That may no longer be the case—both semantically and operationally—as the current buzz phrase for much the same thing as a RHIO is the health information exchange/organization, or HIE/HIO. And the federal emphasis, based on dollars, at least, is now on a program to subsidize the adoption of EHRs and their “meaningful use.” Information exchange is just one of several meaningful-use criteria.
But the same basic problems that beset those early RHIO pioneers remain unsolved for many HIE participants today, according to a newly released study of the commercial IT systems used by HIEs. The survey was conducted by health IT market watcher KLAS Enterprises, Orem, Utah.
Problems with governance, privacy and security date back to the days when the term RHIO was still in wide use, but those same problems were the barriers to HIE development most often cited by participants in the KLAS survey.
Lack of a coherent business case for HIE was the No. 2 most often cited barrier in the survey, a problem that also is at least a decade old. Variability in data standards remains a persistent constraint, the survey participants said. And now, the American Recovery and Reinvestment Act of 2009—the stimulus law that aims to provide some money to promote health information exchange but many billions more for direct EHR subsidies to providers—has given pause to some would-be HIE developers, according to the survey.
Not surprising, then, that HIE software adoption has not been what one could call rampant.
“I was surprised how skinny it was—a mile wide and an inch deep,” said Jason Hess, general manager of clinical research at KLAS and the lead author of the 132-page report Health Information Exchanges: The Reality of HIE Adoption. The survey was based on interviews conducted between July and October of 2009 of users of commercial HIE software at sites where data are actually being exchanged. Hess said he was “surprised how few of these were live,” an indication that the market for commercial HIE products “is still immature.”
Not surprisingly, then, KLAS researchers found the HIE market to be diffuse.
Hess and his fellow researchers found 89 HIEs powered by technology from no fewer than 22 different commercial firms. KLAS did not include in its survey HIEs using home-grown technology or systems that provide interoperability between hospitals or medical groups within the same healthcare organization. KLAS did include vendor-centric exchanges in which different organizations are able to exchange information because they all use the same vendor's EHR system.
Only five vendors had a sufficient number of installations to qualify under KLAS methodology to earn a score, and only one of those five did not have an asterisk next to their score indicating that the data were so sparse that KLAS had “not a lot of confidence” in the number, according to Hess.
“That puts the pressure on the vendors,” Hess said, to demonstrate to potential buyers of their software and services that they can actually provide what their salespeople claim they can do.
HIE system architecture falls in three main categories, according to KLAS.
Aggregated systems use a central data repository to gather and manage data from HIE participants. Records for a specific patient are queried from the repository. Federated systems leave the data with the providers, but tag it and identify its whereabouts pursuant to calls to a centralized master patient index and record locator service. Hybrid systems do not commingle the data as does a repository, but store it in a central location on discrete servers for each of the HIE participants. Queries to a central record-locator service are pointed to the appropriate server where the data are stored.
Several vendors offer clients more than one architectural system, KLAS researchers found, but the market seems to be moving toward the hybrid model, Hess said.
Greg Miller, senior vice president of sales and marketing at Medicity, said he thought KLAS researchers “worked hard to get their arms around the market” and did a good job of identifying “all the different players,” but with increased focus on the stimulus law, the market has changed considerably since last summer. “It's a different animal,” Miller said.
He agreed only in part with the KLAS assertion that healthcare organizations are holding their fire because of uncertainty related to the stimulus law EHR subsidy programs.
Miller said there are “definitely two categories of organizations out there."
“There are those who are focused on doing the right things regardless” of the stimulus money, Miller said. “They know it's good for the physician and good for the community. They're not waiting around, waiting for things to happen, and they're not waiting for something to happen at the state level. They're controlling their own destinies.”
Miller added, “And then you have those others that are definitely driven by meeting the stimulus law requirements. There is a lot of analysis in the marketplace, looking at vendors and, in my sense, waiting on the final ruling on meaningful use, and then they're willing to buy."
The old adage “underpromise and overachieve” seems to be working for some vendors of HIE services, according to KLAS survey respondents.
In a survey section comparing realized benefits to expectations, 53% of all HIE participants said the exchanges provided benefits in terms of better and faster clinical decisions and diagnosis capabilities compared with just 19% who indicated that would be an expected benefit of the HIE. Similarly, 42% of survey participants said they saw benefits from sharing and viewing patient data compared with 32% who expected those benefits.
Laboratory orders and results were the most commonly transported data elements by the commercial HIE systems, exchanged by 93% of the exchange organizations surveyed, followed by medications, 83%; and radiology results, 81% (image sharing was done by just 29%); and records of patient allergies, 74%. After that, though, most HIEs begin running out of things they can exchange.
For example, only about half (48%) could move a complete record summary in the Continuity of Care Record or the Continuity of Care Document formats, according to the survey.
KLAS chose participants by asking all known vendors for lists of all of their customers with live sites. Then KLAS called on all 89 of the customers to verify that they were in fact customers and were using the systems to exchange data between unrelated healthcare organizations.
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