JAMA: Overcoming U.S. HIE adoption barriers? Outlook unclear

Sharing clinical data electronically is a critical challenge for fixing the healthcare system, according to a viewpoint report published this week in the Journal of the American Medical Association.

Julia Adler-Milstein, PhD, University of Michigan in Ann Arbor, and Ashish H. Jha, MD, MPH, department of health policy and management, Harvard School of Public Health in Boston, questioned whether the U.S. will be able to overcome the barriers to health information exchange (HIE).

“The vision of complete patient information available across care delivery settings is compelling and central to a high-functioning healthcare system,” the authors wrote. “However, the vision is deceptively simple: there are enormous challenges to enabling clinical data to flow across organizations. These challenges are substantially greater than those associated with transitioning physicians and hospitals to EHRs.”

There are at least five major barriers; the first being data privacy and security, according to the authors. “There remains uncertainty among clinicians about the legal ramifications of a data breach or unauthorized access through HIE.”

Second, point-to-point exchange could hamper interoperability tools that allow more structured data exchange, the study authors wrote. “Without structured data, the widely touted secondary uses of these data, such as comparative effectiveness research or population health management, will be limited.”

The meaningful use incentive program excludes some clinicians and organizations. Those with low levels of EHR use are less likely to participate in HIE, Adler-Milstein and Jha noted. “The fourth, and a substantially bigger challenge, is that physicians and hospitals are concerned about the competitive implications of sharing their data, which may make it easier for patients to seek care from rival institutions. Hospitals view clinical data as ‘a key strategic asset, tying physicians and patients to their organization.’”

The most difficult challenge, perhaps, is convincing clinicians to demand these data and use them when available. “Physicians are accustomed to making clinical decisions with incomplete information, and the notion that they might be responsible for reviewing patient data from past encounters across all care settings is daunting.”

They suggested that policy makers could take three actions to maximize the likelihood of achieving robust HIE:

1. Provide greater clarity and guidance on the consequences of unauthorized data breaches caused by others.
2. Using the power of Medicare and Medicaid as payors, policymakers should create incentives for all clinicians and healthcare settings to make certain types of data (eg, medication lists, laboratory results) available for exchange in a structured format.
3. Implement policies to encourage clinicians and healthcare settings excluded from meaningful use, including nursing homes and rehabilitation hospitals, to adopt EHRs and participate in HIE.

“Clinicians know when they have more complete information about their patients, they provide safer, more effective and more efficient care,” the authors concluded. “Clinician support is critical to ensuring that HIE becomes commonplace and is used in daily clinical practice. Without clinician support and without broad-based HIE, it will be substantially more difficult to improve the performance of the U.S. healthcare delivery system.”