Shortchanged exchange

As the adoption of electronic health-record systems among hospitals and office-based physicians skyrockets, electronic health information exchange is ready to take off too, fueled by a growing consensus on data transmission standards and protocols and market demands, according to industry experts.

Even so, a sizeable segment of the healthcare industry is likely to remain shortchanged on both full-featured EHRs and full-bodied health information exchange, at least in the short run, in large part thanks to Congress.

The American Recovery and Reinvestment Act, which Congress passed in 2009, created the Medicare and Medicaid EHR incentive payment programs that will spend an estimated $27 billion. That money is limited to acute-care hospitals, office-based physicians and a select group of other healthcare professionals. For them, EHR adoption rates are soaring, boosted by $3.1 billion in payments so far. Roughly 70% of hospitals and better than 1 in 4 office-based physicians have registered with the programs.

Congress, however, excluded from the EHR incentive programs thousands of long-term-care, home health and behavioral health organizations where, according to the National Governors Association, more than 10 million Americans receive care, but where IT use has been dubbed “rudimentary.”

Congress also blessed the Office of the National Coordinator for Health Information Technology with funds “to support regional or sub-national efforts toward health information exchange.” The ONC has allocated more than $548 million to states, territories and the District of Columbia to set up health information exchanges. But only $6.8 million in additional challenge grants was targeted to improve long-term care and post-acute transitions in four states.

In February, the ONC and the CMS released proposed rules for the EHR program that included new requirements on health information exchange.

“We can't wait five years for interoperability and exchange,” says ONC chief Dr. Farzad Mostashari. “We need to move ahead with ‘good enough' standards and we have good enough standards now for transport. I expect to see a hockey stick curve for exchange, just as we've seen for adoption.”

Dr. Leslie Lenert, professor of medicine and biomedical informatics at the University of Utah School of Medicine in Salt Lake City, says the feds took a wrong turn on exchange.

Lenert authored a controversial article, “Shifts in the architecture for the nationwide health information network,” published in the March issue of the Journal of the American Medical Informatics Association. In it he postulates that in 2009, federal IT policy shifted away from an emphasis on not-for-profit, regional health information organizations, or RHIOs, as the chief facilitators of electronic records-sharing. Now, Lenert says, RHIOs are just one of many exchange alternatives that include state exchanges, private networks and one-to-one communications between providers using the ONC developed Direct protocol.

By promoting many alternatives, Lenert says, the feds undermine RHIOs, whose mission includes serving as public utilities, extending connectivity across communities, even to organizations that can't afford to pay for it.

“Premature retiring of the RHIO model through shifts in funding and increased competition from private data exchange networks could result in serious long-term loss of the community-level functions that are critical to the delivery of high quality, cost-effective care,” Lenert writes.

His conclusions were challenged in critiques posted by several IT experts in a lively volley of more than 110 comments on GooglePlus, including responses from Arien Malec, a vice president at RelayHealth, a health information exchange software developer and a McKesson Corp. health IT subsidiary. Malec previously headed several interoperability projects at the ONC.

Malec likened many RHIOs to “rent-seeking” monopolies.

“If you are starting a RHIO and your sustainability model is not based on adding value to your customers, but on extracting monopoly rents on the services your customers are asking for and using those monopoly rents to provide services that your customers aren't asking for but you think they should want, you will fail,” Malec says in one of several posts.

So, where does that leave long-term-care providers in the federal exchange policy scheme?

Claudia Williams, director of the ONC's State Health Information Exchange Program, in a co-authored article on exchange policy published this month in Health Affairs, writes that the ONC “seeks to leverage exchange activity while addressing the gaps and unintended consequences of a market-based approach.” In an interview, Williams says the ONC will be leaning not on mandates, such as requiring providers to join a RHIO as part of meaningful use, a Lenert recommendation, but on payment reforms, to achieve widespread exchange.

“In the context of payment reform, you can't get to the goals without HIE,” Williams says. “It's going to naturally evolve.”

According to the American Hospital Association, there are 15,000 skilled-nursing facilities in the U.S., 10,400 home health agencies, 1,200 inpatient rehabilitation facilities and 430 long-term acute-care hospitals. More than 10 million elderly, disabled and developmentally disabled Americans use long-term-care services, which constitute 32% of state Medicaid budgets, according to the National Governors Association.

