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A Hybrid Approach

July 20, 2011
by Jennifer Prestigiacomo
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Health Information Exchange Pioneers are Mixing and Matching What Works to Address Individual Data and Services Challenges

EXECUTIVE SUMMARY:

Industry experts and HIE leaders have moved past early “model”-based debates to focus on creating core and value-added services, standardizing the meaning of the clinical data, and simplifying point to point connections necessary for information to flow between the HIE and providers EHRs.

The times are changing in the health information exchange (HIE) world, and changing fast. While the discussions of even two years ago tended to center around “model” issues-in other words, which technical architecture (central repository, federated, or hybrid) to adopt, the conversations have since morphed. Now, they are focusing around which infrastructure in any particular situation might best support core and value added services, which services stakeholders need that will also sustain the exchange's business model, how best to standardize the meaning of clinical data to produce usable analytics, and ultimately, how best to get that data to flow from the HIE to providers' electronic health records (EHRs).

What's more, say those who've been tackling the challenges of HIEs, one thing is certain: no one solution fits all.

Back in the 1990s, when provider organizations were creating the first-generation connectivity collaborations called community health information networks (CHINs), early discussions focused on clinical data ownership, breach responsibility, and which technical architecture to adopt. Patrick Rossignol, principal, technology, Deloitte Consulting (New York), remembers two distinct camps emerging years ago-those claiming a federated model wouldn't work because queries took too long to execute; and those claiming a central repository proved too costly and insecure. Other questions began to emerge pointing to organizations' varying comfort levels for sharing and pooling data, and disagreements around how much, if any, data should be comingled in the center, Rossignol says.

CORE AND VALUE-ADDED SERVICES

What has been learned by many in the industry, especially since the December 2006 demise of the Santa Barbara County Care Data Exchange, is that regardless the technical infrastructure, each HIE service must have a value proposition to benefit participants' bottom line. In the last year, HIE vendors Axolotl (San Jose, Calif.) and Medicity (Salt Lake City), have been purchased by analytics companies, United Health Group's OptumInsight (Eden Prairie, Minn.) and Aetna (Hartford, Conn.), respectively, which proves the market is looking to HIEs to not just exchange data, but to produce analytics, Rossignol says.

The Office of the National Coordinator for Health Information Technology (ONC) has given guidance to state HIEs to offer providers at least one way to meet meaningful use (MU) requirements and solve concrete problems, such as lab interoperability, with operationally viable strategies. Core services, such as provider directories, security services, enterprise master person indexes (EMPIs), and record locator services, are key to the success of an HIE, says Greg DeBor, partner of the Falls Church, Va.-based, CSC Health Services. Value-add services like e-prescribing, medication reconciliation, medication history, continuity of care document (CCD) exchange, and immunization registries are also being discussed as essential for long-term HIE sustainability.

It's important to have an open process with all stakeholders when establishing HIE value propositions, says Gina Perez, president of Advances in Management, a Dover, Del.-based consulting firm, and former executive director of the Delaware Health Information Network (DHIN). She adds that the specific healthcare environment needs to be analyzed, and from those needs a technical environment to support value propositions should be chosen. Perez says that any value-added functionality must support provider goals and enhance sustainability.

Devore Culver
Devore Culver

DHIN chose a measured approach to providing services, focusing on basic services and provider adoption first, before adding value-added services. “A good many years were spent just on developing consensus around what the initial services were going to be,” says Jan Lee, DHIN's executive director. Phase one services were delivering lab results and Admission, Discharge, Transfer (ADT) summaries to providers to reduce the cost of results delivery. Provider query has since been added.

CENTRAL VS. FEDERATED] WAS A BIG DEAL TO PEOPLE A FEW YEARS AGO, BUT THEY'VE MOVED BEYOND THAT. A LOT OF PEOPLE REALIZED THAT EVERYTHING IS HYBRID. - GREG DEBOR

Gina Perez
Gina Perez

DHIN project manager Melissa Macolley notes that this long-term strategy of adoption over functionality was partly based on her belief that HIEs have only one chance to roll out a product correctly or risk losing stakeholder confidence and utilization. She says “quality over quantity” has been DHIN's motto from the start. Proof of its adoption efforts, DHIN has garnered 75 percent of Delaware hospitals and 80 percent of providers as members, as well as having brought two of the largest laboratories in the state, LabCorp (Burlington, N.C.) and Quest Diagnostics (Madison, N.J.) onboard. By the end of this fiscal year, Lee hopes that 80 to 90 percent of hospitals, several radiology groups, and major health plans will be DHIN financial contributors. DHIN also plans to roll out value-added services that align with MU requirements like public health immunization reporting, medication history, and CCD exchange.

