Networking and Health Information Exchange, Health Information Exchange

Audio Transcript

Slide 1
Welcome to Networking and Health Information Exchange, Health Information
Exchange.

This unit summarizes the networking standards and the standards required for
interoperability to enable the creation of Health Information Exchanges. Not surprising,
there are many approaches to creating an HIE and even differences to just what an HIE
should be. This unit provides some of those points of view, provides some examples,
and identifies some HIE programs that currently exist at some level or are being
developed.

Slide 2
The Objectives for this unit, Health Information Exchange (HIE) are to:
Understand the purpose and importance of a Health Information Exchange strategy,
Understand what an HIE is,
Understand the components of an HIE, and
Explore some examples of HIEs.

Slide 3
Health Information Exchange enables the interoperable linkage of healthcare
information across organizations within a hospital, an enterprise healthcare system, a
region, or a nation.

Slide 4
Issues of patient safety, effective and efficient care, quality care, lower cost care, and
appropriate care all require the aggregation of all relevant data from and about a
person, consolidated into a single real or virtual record the patient-centric EHR.

Slide 5
This figure graphically displays examples of settings that create data about a patient.
Each of the sites or settings in this example both push data into and pull data out of the
EHR. The timing of data exchange and the amount of data exchange depends on the
type of the site and the purpose of the interchange.

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the National Coordinator for Health Information Technology under Award Number IU24OC000024.
What is common and what is different among these sites of care? How do we
effectively put this package together?

A real patient-centric EHR brings the data together from each of the sources into a
single, physical record. This approach is called a centralized EHR. If the data is left at
the source and pulled whenever it is required, the result is a virtual EHR. This approach
is called a federated EHR. These two approaches will be discussed in a later slide.

It is likely that each institution will have an EHR that meets its specific needs. We refer
to that EHR as the Institutional-based EHR. Among other things, this EHR will be the
source of the management of the care of the patient, for reporting and auditing, and for
billing.

A nursing home, for example, will have an institutional EHR that will be different from
the EHR of a hospital. However, for interoperability, it is important that data elements
have the same coding and meaning and that they can be interchanged when necessary.
Complete interoperability does not exist at present. Consequently, data elements must
be mapped, often with a subsequent loss of information, between the different sites.

Slide 6
This slide shows much of the same idea, but creates a bigger picture of many of the
standards we have discussed in the previous lectures as well as introduces various
views of the EHR. All of the sites of care contribute to the patient data set, using the set
of standards that relate to data structure and data transport. That data in turn populates
the institutional EHR which should be provider-centric that is, its structure and
functionality support the workflow and use by the provider, users, and others. The
essential EHR is the name we use to identify the patient-centric EHR that represents
the aggregation of data across the sites. We suggest an additional constraint. This
Essential EHR contains only the data that contributes to a patients present and future
care. This EHR will contain data from the past but only as it relates to the present and
future care. The personal EHR is derived from the database but its focus is the patient.
The block labeled DATA is called different names, including a Clinical Data Warehouse
(CDW) or a Data Storage Repository.

The CDW is used for data mining to create new knowledge that is used with decision
support algorithms, clinical guidelines, care plans, and other tools. EHR functionality
standards are used to manage process workflow. Document standards are used for
reports, audits, billing, and other such data presentation. These systems must be built
from a public/private relationship as well as a vendor/provider relationship. Keys to
success are privacy, security, trust and integrity of the systems.

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Version 3.0/Spring 2012 Health Information Exchange
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the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Slide 7
Looking more closely at the data flow within an HIE, this figure illustrates data coming
into the aggregated EHR, for example, using an HL7 message. That message should
be encrypted. As the message is processed, the identifying data is stripped out and
stored in a more secure, sensitive storage. Key to correct aggregation of data into the
correct patient EHR is a unique, global person identifier, which unfortunately, does not
exist at the present time in the U.S. Instead the identifying demographic data elements
are used in an algorithm to try to guess the patients ID. The error rate is likely to be
around 10% or higher. For real security, the external identifier of the person is
encrypted in a double encryption algorithm that cannot be reverse decrypted and stored
in silicon to make it inaccessible to hackers. This new secure algorithm is included in
the aggregated essential EHR which is accessible to authorized parties, but is de-
identified. The identifying data, such as name, DOB, address, gender, race and such,
are included in the more secure area and are accessed only when necessary as part of
the direct care process, this backwards linkage is necessary for many reasons and
many occasions to communicate with the patient. Certain decision support algorithms
need to access this data, but the data would not have to be shared with a human.

