The United States faces the largest shortage of healthcare practitioners in our country’s history, compounded by an ever-increasing senior population. In 2005, one geriatrician existed for every 5,000 US residents over 65, and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage, combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information uniformly to those who need it. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English.
This example captures the urgency and critical nature of our need for standardized communication in healthcare. Healthy information exchange can help improve safety, reduce the length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures, and make the health system faster, leaner, and more productive. The aging US population, along with those impacted by chronic diseases like diabetes, cardiovascular disease, and asthma, will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.
This efficiency can only be attained by standardizing how the communication takes place. Healthbridge, a Cincinnati-based HIE and one of the largest community-based networks, reduced their potential disease outbreaks from 5 to 8 days to 48 hours with a regional health information exchange. Regarding standardization, one author noted, “Interoperability without standards is like language without grammar. In both cases, communication can be achieved, but the process is cumbersome and often ineffective.”
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United States retailers transitioned over twenty years ago to automate inventory, sales, and accounting controls, improving efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid-America packed with inventory on shelves, ordering duplicate widgets based on a lack of information regarding the current list. Visualize any Home Depot or Lowes, and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the “art of medicine” is a barrier to more productive, efficient, and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to the standardization of regional and state health information exchanges.
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History of Health Information Exchanges
Major urban centers in Canada and Australia were the first to implement this successfully. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has successfully replaced antiquated interactions like faxing, mail, and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks and health systems to integrate and communicate.
Standardization will ultimately impact how effective communication functions in the same way grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that enable this communication delivery between health networks. HL7 is now on its third version, which was published in 2004. The goals of HL7 are to increase Interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO, concerned with process improvement.
One of the earliest HIEs started in the United States in Portland, Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The network’s goals are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly, and expand patient record access. The four founding groups, the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum, and Maine Health Information Center (Onpoint Health Data), began their efforts in 2004.
In Tennessee, Regional Health Information Organizations (RHIOs) were initiated in Memphis and the Tri-Cities region. Cars Park, a 501(3)c, in the Tri-Cities region, was considered a direct project where clinicians interact directly with each other using Carespark’s HL7-compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta, the midsouth eHealth Alliance is an RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical Center, UT Medical. These regional networks allow practitioners to share medical records, lab values, medicines, and other reports more efficiently.
Seventeen US communities have been designated as Beacon Communities across the United States based on their development of his. These communities’ health focus varies based on the patient population and prevalence of chronic disease states, i.e., CVD, diabetes, and asthma. The communities focus on specific and measurable quality, safety, and efficiency improvements due to health information exchange improvements. The closest geographical Beacon community to Tennessee, in Byhalia, Mississippi, just south of Memphis, was granted a $100,000 grant by the Department of Health and Human Services in September 2011.
A healthcare model for Nashville to emulate is located in Indianapolis, IN, based on geographic proximity, city size, and population demographics. Four Beacon awards have been granted to communities in and around Indianapolis, Health and Hospital Corporation of Marion County, Indiana Health Centers Inc, Raphael Health Center, and Shalom Health Care Center Inc. In addition, Indiana Health Information Technology Inc has received over 23 million dollars in grants through the State HIE Cooperative Agreement and 2011 HIE Challenge Grant Supplement programs through the federal government. These awards were based on the following criteria:1) Achieving health goals through health information exchange, 2) Improving long-term and post-acute care transitions, 3) Consumer mediated information exchange, 4) Enabling enhanced query for patient care, 5) Fostering distributed population-level analytics.
Regulatory Aspects of Health Information Exchanges and Healthcare Reform
The Department of Health and Human Services (HHS) is the regulatory agency that oversees health concerns for all Americans. The HHS is divided into ten regions, and Tennessee is part of Region IV, headquartered out of Atlanta. The Regional Director, Anton J. Gunn, is the first African American elected to serve as regional director. He brings a wealth of experience to his role based on his public service, specifically regarding underserved healthcare patients and health information exchanges. This experience will serve him well as he encounters societal and demographic challenges for underserved and chronically ill patients throughout the southeast.
The National Health Information Network (NHIN) is a division of HHS that guides the exchange standards and governs regulatory aspects of health reform. The NHIN collaboration includes departments like the Center for Disease Control (CDC), social security administration, Beacon communities, and state HIEs (ONC).11 The Office of National Coordinator for Health Information Exchange (ONC) has awarded $16 million in additional grants to encourage innovation at the state level. Innovation at the state level will ultimately lead to better patient care through reductions in replicated tests, bridges to respect programs for chronic patients leading to continuity, and timely public health alerts through agencies like the CDC based on this information.
Beacon communities and the Statewide Health Information Exchange Cooperative Agreement were initiated through HITECH and ARRA. 12 The Health Information Technology for Economic and Clinical Health (HITECH) Act is funded by dollars from the American Reinvestment and Recovery Act 2009. HITECH aims to invest dollars in community, regional, and state health information exchanges to build effective networks connected nationally. To date, 56 states have received grant awards through these programs totaling 548 million dollars.