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Peeling the Layers of the Onion Around HIE Policy, with Julia Adler-Milstein, Ph.D.

August 1, 2016
by Mark Hagland
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Dr. Adler-Milstein offers a healthcare policy researcher’s perspectives on HIE development

Earlier this month, HCI Editor-in-Chief Mark Hagland wrote a blog analyzing two articles about health information exchange (HIE) that had appeared in the July issue of Health Affairs. The two articles are entitled “The Number of Health Information Exchange Efforts Is Declining, Leaving The Viability Of Broad Clinical Data Exchange Uncertain,” authored by Julia Adler-Milstein, Sunny C. Lin, and Ashish K. Jha; and “Engagement In Hospital Health Information Exchange Is Associated With Vendor Marketplace Dominance,” by Jordan Everson and Julia Adler-Milstein.

As referenced in the blog, the way in which HIE is described in the first article is as a fairly fragile phenomenon in the wake of the loss of most federal and state funding in the past two years—something that has been widely known—with a strong need for operating HIEs to prove strong market value (though that term is not used) in order to survive. Meanwhile, the second article looks at the issue of intense market dominance by a few large electronic health record (EHR) vendors, and its strong impact on how HIE is pursued in markets in which a single vendor dominates. The authors of the second article did make it clear that the impact of market dominance on the part of the Verona, Wis.-based Epic Systems Corporation is quite different from that of market dominance on the part of any of the other largest EHR vendors—the Kansas City-based Cerner Corporation, the Chicago-based Allscripts, or the Westwood, Mass.-based Meditech.

As a follow-up to the publication of the blog, Julia Adler-Milstein, Ph.D., the co-author of both articles, spoke recently with Hagland recently, to discuss some of the implications of the two articles at this moment in the ongoing evolution of the HIE phenomenon. Dr. Milstein is an associate professor at the University of Michigan, with appointments in both the School of Information and the School of Public Health. in Below are excerpts from that recent interview.

Reading both Health Affairs articles carefully, I came to the unmistakable conclusion that there is no ideal “silver bullet”-type solution for fixing all the challenges facing the HIE phenomenon. Whatever we do, we’re trying to make the best of what was not an optimal seedbed for HIE development to begin with, correct?

Yes, I definitely agree. Now, if I put on my policy hat, from a policy perspective, I would ask, what was the market likely to under-invest in? And it was pretty clear from the start that HIE was not something that the market felt it needed to invest in. So it seems like that is the place where we should have started doing the most policymaking around. We started doing the most policymaking around EHR, but it really should have been the opposite. I think it should have been much more on interoperability and not as much around EHR adoption. We put so many eggs in the EHR adoption basket, and so few into interoperability, so now we’re having to catch up.

Julia Adler-Milstein, Ph.D.

And because of the diversity of HIEs, it makes it that much more difficult to give good policy guidance?

Yes. I think running an HIE is one of the most difficult things to do. The governance, the technology, the business processes, and the workflows, are all too diverse. And the problem is not well-defined. Are we really envisioning that every piece of data can be shared seamlessly with every other piece of data? We’ve never defined the endpoint. I don’t think HIEs were ever going to get to that seamless interoperability. But there remains that fundamental problem of what we want to get to at the end of the day. We let ourselves think that we’d get there by having everyone share everything with everyone. But that was never feasible. But we never had the discipline to say, OK, what is feasible, and where can we reach consensus?

If you were the federal HIE fairy, and you could just wave a wand, what ideal things would you make possible, from a policy standpoint?