Slide 8
First, lets discuss the model for the Essential EHR. There is an inherent fear that a
national health information interchange means that there will be a big database in
Washington DC, run by the US government, and any privacy will not exist. There are
even concerns at the state level. So, primarily for reasons of privacy and control on the
part of the institutions, the federated model has a lot of supporters. On the other hand,
there are problems with the federated systems. Perhaps the most serious is access to
that data in an emergency situation, such as Hurricane Katrina. Even with off-site
backups, new gateways would have to be identified. Further, the backup system is
unlikely to support the messaging functionality. Another concern is that the data would
have to be mapped and cleaned with each access, whereas in the centralized system,
the data would be already be mapped and cleaned. There are issues as to how long
data will be kept in an accessible state. With a federated system, each site would have
to deal with n (n-1) sites, where as in a centralized system, the link is always to one
system. The centralized approach offers better control of security and privacy, better
reliability, and better quality control.

Slide 9
What must exist to support an HIE?

Standards what we have discussed in this component,

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the National Coordinator for Health Information Technology under Award Number IU24OC000024.
 Infrastructure to support aggregation of data into a single patient record which
requires
Infrastructure to support a regional network
Infrastructure and linkage of regional networks to provide a virtual national network
A business case based on supported facts and includes a financial model that
balances rewards with costs
A workable process that permits us to reach the destination in doable chunks
Understanding and creating the necessary linkages among stakeholders
State efforts blended into a common process that will support interoperability among
states

Slide 10
An HIE must serve .
Real-time connectivity to provide appropriate and controlled access to aggregated
patient data.
Disease registries permit the monitoring and assurance of high quality care.
Research databases are derived for specific purposes and for specific periods of
time.
Reimbursement is derived from clinical data, ideally in real time.
Accreditation, credentialing and statistical reporting are derived products.
The data warehouse contains all data for legal and archiving purposes.
Support consumer driven healthcare
Mandatory reporting such as immunizations, Healthcare Acquired Infections (HAI),
etc.

Slide 11
Whats in it for the consumer?
Appropriate care is enhanced by a complete set of data about the patient, particularly
when combined with decision support,
Patient safety is enhanced by complete and timely data at point of care,
Effective and appropriate treatment, and
Patient satisfaction and trust is enhanced by a care giver who knows all about the
patient, without the patient having to remember and repeat a full medical history.

Slide 12
The following are also advantages for the consumer.
Personal health data that is timely and understandable by the consumer,
Understanding the importance and the significance of data,
Personal health plans,

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Version 3.0/Spring 2012 Health Information Exchange
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the National Coordinator for Health Information Technology under Award Number IU24OC000024.
 Understanding treatment options including the tradeoffs between risks of death and
quality of life
Manage the event flow related to health such as doctors appointments, drug
management, costs of care, and expectations of care, and
Provide encouragement for good health.

Slide 13
And continuing
People over the age of 65 have on average 3 or more chronic diseases. Disease
management means a higher quality of life as well as a longer life. Proper disease
management means complete data about the patient as well as having and using the
appropriate knowledge about the patient and the disease.
Proper management of health and constant monitoring of health extends independent
home living.

Slide 14
The first implementations of HIE were called Regional Health Information Organizations
(RHIOs). In some places, the name Health Information Exchange Organization (HIEO)
is used. They mean the same thing.

An RHIO is a Regional collaboration of multi-stakeholder organizations working together

to connect healthcare communities with the goal of improving quality of care, safety and
efficiency.

Typical objectives are to develop a community-wide health information exchange; to

create a healthcare portal with interoperable applications; to create a training and
support infrastructure to ensure adoption of applications, and to engaging payers in
programs that align incentives appropriately.

There were many models that were implemented, and most met with failure. Failure
was likely due to a misunderstanding of what the purpose of an RHIO should be. Some
people argued that a region could and should have more than one RHIO. So the clinic
on the right side of the street might be in one RHIO, and the clinic on the left side of the
street might be in a second RHIO. But the patient might be seen at both clinics, and
now we are back to the old problem of separate records. If the records were merged,
then why not have a single RHIO? There have been several successful RHIOs,
including Memphis, Indiana Primary Care Network, RedWoods in California and many
others.

Slide 15

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Version 3.0/Spring 2012 Health Information Exchange
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the National Coordinator for Health Information Technology under Award Number IU24OC000024.
There are really no boundaries that encapsulate the area of care for a population. If you
were to draw a boundary around the sites where a patient receives care, and one
around where the spouse receives care, the boundaries would be different. People who
live on a state boundary are likely to receive some care in one state and more care in
the other state. Even internationally, persons receive care in multiple countries. Within
Europe, people routinely cross country boundaries for care. People from around the
world come to the U.S. for care. So, in order to aggregate all data about a single
patient, interoperable connectivity must be enabled across all boundaries. For a state,
whatever fabric is woven using the regional models, it must provide a framework to
accept and share data across all boundaries.

Focusing just on the United States, that means that whatever system is in place to
support HIE, it must be at a national level.

Slide 16
The resulting infrastructure, then, is some form of a national healthcare information
network. There are several models and activities that attempt to enable this
infrastructure, and they will be discussed in subsequent slides. The purpose of a
national healthcare information network is:

To provide a secure, nationwide, interoperable health information infrastructure that

will connect providers, consumers, and others involved in supporting health and
healthcare.
E-health information to follow the consumer, be available for clinical decision making,
and support appropriate use of healthcare information beyond direct patient care so
as to improve health
De-identified regional data can be analyzed nationally in aggregate. There is a
national MPI which permits authenticated and authorized access to RHIOs for legal
health-related purposes.
Security and privacy are top priorities.

