Health Information Exchanges: The Health IT Inside

Healthcare officials in Washington are discussing standards for the technical architecture of modern health information exchanges. And while such standards haven’t yet been finalized to meet the objectives of meaningful use of electronic medical records, the U.S. government starts doling out $564 million in grants to states in early 2010 to fund state-level networks for exchanging electronic patient information. 

States are expected to receive this money, which was made available through the Health Information Technology for Economic and Clinical Health (HITECH) Act, at varying levels of readiness to deploy statewide health information networks. Indiana and Utah have considerable infrastructure already in place, for example, while Vermont and West Virginia are in the nascent phases of planning exchanges. This means that many budding health information exchanges are still deciding which IT tools and architectures are most suitable. These exchanges can learn a lot from operational regional HIEs (also known as regional health information organizations, or RHIOs) in places such as in Indiana, New York, and Wisconsin.

Making wise choices about technical architecture is crucial for HIEs because they impact not only the general connectivity among exchange participants, but also important areas such as the security of patient data and the financial sustainability of the network. “Sustainability needs to be tattooed on the inside of your eyelids,” says John Kansky, vice president of business development for the Indiana Health Information Exchange. “There’s always going to be somebody on the planning committee who wants to build something that, from a societal standpoint, is a homerun—but it’s not sustainable.”

Indeed, health IT leaders are already factoring the costs of technology infrastructure into their plans for the $564 million State Health Information Exchange Cooperative Agreement Program, which calls on states or their designated entities to begin matching federal funds awarded by the program in 2011 and provides grant support only through 2013. By 2014, exchanges will likely need to generate revenue from participants to remain in operation.

Embracing web services

Several organizations around the country are embracing the benefits of web services and service-oriented architecture (SOA) for their HIEs, reducing their need for expensive physical computing infrastructure to operate the exchanges. These architectures offer HIEs the ability to efficiently expand services over time as well as the flexibility to tie into larger statewide and national health information networks. The National Health Information Network, which is expected to be the network of networks for the U.S. healthcare system, also is testing web services to enable the exchange of health information among stakeholders across the country. 

At the Brooklyn Health Information Exchange (BHIX) in New York, which facilitates patient data sharing among six hospitals and seven nursing homes in Brooklyn and environs, the vision is to eventually adopt a complete web services model, according to Irene Koch, executive director of the regional exchange. 

Toward this end, BHIX decided to implement the HealthShare health information exchange platform from InterSystems. HealthShare consists of a database tool for indexing patients in the exchange, integration software to connect participants at separate sites to the exchange, and other tools required to securely share data over a network. Though the vision for the exchange is to eventually not have to store any patient data, Koch says, the network still keeps some information from stakeholders on servers. BHIX, which began operations last year with a different platform, expects to complete its switch to the HealthShare-based system in November.

“We wanted something flexible, standards-based, and malleable because we know that in this industry things are going to be changing all the time,” Koch says. A goal for HIEs in New York is to be able to connect to an emerging statewide health information exchange known as the State Health Information Network for New York, or SHIN-NY, which is also embracing web services and SOA to connect to HIEs across the Empire State.

Data models gaining traction

So where do the major challenges lie in selecting IT tools and system architecture? In appeasing the multiple participants and stakeholders, HIE leaders agree. “It’s still not easy, because there’s a lot of politics,” says Todd Rowland, MD, executive director of HealthLINC, an HIE in Bloomington, Ind. Like many exchanges, HealthLINC enables each hospital and stakeholder to maintain control of their own data while providing the network and means to share health data.

HealthLINC uses a community-wide patient index, provided by Axolotl, that enables authorized physicians to locate patients whose medical data can then be retrieved from the site that stores their information. The index has only demographic information on patients, and there is no central repository operated by the exchange that stores detailed clinical data on patients. Also, the Axolotl platform provides physicians linked to the exchange with inboxes that they use to receive electronic patient data. The software also includes workflow tools that enable practitioners to view high-priority messages, such as cancer diagnostic test results, that could easily be lost otherwise. 

While the so-called federated data model, in which patient data are stored at separate sites, works for HealthLINC, other exchanges have adopted infrastructures that put more emphasis on centralized storage of patient data. “Our implementation specifically centralizes data but does not mingle the data [of participants], so each source maintains control over the data that they have shared with the exchange,” says Kim Pemble, executive director of the Wisconsin Health Information Exchange (WHIE), which provides HIE services to stakeholders in the Milwaukee area. The WHIE, which uses the Microsoft Amalga platform, maintains a policy that any member can decide to opt out of the HIE and have their data returned to them.

Delivering valuable information

For the WHIE, centralizing patient data serves a key mission of the exchange to provide information for the public health setting. The exchange implements IT tools within the Microsoft Amalga platform to de-identify individual patient information and to aggregate it into reports on emerging health threats. Pemble says this capability is enabling the exchange to provide H1N1 influenza surveillance in the Milwaukee area.

The WHIE also offers hospitals a service that links emergency department records, providing clinicians at the point of care with such information as patient intake dates and locations to track patients’ use of emergency rooms. The service can identify patients who are misusing ER services, which can drive up costs for hospitals. The hospitals use HL7 and other healthcare communication standards for sharing this information.    

The Indiana Health Information Exchange (IHIE) operates with a records management system developed by an Indianapolis medical informatics nonprofit called the Regenstrief Institute. The exchange provides a service called DOCS4DOCS for electronic delivery of lab test results and other clinical information to physicians. The messaging service—which uses Logical Observation Identifiers Names and Codes (LOINC) standards to codify lab results—is valuable to participants in the exchange because paper-based systems often lead to lost records and duplicate testing, says IHIE’s Kansky.

Regardless of the technical infrastructure of an HIE, at the end of the day there has to be a way to pay for the exchanges. “We’re very, very big on sustainability of services and we believe HIE is a business,” Kansky says. “You have to build services that deliver value that someone will pay for.”