In past blogs, we’ve discussed how health information exchanges (HIE) play a crucial role in transforming the healthcare industry by enabling the systematic sharing of health-related information between disparate clinical systems and various organizations, or stakeholders. HIEs have demonstrated their ability to improve the clinical and financial performance of healthcare organizations and, if properly designed, can have a clear and commanding return on investment. Promoting sustainable HIEs plays an important role in the improvement of quality, safety and cost-effectiveness of healthcare delivered throughout the country. They ensure that patients, providers, payers and others involved have access to the right information at the right time.

To ensure success, however, HIEs must be able to share a patients’ medical information. For that to happen, an HIE must have a way to obtain meaningful consent and the support of patients. One of the main issues affecting the development of health information exchanges is the role of consumer participation. Consumer education is necessary for establishing trust in an HIE. Many polls and surveys have shown that consumers support the implementation and exchange of EHRs because they can improve patient care and reduce the number of unnecessary tests and procedures.

In our blog on the privacy and security of HIEs, we pointed out that even as an HIE enables an environment with new capabilities and opportunities, it also brings about new challenges. Without consent from patients to share their data, the viability and therefore sustainability of an HIE is limited significantly. Thus, HIEs face a multi-faceted decision on how and when to obtain patient consent. The choice of a consent model affects a multitude of stakeholders, from patients to payers and providers, and can have an impact on the way the HIE is structured.

The two main options HIEs usually use for patient consent are the opt-in and opt-out approaches. With the opt-in consent model, patients have to give formal consent before any of their data is shared through the HIE. Conversely, with the opt-out model, patient information is automatically included unless patients choose to remove some or all of their data. According to Jennifer Covich Bordenick, CEO of eHealth Initiative (eHI), the opt-out approach is currently used most among HIEs because it is the easiest to do initially, although more HIEs may switch to the opt-in model as other HIEs have success with that model.

With either model, the decision must take into account consumer concerns and needs, state laws, structural limitations, policy decisions and more. Decisions should only be made following research of all related issues and should focus on the needs of all involved stakeholders. Education on consent needs to highlight the safeguards to ensure high levels of privacy and security. Therefore it is necessary to educate patients on the consent process including who has access to their information and privacy issues concerning confidential medical records such as substance abuse records, mental health records and STI/HIV related records.

A prime example of a current HIE utilizing patient consent is HEALTHeLINK, one of the country’s most successful RHIOs. Companion to HEALTHeLINK, is Western New York’s administrative information exchange, HealtheNet, powered by APP Design’s RHIOnet. RHIOnet provides real-time, online services including health plan eligibility and benefit verification, claim status and inquiry, referral submission, single sign-on and more. APP Design was selected to design and develop a real-time patient consent interface to HEALTHeLINK to increase patient consent by delivering consent status through the eligibility transaction.

The interface, using NHIN XDS.b standards, enables HEALTHeLINK to gather more consent for an opt-in state and further integrates administrative and clinical workflows to reduce costs and improve outcomes for WNY patients. Through the interface, authorized users of WNYHealtheNet are able to retrieve HEALTHeLINK patient consent status during eligibility verification, saving time and multiple logins. This project again uses APP Design’s RHIOnet, a Web-based healthcare information exchange system designed to deliver accurate and timely healthcare data to caregivers distributed across wide geographical areas.

APP Design also was recently awarded a contract by the Office of the National Coordinator (ONC) for Health Information Technology to support its e-consent trial. The e-consent pilot program is scheduled to take place at four provider sites within HEALTHeLINK. Once a consent form is signed by a patient, physicians and other health-care providers who are involved in the patient’s care can securely access their lab results, tests, radiology reports, transcribed reports, medication information and a range of other health information to better treat the patient.

Though the model implemented by WNYHealtheLINK has proven successful, an HIE is only as good as consumers’ willingness to allow their data to be shared in ways that clinicians find valuable. In addition, that willingness will drive the usefulness of the HIE and its sustainability. HIE administrators and healthcare providers are themselves healthcare consumers, and their decisions about patient involvement in the HIE should reflect that.

