HIEs Are Not Just for EHRs Anymore

Connecting HIEs with a “Universal” PHR

Robert Rowley, MD, Healthcare and health IT consultant, practicing family physician

Health Information Exchanges (HIEs) are hubs where different parts of the healthcare system can exchange information with each other. Doctors can communicate with other doctors, with hospitals, with labs, etc. Funding that encouraged the creation and maturation of HIEs were part of the 2009 American Reinvestment and Recovery Act (ARRA), just like Meaningful Use was also a part of the 2009 ARRA legislation.

Initially, HIEs were conceived as being regional or statewide entities (which received seed money through the Office of the National Coordinator for Health IT, or ONC) where everyone would connect, and would create an envisioned Nationwide Health Information Network (NwHIN) Exchange. More recently, the NwHIN Exchange (or simply, the Exchange) has moved away from being an ONC product, and towards becoming a public-private partnership that will encourage its growth in the coming months and years.

Adoption of this envisioned Exchange has lagged for a variety of reasons, some for technical reasons (lack of adoption of true standards by which different health information systems could communicate), and some for business reasons. The business reasons have been more problematic – why should competitors in healthcare share information with each other?

Separate from the national attempt to create a universal network of health exchange, private and proprietary health systems have created their own internal hubs – so-called “private HIEs.” Such organizations, such as academic medical centers and their surrounding clinics and doctors, or Accountable Care Organizations, have a compelling business reason for exchanging data – they need to provide efficiency and high quality and cost savings in order to stay afloat. And these “private HIEs” use the same kinds of technology that “public HIEs” use. In fact, software companies that build technology to support HIEs (there are about 20 large vendors, and a myriad of small startup companies with technologies in the connectivity space) have noted the greatest growth in their installation base among private HIEs.

Challenging the premise behind HIEs
HIEs were conceived as hubs for connecting health care providers. They were meant to attach doctors’ and hospitals’ Electronic Health Records (EHRs) to each other, and to outside services like labs. The business models for HIEs are provider-centered, just like the technologies are.

However, we are now entering an era where a new kind of patient-facing technology is emerging. A new generation of stand-alone, yet universally connected Personal Health Records (PHRs) is starting to take shape. This is something a consumer can sign up for directly, and which contains intrinsic value on its own, while being able to connect to physician EHRs upon patient-initiated request (as opposed to the doctor-initiated push-out of tethered PHRs which has been the paradigm heretofore).

This new kind of “universal PHR” is something we are seeing emerge. A number of startup companies are converging on this vision, and are moving in this direction from a variety of approaches. The key, of course, is the ability to connect with the doctor’s EHR system.

Many – arguably, most – EHR companies are focused on their physician (or hospital) facing technology. Their PHR portal is a side-line of their core technology, and often one that is fairly primitive. Much of the functionality of the EHR-based PHRs is required for ONC certification for Meaningful Use, while some of it is market-driven. The niche of an independent fully-functional PHR connecting from the outside to an EHR, driven by engaged and motivated patients (by definition), can be a compelling proposition.

But does that mean there should be integrations with several hundred EHRs? Probably not. Direct connection with EHRs may be a bit simpler, mainly due to the market status of the EHR vendor community. Of the 558 vendors who created 949 products (modular and complete) on the Certified products list (CHPL), 70% of the market was served by 12 vendors; 30% of the market were served by 272 vendors, and 295 vendors had products that were used by nobody for 2011 Meaningful Use attestation.

But, beyond direct connection with EHR vendors, perhaps there is a better path, or at least a concomitant path: connect with HIEs. Both private HIEs, which exist now, and regional HIEs, which are starting to evolve and emerge, could be the more effective way for an independent, patient-controlled PHR to connect with their doctors.

Something to ponder. The kinds of connectivity needed would allow the “universal PHR” to have the kind of function that a tethered PHR has – download of problem lists, medications, allergies, immunizations, and even two-way secure email routing between the patient and the doctor.

The “universal PHR” space is still in its early stages of emergence. And leveraging the connectivity technologies that have grown up around HIEs can be an effective way of connecting engaged consumers with their doctors. This should be an exciting area to track.

Robert Rowley is a practicing family physician and healthcare information technology consultant. From its inception through 2012, Dr. Rowley had been Practice Fusion’s Chief Medical Officer, having created the underlying technology in his own practice, and using that as the original foundation of the Practice Fusion web-based EHR. This article was first published on Dr. Rowley’s web site www.robertrowleymd.com.