, financial, administrative and research data have been gathered, hundreds of game-changing analytics applications can be developed. Early targets will include gaps in care analyses, population health management analytics, performance and financial risk management, predictive analytics for patient stratification by outcome and cost factors, readmissions, as well as meaningful use and other public reporting.  

"We cannot [yet] tell the public about our quality in any meaningful way," Blum notes. "Clinical intelligence and clinical analytics are a big part of this."

In addition to providing greater transparency, clinical analytics will be critical to care management for individuals and populations. "Every hospital system is going to roll-out its own care management analytic applications," Fasset predicts. "A new generation of care management tools is likely to evolve that puts the provider at the center of this critical function." Echoing the concerns about the patient engagement discussion, it was resoundingly agreed upon that physicians and administrators will need to embrace analysis of their care and learn to evolve with the insights those analytics yield. "That's the other potential hang-up as we move into the future of using data for analytics," Graham says. "Many providers don't understand why we need these data, and not just physicians, but even operational leaders who don't quite understand its importance. We could learn from Lean Management."  

The discussion came full circle in its conclusion—back to the need for high quality, usable data. It is well-known across the healthcare continuum that large amounts of data are being collected in health systems today, but the data remain siloed. Bending the quality versus cost curve requires the healthcare organization to pull data from a broad range of clinical and non-clinical sources and create synchronization and value. "Once we achieve that harmonization, the sky will be the limit in terms of what can be accomplished," Fassett concludes.