HIEs which promote an environment where people can achieve their full potential, increase their productivity and expand their professional horizons are most likely to achieve long-term profitability. Learning is essential given the ongoing and rapid changes in the work world, especially in relation to technology. Therefore, investing in the development of the skills of those who are part of an HIE is essential, and a primary method for this development and education is online training, also called e-learning.

Online training provides flexibility and convenience not always available in onsite training by allowing users to train on their own time and at their own pace. Materials can be accessed 24/7 anywhere there is Internet access. An HIE can set up online training specific to its region, allowing other involved entities to access the same program or materials and taking the burden off hospitals in that region.

One of the biggest benefits online training offers an HIE is reduced cost. According to Training Magazine, corporations save between 50 to 70 percent when replacing instructor-led training with electronic content delivery due to reduced or eliminated travel costs and more targeted training. HIEs can pay for the training used without having to pay for a training professional, and they don’t have to print and ship expensive manuals.

Research also shows that online training can be nearly 93 percent cheaper than instructor led training while offering customized content to meet specific learning objectives and needs. It allows for the simple yet effective management of targeted, up-to-date content for any size group, especially important for an HIE. Along these same lines, online training enables an administrator to highlight areas of special interest to a group or region.

Online training and e-learning allow HIEs to thoroughly educate and/or train in an engaging and interactive manner through an easy-to-use, intuitive design. They ensure that all users have the in-depth knowledge of the programs they are using, maximizing productivity and improving the quality of their work. They may also assist users in adapting a new technology or provide immediate information on new products or procedures.

On the administrative side, using e-learning in an HIE offers measurable tracking of users’ progress with advanced reporting. Those needing to check a user’s progress can do so 24/7 without having to sift through a broad spectrum of data. Administrators can compare and contrast results by user, subject, region and more.

As discussed in a previous blog, HIEs must have safeguards and guidelines in place to ensure high levels of privacy and security across the board. The issue of privacy is also relevant in online training and e-learning as sensitive data may be exchanged in such processes. Again, the privacy and security rules of HIPAA require that protected health data is accessible to patients, released according to both state and Federal laws and maintains the privacy, security and integrity of patient data.

While conventional training and instruction may still be the best option in some cases, online training and e-learning provide a quick, effective and cost-saving method for HIEs and their users. As a value-added service, these processes provide a measurable return on investment for an HIE while offering an integral service to those users.

A survey run recently by the National eHealth Collaborative (NeHC) polled healthcare providers, government units, HIE operators and other officials and found that the issue they believed was most likely to potential derail HIEs was privacy and security. The United States government is taking steps and performing research to combat this issue. For example, Office of the National Coordinator for Health IT (ONC) is working with President Obama’s cybersecurity initiative to obtain input from security experts across the country, input which will then be used by the ONC to offer standards for HIEs to follow.

There are Federal regulations in place for the exchange of patient health data, and some states have their own laws targeted toward the privacy of such information. As for HIPAA, the law follows the Federal government in that it provides specific rules for the protection of patient data, although it does not override state-level laws which offer higher levels of privacy protection for patients. The privacy and security rules of HIPAA require that protected health data is accessible to patients, released according to both state and Federal laws and maintains the privacy, security and integrity of patient data.

Even with these laws and regulations in place, HIEs should follow a set of guidelines to ensure the privacy and security of their data is handled appropriately and with the right amount of protection. By tackling this issue in the planning stages of the HIE, the correct policies will be in place to offer the most secure solution to protect patient data. Although these guidelines aren’t state or national-level law, they should work with the specific rules and regulations of the area(s) in which they serve.

First, an HIE should draft an agreement outlining the specific rules and requirements for the parties involved. This agreement should include the terms of inclusion in the HIE along with the rights and responsibilities of all involved. All stakeholders have a right to have a say on the structure of the HIE, especially patients. Without the involvement of patients and their trust, the success of an HIE is severely threatened.

Along the same lines, patients need to be educated on the advantages of HIEs and what safeguards are in place to secure their data so that it doesn’t fall into the wrong hands. They need to know what data is included in the HIE, what purpose it serves and who has access to it. Those who are authorized to view patient data must have in place specific accounting for disclosures, risk management and control, limited use statements and an appropriate opt-out procedure. Patient data should be protected by safeguards for unlikely but possible risks including unauthorized access, unnecessary disclosure, loss, significant changes and more.

