Federal efforts to promote state health information exchanges has resulted in some gains, yet adoption and use varies heavily by state and many opportunities to expand remain, according to a recent report commissioned by the Office of the National Coordinator for Health Information Technology (ONC).
The Health Information Technology for Economic and Clinical Health (HITECH) Act provided $564 million to ONC to enable rapid development of health information exchange (HIE) across the nation. Through the State Health Information Exchange Cooperative Agreement (State HIE), organizations in all 56 states and territories received funding during the four-year program.
The State HIE Cooperative Agreement Program funds states’ efforts to rapidly build capacity for exchanging health information across the health care system both within and across states. Awardees are responsible for increasing connectivity and enabling patient-centric information flow to improve the quality and efficiency of care. ONC funded NORC at the University of Chicago to conduct a multi-year program evaluation to obtain a comprehensive understanding of the planning, implementation, operation and impact of the program.
The recent report reflects NORC at the University of Chicago’s independent program evaluation of the State HIE from 2011 to 2014. The evaluation focused on three aims—characterize the approaches taken to enable HIE and how they evolved over time; characterize HIE levels at baseline and how they changed over time and assess overall program effectiveness.
As part of its evaluation, NORC measured HIE activity. Acute care hospital participation in directed exchange increased from just over 124 to just under 938 in 2013, while participation of ambulatory entities increased from 4,500 in 2012 to 21,000 in 2013.
The number of acute care hospitals participating in query-based exchange increased from less than 400 in 2011 to 2,000 in 2013 (nearly a threefold increase), while participation of ambulatory entities increased from 2,200 to 8,800 (a fourfold increase). In addition, 67 percent of clinical laboratories reported the capability to send structured laboratory results electronically in 2012, again with significant variation across states, the report stated.
“Although these numbers represent considerable growth, national averages of participation were driven by a small number of top performing states, rather than by high participation across all states,” the report authors stated.
NORC also developed a composite HIE score and the report authors stated that results “showed positive change on multiple dimensions.”
The national composite HIE score increased from 36 to 79 percent from 2010 to 2014—an increase that was reflected in each of the seven measures making up the composite.
“In 2014, the level of HIE activity ranged from 51 percent (Nevada) to 97 percent (Minnesota). The gap between hospital-to-hospital and hospital-to-ambulatory care provider exchange also narrowed over the period—by 9 and 13 percentage points, respectively, for clinical care summary and laboratory results exchange,” the report authors wrote.
“Together, these results indicate a positive trend in HIE adoption and use, across the program years, states, and multiple services. Nonetheless, adoption and use varies heavily by state and many opportunities for expansion remain,” the report authors wrote.
On the issue of sustainability, the report authors noted that the State HIE program catalyzed HIE through a substantial, one-time infusion of funds and “many factors will contribute to the sustainability of HIEs services, whether state-led or otherwise—including diverse stakeholder engagement, a flexible infrastructure, continued marketing of benefits and clear and consistent policies and regulation.”
Grantees expressed concerns about the financial sustainability of their HIE efforts and seven grantees are no longer operational, the report noted. “Long-term sustainability requires that grantees seek out new financial contributors, including payers, ACOs and long-term care providers, and offer them reasonably priced services that address their needs and priorities for exchange,” the report authors wrote.
The report also outlines a number of efforts needed at the state and federal level to continue to support HIE adoption and use. The role of state leaders should include leadership and coordination, particularly in convening stakeholders, and engaging in future HIE efforts through Medicaid and social services. The federal role includes crucial guidance around HIE governance and technical standards and strong leadership and support for interoperability, among other recommendations.
The report authors also noted that HITECH funding, including awards made under the State HIE Program, created and expanded HIE-related infrastructure—both in the technical sense of services and infrastructure and in the legal, governance, consent, and policy structures to support it. “This HIE infrastructure is now available and delivery system reform efforts are likely to leverage it. Our evaluation findings demonstrate that there is no one-size -fits-all solution with HIE; instead, development and use of HIE is predicated on the state and local environments within which it exists.”
That said, certain factors influence HIE and are helping some states gain traction, the report authors stated.
For instance, the report authors concluded from the evaluation that states with state-led HIE had significantly higher composite HIE compared to states where State Designated Entity (SDE) or SDE-like entities led HIE efforts. “For example, both Minnesota and Oregon are state-led efforts with high composite HIE scores. They used a ‘thin layer’ strategy for central services and focused on connecting HIOs and filling ‘white space’ areas with little to no connectivity,” the authors stated. “Consistent with our qualitative findings, state-led efforts were able to leverage existing infrastructure and state finances, and benefitted from their capacity to create HIE-supportive policies and bring together public and private stakeholders in a neutral way.”
The report authors also note that many State HIE fund grantees enacted legislation to promote HIE participation, electronic health record (EHR) adoption, or both. The report cites Minnesota specifically for enacting the 2007 Interoperable Electronic Health Record Mandate requiring all providers to use an EHR system by 2015, while the 2010 Electronic Prescribing Mandate, which became effective in January, 2011, required all providers, group purchasers, prescribers and dispensers to establish, maintain and use an e-prescribing drug program.
“These factors and exemplar states may serve as lessons learned for health information organizations (HIOs), grantees, and state and federal policy makers interested in continuing HIE development,” the report authors concluded. “Throughout the program, grantees overcame many challenges to HIE, and new challenges emerged in the process. Some states were more successful than others in navigating these challenges and in enabling exchange. Though not all such challenges have been resolved, there is now more HIE capacity than before the program, as well as a path forward toward greater data liquidity for both exchange and interoperability.”