Selecting a vendor that has a variety of core services was an important early step for the Kansas Health Information Network (KHIN), says Laura McCrary Ed.D, KHIN's executive director, since her state has providers in different stages of EHR adoption. KHIN sought a vendor that had a portal for practices that were still paper-based, an EHR-lite product for organizations that would not be implementing full EHRs, and functionality for organizations with EHRs. Over time as stakeholders' needs emerged, more products like secure clinical messaging were rolled out. “We need to be able to provide to our stakeholders the ability to connect through the Direct Project (for more on this, see page 14), so we asked our vendor to make sure we had a Direct product that we could roll out also,” adds McCrary.

TAKING A HYBRID APPROACH

Many in the health IT industry are seeing the technical architecture issue shifting from being less of a black and white issue to more of a gray one, as many HIEs are finding hybrid architectures suit their needs for core and value-added functionality. In a hybrid model, each organization manages its data separately, with some data physically stored and managed in a central location that allows for analytics and population health management. “[Central vs. federated] was a big deal to people a few years ago, but they've moved beyond that. A lot of people realized that everything is hybrid,” says Greg DeBor, who is one of the founders of the New England Healthcare Exchange Network (NEHIN). “Today, the more useful constructs are talking about core and value-added services you want to have in the middle and that determines your degree of centralization.”

Rossignol agrees that the industry has moved “much more towards a centralized hybrid model,” and toward focusing on data analytics and population management activities using de-identified patient data. “I believe the balance is going to accelerate toward a hybrid model that will at least offer you a good equilibrium of the need to ensure privacy and the need to have access to enough data to have analytics,” he says.

Of course, a minority of those developing HIEs still believe that a centralized model offers the best architecture for information exchange. “Inherently flawed in the federated model is the ability to accomplish some very core value-based missions,” says Devore Culver, executive director of HealthInfoNet, Maine's statewide HIE. One of those missions is disease reporting to public health, which can only happen if the data is centralized and standardized, Culver says. HealthInfoNet itself has grown from a five-year-old statewide claims database. Because of the value of that aggregated data set to public health and to the private sector, Maine leaders saw the importance of a clinical data exchange. After a request for information (RFI) with 36 vendors in 2005, Culver says it was evident that federated models couldn't provide the speed requirements needed for queries and reporting.

According to Jason Hess, general manager of clinical research at the Orem, Utah-based KLAS Research, the HIE market isn't mature enough to really assess which technical architecture best serves the needs of HIEs, as most are still struggling to stay viable and gain stakeholder buy-in. “I suspect that you're going to have HIEs running a federated model that, unless the vendor comes up with some unique hybrid angle on that, you're not going to be able to do some of the things you can do when you're aggregating data to some extent,” he says.

FOR BETTER OR WORSE THE WAY HEALTHINFONET WAS DEFINED FROM THE OUTSET, [STANDARDIZATION] WAS A COMMITMENT. I THINK THAT WILL BE FUNDAMENTAL AND CENTRAL TO THAT LARGER VALUE PROPOSITION. -DEVORE CULVER

Mark Allphin, research director at KLAS, adds that some vendors are banking on the centralized repository model to achieve their analytics goals. “A couple of vendors I've spoken with [say] they may support just the aggregated model specifically,” he says. “And for that reason they feel it will be more conducive to plug in an analytical piece and tools right on top of it and have all the data centrally organized.”

“We know it's not just about moving data around; we have to report out of [the HIE],” says Hess. “You have to have some kind of bringing together of that data to be able to do so, whether it's an aggregated model with comingling, or it's a hybrid.”