Patient data for an HIE should be obtained with the consent of the patient and used only for the purposes for which it was received. To provide another layer of security, the HIE should draft a list of who can access the data. Also, the HIE needs to make sure that the people on that list are equipped with appropriate authorization. Unnecessary and/or unlawful use of such patient data can only hurt public opinion on HIEs, placing an unfortunate obstacle to an otherwise comprehensive and innovative system and solution.

Again, while not all security and privacy measures in an HIE are foolproof, having the appropriate guidelines in place to address this issue is integral to the success of an HIE. With the growth of HIEs, the potential benefits they offer can only help improve the delivery of healthcare in this country.

No, it’s not a recipe for a summer road trip, it’s a list of things that have staying power. Though the facade of Mount Rushmore may change over the years because of environmental conditions, it has been around for many years and will be for years to come. Rock music may get harder and less original, but it’s still a basic of the music scene. As for baseball and apple pie, while other sports may occasional eclipse it in popularity from time to time, stories of fathers and sons – and daughters! – bonding over nine innings of strategy and scorekeeping are numerous and legendary.

As discussed in one of our previous posts, an integral part of a successful HIE is working to ensure that it is sustainable long-term. Part of this success involves providing services that reduce existing costs along with services that offer administrative transaction cost savings, thereby balancing the cost of other  services such as clinical data exchange. A service we consider to be high in value is that of eligibility verification or checking.

A properly designed eligibility verification solution allows an HIE to quickly and effectively connect healthcare providers and health plans in real-time for the exchange of eligibility and benefits data. This eliminates the need to verify patient eligibility through multiple steps, from faxes and phone calls to less efficient paper-based processes. For payers, such a solution renders the ability to communicate patient-specific pre-authorization or eligibility to respond to various patient and provider queries. Also, eligibility verification can provide access to transactions like claim status checks and others. The ability of providers to access this information from one central place, the HIE, instead of multiple payer sites, saves the providers time and money.

A significant benefit of an eligibility verification or checking solution is its ability to lower administration costs for an HIE. By streamlining assorted transactions, the solution reduces rework, provides immediate and current patient data and results in a higher level of accuracy. In the area of patient medication safety, eligibility verification coupled with the reconciliation of prescribed medication and generation of electronic prescriptions can improve patient medication compliance and, most importantly, reduce prescription errors.

Security is a concern in any technology solution, a high quality eligibility verification solution allows for the appropriate exchange of various types of data while insuring the privacy for all those involved in an HIE. Today’s technologies are able to successfully accomplish this level of security at a much lower initial cost than was previously possible. In addition to the privacy, a well-built eligibility verification solution is by far more reliable that using any paper-based solution.

Advances in eligibility verification and checking put eligibility and benefit information instantly at the fingertips of those who require it in an HIE. Therefore, by implementing such a select service in the early stages of an HIE, a major step toward its sustainability is achieved. Incorporating such an integral solution at this stage also gives those involved a single point of connectivity to access necessary data. Just like with Mount Rushmore, rock music and baseball and apple pie, a successful eligibility verification solution should indeed do a large part to result in the necessary staying power for an HIE.

As defined in the previous post, value-added services assist providers in simplifying the administrative side of healthcare while generating a significant amount of revenue with which to sustain the HIE. An especially integral service, single sign-on functionality and/or authentication provides the ability for an authorized user to enter the same identification and password to log on to multiple applications within an HIE, eliminating the need for the memorization and/or storage of assorted passwords.

Provided at the Web portal to an HIE, a single sign-on server stores multiple passwords in a secure database, making it available to the user transparently during the login process. This value-added service eliminates the often frustrating need for management of multiple passwords and saves time by not having to repeatedly log in and out of applications.

Through use of single sign-on (SSO), an HIE is able to centralize authorization credentials from multiple back-end applications through a portal that uses application definitions. Because the ability to easily and securely access data from any location plays an integral role in maintaining unimpeded workflow and directly impacts the quality of patient care, single sign-on benefits providers as well as the HIE.