Slide 17
This slide shows one model in which many RHIOs are interconnected to create and
enable a national healthcare information network. In this view, the state of North
Carolina is supported by 3 regional healthcare information organizations, each of which
supports a population of 3 to 5 million persons an easily scalable model.

The population of the U.S. is just over 300 million persons. Using the figure of 3-5
million per RHIO, the U.S. would be easily covered by 100 such RHIOs.

Each RHIO would provide backup for other RHIOs within some geographical proximity.
In this example, one RHIO might be in Charlotte, one in the Research Triangle, and one

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Version 3.0/Spring 2012 Health Information Exchange
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the National Coordinator for Health Information Technology under Award Number IU24OC000024.
in the coastal region, say Wilmington. Each RHIO would backup the other two, and
could immediately take over functioning in case of a disaster. Within well-defined
geographical boundaries, all patient data would be aggregated into a patient-centric
record within a centralized database.

If a patient is seen outside their assigned area, that data would be sent to their home
database. Likewise, the clinic outside a geographic area could request data in real time
from the home RHIO.

One automatic way of knowing the home RHIO would be to assign each person an
identifier that would consist of the RHIO ID + the unique patient identifier. The same
strategy would work globally, if global identifiers were assigned.

The RHIOs would be operated by trusted, reliable organizations.

What might such a network cost? Given that issues of interoperability were solved, then
numbers such as these might be realizable:

The implementation cost of each center might be in the range of $10 million, with annual
maintenance fees of $3 million. Then implementation costs for the U.S. would be $1
billion with maintenance costs of about 300 million dollars.

Slide 18
In summary, a regional center would:

Accommodate 3 to 5 million persons,

Contain aggregated data for an Essential HER,
Be local to the region database,
Be Available 24/7,
Contain linkages to other centers so patients crossing boundaries of regions can be
aggregated, and
Have de-identified data available for local or global queries and analysis.

Slide 19
The Nationwide Health Information Network (NwHIN) is an initiative of the ONC. Its
purpose is to tie together information exchanges using a Java platform and Open
Source code. Participating organizations are assigned an Object Identifier (OID) to
identify them as a trustee entity. This initiative is supported by both public and private
entities.

Slide 20

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Version 3.0/Spring 2012 Health Information Exchange
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the National Coordinator for Health Information Technology under Award Number IU24OC000024.
CONNECT is an open source software package that implements the NwHIN
architecture.

Federal agencies collaborated through the Federal Health Architecture (FHA) to create
the CONNECT package.

Slide 21
The DIRECT Project was launched in March 2010. The DIRECT project specifies a
simple, secure, scalable, standard-based implementation guide for users to send
authenticated, encrypted health data directly to known, trusted recipients over the
Internet. The DIRECT Project is a collaborative whose stakeholders represent over 50
provider, state, HIE, and HIT vendor organizations. The DIRECT Project addresses key
Phase I requirements for Meaningful Use.

Organizations engaged in the Direct Project include Rhode Island Quality Institute,
Redwood MedNet, Carespark in Tennessee, and others.

Slide 22
The State Health Information Exchange Cooperative Agreement Program is designed to
promote HIE and advance information sharing across the health care system. The long
term goal is to enable a nationwide HIE and interoperability. In total, 56 states, eligible
territories and State Designated Entities received awards.

As work progresses, each state appears to be doing its own thing. The approaches
differ from state to state. Although there are coalitions among a few states, a common
approach has not happened, creating problems for patients who are seen across state
boundaries.

Slide 23
A group of federal agencies, local, regional and state HIOs have created a
confederation of trusted entities, known as the NHIN Exchange.
Its mission and purpose is to securely exchange health information. The NHIN
Exchange had 35 entities at the end of 2011 and is expected to grow.

Members of NHINE include CMS, CHIC, DoD, VA, HealthBridge, Kaiser Permanente,
Marshfield Clinic, NCHICA, MedVirginia, Regenstrief, Utah Health Information Network,
Western New York Clinical Information Exchange and others. Most of the ONC-funded
Beacon Community programs are also members of this organization

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Version 3.0/Spring 2012 Health Information Exchange
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the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Slide 24
This concludes the Health Information Exchange lecture.

In this lecture we learned about Health Information Exchanges. We have examined the
concept, purposes and value of HIEOs.

We have looked and several different models for realizing HIEOs or RHIOs. We have
looked at several federally- initiated programs. Those programs include NwHIN,
CONNECT, DIRECT, NHINE, and the various State HIE Programs.

Slide 25
No audio.

End.

Health IT Workforce Curriculum Networking and Health Information Exchange 9

Version 3.0/Spring 2012 Health Information Exchange
This material Comp9_Unit10 was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024.