And yet, “clinical data with long-term-care providers is often fragmented due to antiquated record systems that collect only a portion of a patient's health information,” according to an NGA brief on IT integration in long-term care.

The headline of another article in the March issue of Health Affairs, “Hospitals ineligible for federal meaningful-use incentives have dismally low rates of adoption of electronic health records,” tells their IT story.

According to its authors, whose work was based on a 2009 AHA survey, while 12% of ARRA-eligible acute-care hospitals had at least a “basic EHR,” among ARRA-ineligible organizations, just 6% of long-term acute-care hospitals, 4% of rehabilitation hospitals and 2% of psychiatric hospitals had basic EHR systems. No more than 2% had full-featured, “comprehensive EHRs” and “very few” had the IT capacity to meet federal meaningful-use standards under the ARRA.

Congress excluded long-term-care providers from the ARRA “primarily because of funding constraints and uncertainty about their readiness to adopt EHR systems,” the authors say. But ignoring these providers' IT needs will have negative “spillover effects,” they say. “If large segments of the healthcare system remain paper-based, then investments to support EHR adoption and use by eligible hospitals and physicians might not produce the expected quality and efficiency gains.”

There is no similar, current, nationwide survey of EHR adoption in nursing homes, according to Michelle Dougherty, director of research and development at the AHIMA Foundation, which acts as the convener of the annual Long-Term and Post-Acute Care Health IT Summit.

The common perception is that long-term care is totally bereft of IT, “and that's not the case,” Dougherty says. Most nursing homes and home-care agencies have some electronic record-keeping capability to compile and file electronically minimum data sets and outcome and assessment information reports with the CMS, she says, while many “are expanding their repertoire” to include clinical systems. Meanwhile, ONC-funded challenge grant programs are making some progress in connecting hospitals with nursing homes and other long-term-care and post-acute providers, she says.

In its recent proposed rule, the ONC asked for public comments on whether it would be “prudent” for it to approve testing and certification programs—as it does with such programs for EHRs for ARRA-eligible providers—for IT systems for ARRA-ineligible providers in long-term care, post-acute and mental and behavioral health, or leave such testing to the private sector.

Last year, the not-for-profit Certification Commission for Health Information Technology launched its own testing and certification programs for IT used in long-term care and behavioral health. So far, however, only handful of vendors have sought certification, according to C. Sue Reber, a CCHIT spokeswoman.

David Whitlinger, executive director of the New York eHealth Collaborative, which oversees New York's ARRA-supported statewide health information exchange, says he's all in favor of federal support for testing and certifying systems in the long-term-care market where IT capabilities are “rudimentary.”

“Anything that the government can do to set the bar on standards in interoperability is a good thing,” Whitlinger says.

The Colorado Regional Health Information Organization, one of the four ONC challenge grant recipients, seeks to connect its 18 member hospitals statewide with 160 long-term-care providers in four target communities, says Phyllis Albritton, CoRHIO's executive director.

Only a few of CoRHIO's targeted long-term-care providers have EHRs, Albritton says. Most will access hospital data through CoRHIO's package of Web-based services, where “they can share and view all the information they need,” she says. “The discharge summary, immunizations, lab test, notes are all available.”

“We went live a couple of weeks ago,” says Scott Buck, a Pueblo, Colo.-based registered nurse and branch director of home health provider Gentiva Health Services, which serves 150 patients a day in Pueblo, and was CoRHIO's first long-term-care customer under the challenge grant. Gentiva also added a CoRHIO connection in its Colorado Springs office and plans to link its Denver office soon.

“We've always been able to get a history and physical,” Buck says, but now, “there is so much more—a lab report, a radiology report, whether they've had a swallow study, a supplemental report that really rounds out what happened to a patient in a hospital.”

According to Buck, Congress missed an opportunity by not providing IT incentives to skilled-nursing providers.

“I think a lot of what happened was the legislators didn't understand healthcare,” Buck says. “When you think healthcare, you think hospital. You think doctor—even though home care costs less. One day in the hospital can cost you more than 60 days on home health. I think this is the track that this has to go. We have to get strongly into the care-transition process.”