Evaluating health information exchanges

Imagine that you are hundreds of miles from home and you need medical treatment. When the nurse asks for your health history, you might be able to rattle off a list of your current medications and major allergies, but when they start probing more deeply (What doses of the medications do you take? What were the results of your last blood test?), you’re stumped.

If both your primary care physician and the health care provider treating you out of town—or even just the specialist you might see next door—participate in the same health information exchange (HIE), pulling up your complete medical history would be easy. And with government incentives making it almost imperative to do so, most providers have moved to electronic health records. In theory, this should make electronic sharing of patients’ medical charts seamless, but it’s not that simple.

Health systems, which are groups of hospitals, physician groups and other health care providers, are developing their own “enterprise” HIE systems for use by their affiliated network providers. Community HIEs, on the other hand, are similar but they are open to everyone and facilitate information sharing among a broader group of providers within a region or state, leading to more dispersed benefits to all participants, the community and patients.

“You can think of it almost as UPS versus the post office,” said Bita A. Kash, PhD, MBA, associate professor at the Texas A&M Health Science Center School of Public Health. Enterprise HIEs might be better populated with relevant patient information, according to research published recently in The Milbank Quarterly by Kash and a co-author, Joshua Vest. They interviewed 40 policymakers, community and enterprise HIE leaders and health care executives to help them understand and analyze the differences between the two systems.

“The community HIE is a public good,” said Kash, who is also director of the National Science Foundation (NSF) Center for Health Organization Transformation (CHOT) at the Texas A&M Health Science Center. “The enterprise HIE is more of an enterprise strategy tool.”

And just like it has done for the post office, the United States federal government has invested millions in community HIEs. However, most of the people Kash and Vest interviewed preferred their own proprietary version. “There are just fewer barriers to developing an enterprise HIE,” Kash said. “It takes priority because health systems have complete control over their enterprise HIE and the information is pretty perfect, while the community HIE only adds value when there are patients outside the network to be tracked, and so that’s not really their first priority.”

Smaller hospitals and community providers without resources to build their own enterprise HIE are more motivated to participate in the community HIE, which is a good thing, Kash said. “The purpose of the information exchange is to provide better care for all patients, especially those who travel from provider to provider,” Kash said.

Both approaches face challenges due to vendor costs, patient consent and technology that doesn’t tend to work universally, and although—in theory, at least—they can be complementary, community and enterprise HIEs compete for providers’ attention and organizational resources like time, skilled staff, and money. “Right now, there are no incentives for the enterprise HIE and the community HIE to work well together,” Kash said. “For the community HIE to work well, you need competing hospital systems to be willing to make information sharing a priority because ultimately it’s better for the public and better for you as the patient.”

The sustainability of a community HIE, potentially a public good, may necessitate ongoing public funding and supportive regulation. Kash said that one potential use for community HIEs will be in tracking readmission to any hospital after being discharged from one hospital. Reducing these so-called avoidable re-admissions is linked to the government’s payment to the hospitals, which may make community HIEs a better value proposition for competing health systems in the near future.

“As a patient, I think I would feel better to have my chart with me at all times,” Kash said. “And technologically we can do that today.”