Pam Matthews
Pam Matthews

Pam Matthews, R.N., senior director, regional affairs, at the Chicago-based Health Information and Management Systems Society (HIMSS), recommends that HIEs focus on what services they will provide to customers and how this will translate into financial sustainability. Only then should they figure out the technical underpinnings needed for the HIE architecture, and in turn, what solutions need to be sought from a vendor. “Looking back, to me the successful RHIOs [regional health information organizations] out there really took the approach of what is the business model, what are the services provided, and built the technical architecture and strategy based on their business,” says Matthews. She adds that this is not a one-size-fits-all strategy; rather it's the HIE's goals, trust between participants, regional characteristics, and other factors, that will shape the architecture.

STANDARDIZING DATA MEANING

Laura McCray
Laura McCray

A major challenge for HIEs moving forward is standardizing the meaning of the data being shared so value-added analytics can take place, says Deloitte's Rossignol. He admits the industry has come to terms with standardizing data, like creating the CCD format, standardizing the transmittal of that data by using HL7, but still has much to do to standardize the meaning of the data. “As long as I don't have the meaning of the data defined that I'm agreeing to exchange, what it really means is that I am using a different nomenclature, which typically each system does, and the only thing I am really doing is exchanging free-text data,” Rossignol says. He advocates the need for conversations around national-level standards so semantic interoperability between organizations can be achieved.

HealthInfoNet's Culver believes the industry has a long way to go on standardization and that the vendor community has focused more on the transport protocol and less on standardizing data elements. “To me, until you do that you don't have true interoperability,” adds Culver. “For better or worse the way HealthInfoNet was defined from the outset, [standardization] was a commitment. I think that will be fundamental and central to that larger value proposition, because you can't do analytics if you don't standardize the data. You don't truly optimize the value of the data set unless you standardize it.”

CONNECTING EHRs TO A HIE

The best way to address the challenge of making point to point connections from providers' EHRs to a HIE is to be flexible to address the variety of scenarios that are out there, says KHIN's McCrary. McCrary says that many EMR vendors are just not there yet from a technical standpoint to be able to create a CCD, one of the requirements of meaningful use. To work around this issue, she says KHIN has been working with vendors to provide HL7 interfaces for large hospitals. “We have the additional problem that it's still difficult to deconstruct the CCD and take those unique data elements out to populate either someone else's EMR, or the immunization registry, or public health, so we're still in the process of creating the technology to actually take the CCD apart,” she says. “We're pretty confident we'll have this resolved by the end of this year.”

WE KNOW IT'S NOT JUST ABOUT MOVING DATA AROUND; WE HAVE TO REPORT OUT OF [THE HIE]. YOU HAVE TO HAVE SOME KIND OF BRINGING TOGETHER OF THAT DATA TO BE ABLE TO DO SO, WHETHER IT'S AN AGGREGATED MODEL WITH COMINGLING, OR IT'S A HYBRID. -JASON HESS

Phyllis Albritton, executive director of the Colorado Regional Health Information Organization (CORHIO), notes that health information exchanges should involve everyone in the community, even though the ONC has been primarily focusing on physicians and hospitals. She says CORHIO connects those two constituencies, as well as public health, long-term care facilities, behavioral health, and Safety Net providers. “We have to have the capacity to both support those with EHRs, as well as those who have nothing,” she says. Ideally, for those providers who have EHRs, viewing information from the HIE should be seamless, and for those with no EHRs should have access through a virtual health record or portal.

Following national data standards whenever possible, says Matthews, is the key when working with vendors to ensure reliable connections between participants and the HIE. Matthews does acknowledge there are many areas with no standards, so adopting established frameworks like IHE (Integrating the Healthcare Enterprise) profiles or HL7 will ensure interoperability. She also recommends that a HIE find out what standards its state is adopting, so it can align with these larger initiatives. Also, getting to know your state CIO is helpful for a successful outcome.

Currently, a national Multi-State/Multi-Vendor EHR/HIE Interoperability Workgroup is focusing on leveraging existing standards through a collaborative process to define consistent plug and play standards for connections between EHRs. Members include California, Maryland, Massachusetts, and New York, as well as vendors like Allscripts, eClinicalWorks, eMDs, among others. Down the line, the group seeks to implement a preferred vendor certification program.

Healthcare Informatics 2011 August;28(8):08-13


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