In addition to eliminating the need for multiple passwords and saving time for users, single-sign on provides a whole host of benefits for an HIE. Users have a convenient and more efficient way to access the data they need, resulting in increased productivity. Also, by allowing the user to navigate through multiple applications without repeated logins, the possibility of human error is dramatically decreased.

For those who manage an HIE, single sign-on allows them to better monitor, control, protect and update authorization data for increased compliance and security. Through easier management of authorization data, it enables centralized security reporting and auditing for compliance adherence. Single sign-on also provides them with a common authentication framework, improving developer productivity. Access to applications or functions within applications can be restricted when the user is not at work or not on the assigned work location. Plus, through simplified administration, an HIE doesn’t have to spend more time and money retrieving forgotten passwords for users, thereby reducing operational costs.

It is important to note that single sign-on is not the only answer to improved security within an HIE but rather an integral part of the bigger picture. In order for single sign-on to be effective for a sustainable HIE, it must involve comprehensive planning and the correct combination of infrastructure tools. It also needs to be designed correctly to achieve the many benefits it is able to provide. With each of these things in place, single sign-on can provide an invaluable contribution to the success of the HIE.

Many of us have least heard, if not spoken, these phrases once or twice in our lifetime. Often we think businesses are in too much of a hurry these days to give us the level of service we deserve and that products are not made as well as they were decades ago. It’s as if taking enough time to make sure something is done right isn’t part of our culture anymore.

When it comes to building and maintaining a sustainable HIE, though, taking the time to do it right is essential. As we discussed in our previous post, there is there is no magic bullet for long-term HIE sustainability, but HIEs that make sustainability an integral part of their long term plan can reduce or eliminate their dependence on grant funding. Also as previously mentioned, grants can be use in the initial, start-up phase of an HIE but should not be relied upon past that stage. This post will highlight one of the steps in the plan – offering value-added services alongside the clinical exchange to fund the HIE.

For our purposes, value-added services are defined as those which assist providers in simplifying the administrative side of healthcare while generating a significant amount of revenue with which to sustain the HIE. They should be services that the community wants at a fee applicable to their specific market, and they should contribute to the sustainability of the HIE while matching its clinical priorities. HIEs may even layer such services to add to their contribution to the community and stakeholders whom they serve. Again, a small margin on these services can result in considerable amounts of funding for the HIE while still providing savings to members over current costs.

Those HIEs that have enjoyed long-term success have typically implemented value-added services incrementally, starting with those that encourage participation and result in measurable revenue right off the bat. Though not all value-added services revenues are directly measurable, they should all provide some level of value to the HIE. These services have to offer solutions to meet the needs of various stakeholders in order to improve quality of care and provide more favorable patient outcomes. As each HIE and region is unique, the menu service offerings depend upon which services deliver the most “bang for the buck” for its members.

Pricing of value-added services for an HIE has to be figured so that what the HIE charges to cover the cost of a service covers its expenses and surpasses the value of that service in the community or marketplace. The HIE should be careful in offering “loss leaders”  that encourage usage without significant revenues.  Though Tthese can be helpful in early stages, by driving towards increased usage that will ultimately result in significant revenues, the HIE must have reasonable expectation the revenues will soon materialize. And of course, the quality of the services an HIE offers needs to be even with or above those of similar service providers within the community.

Development and deployment of value-added services within an HIE must consider the specifics of the community it services. The market for value-added services in each area should be examined along with the geographic reach and demographics of that community. Even though evaluating a prospective service can involve measuring its technical, operational and economic viability, that process is all for naught if that service does not fit the needs of the HIEs community.

Some value-added services an HIE can provide include payer eligibility and claim submission/inquiry, transcription and coding services, community-wide credentialing, authentication,  authorization and enrollment/screening services. Others may involve , quality reporting, patient access, community-wide analysis  and more.. In our next post, we’ll highlight some of these servicesone specific service, single sign-on, and explain why they’re its especially important to a sustainable HIE.

Although health information exchanges (HIE) play a crucial role in transforming the healthcare industry by enabling the systematic sharing of health-related information between disparate clinical systems and various organizations, or stakeholders, there is no magic bullet for long-term HIE sustainability. For HIEs, also often referred to as regional health information organizations (RHIOs), to achieve future sustainability, there are certian steps that have to be taken, steps that do not result in instant gratification.

First, it’s important to note that HIEs which rely heavily or solely on major grant funding face considerable sustabinability issues. While grants can play an important part in the start-up or initial stages of an HIE, this funding is usually given all at once or only available during a specific period of time. Grants allow organizations to pursue implementation without establishing a self-sustaining revenue model up front. As a result, such HIEs must be prepared with a solution for when the grant money runs dry.

Second, if an HIE is to be sustainable, a framework that is centered on what its stakeholders value is necessary. This requires community participation and effort by the stakeholders as they address issues that could affect the HIE. For most organizations, a successful HIE allows relevant healthcare data to be available when and where it is needed. It must not only contribute to improved patient care and safety but also assist in reducing the time and costs of delivering healthcare for it stakeholders. An HIE that benefits patients by placing increased burdens on providers is ultimately unsustainable. The HIE must also deliver significant benefits to providers, both large and small, to encourage participation.

Third, being able to measure the return on investment, or ROI, by stakeholders and the community in general is a necessary step in creating a sustainable HIE. By demonstrating sufficient value, both existing and potential, in the early stages of an HIE, those funding it are able to see its inherent value and benefits. Adding a consistent review process to measure its success both financially and clinically allows those invested in an HIE to realize the need for continued involvement, providing another step in sustainability.

Next, an HIE that is to remain sustainable for years to come must become a hub for healthcare related information. Ask the users of one of our customers, WNY HealtheNet. They will say they cannot remember how they got along without it. It has simply become a part of their daily life, and they cannot imagine going back to the “bad old days.” In addition, an HIE should offer value-added services, reduce administrative costs and facilitate reduced operational costs. It should become the central point for healthcare information for patients, providers and payers. In our next few posts, we’ll explain how offering value-added services alongside the clinical exchange can be used to fund the HIE, eliminating a dependence on grants.

According to a report just released by eHealth Initiative (eHI) titled “The State of Health Information Exchange in 2010: Connecting the Nation to Achieve Meaningful Use,” there is continued growth in the number of HIE initiatives and those which are operational. eHealth Initiative counts 234 active HIEs in the country as of July 27, 2010, and those operational initiatives are currently transmitting data that is being used by stakeholders.

Even as HIEs have been shown to improve healthcare and lower costs, implementing a business model which highlights the need for funding from stakeholders who obtain value and benefits using technology to share health information among key healthcare providers is critical. HIE developers must know what participants expect to receive from the exchange. Especially for those organizations not reliant upon grant funding, sustainability is an attainable goal for HIEs as more and more organizations are providing services to patients and providing access to patient data through them.

1. Built to Last: Successful Habits of Visionary Companies by Jim Collins and Jerry I. Porras
2. Good to Great: Why Some Companies Make the Leap… and Others Don’t by Jim Collins
3. In Search of Excellence : Lessons from America’s Best-Run Companies by Thomas J. Peters and Robert H. Waterman

I’m very glad that Mr. Rosenzweig bothered to do it. I read “Build to Last” several years ago and it immediately struck me a pile of bovine manure and, yes, it’s easy for me to say in hindsight. You see, I’m a former scientist and the main argument of these books is logically similar to this:

1. Start tossing coins.
2. Discard all the tails.
3. Claim that coin toss produces heads.

And that was just a start. If I dared to present something like this at any scientific forum or journal, I would be laughed off the podium and never allowed to speak again. Yet, Messrs. Collins, Porras, Peters, and Waterman have managed to build a nice cottage industry out of their respective delusions.

Phil Rosenzweig has many more insights into the fallacies of these books, but the most crucial idea is simple: they tell compelling stories we’d like to hear – similar to motivational speeches – and we suspend our critical thinking in awe. The actual facts produced by the scientific methods are far less glamorous, but much more honest: we simple do not know the recipe for success and our chances of finding out are slim given the complexities of the business world. There are some subtle hints, though.

So, I’m now a big fan of Mr. Rosenzweig now and I highly recommend this book.