Family physician Deanna Willis, M.D., cannot count how many times the health information exchange (HIE) in her home state of Indiana has enabled her to clarify a diagnosis and saved her from conducting duplicative or unnecessary tests. Patients often arrive at her practice in Indianapolis saying they have undergone a medical procedure or treatment without knowing exactly what was done or how the procedure or treatment affects their ongoing health.
"One of the most common examples is women who have had hysterectomies," says Willis, an associate professor of medicine at the Indiana School of Medicine who practices with Indiana University Health Physicians. "They're uncertain if their ovaries were removed. They don't know if their cervix was removed, and they may not know why they had a hysterectomy."
Before the electronic age, Willis might have spent hours and, possibly, even days trying to track down a patient's medical records or medical history to reach an accurate diagnosis. But because Willis' practice participates in the state's HIE, she can access a patient's medical records with a few clicks of the computer mouse, making it much easier for her to diagnose and treat a condition. This saves time and money and, ultimately, improves patient care, according to Willis.
- Many family physicians are using health information technology to partner with their subspecialist colleagues in integrating and improving patient care.
- Health information exchanges allow family physicians to join with local subspecialists and hospitals to create medical neighborhoods that provide seamless health care transitions and a more effective health care foundation.
- The health care field, however, still lags behind other industries when it comes to the adoption and use of technology.
"I can access the HIE and actually see discharge summaries from hospitals," she says. "Sometimes, I can actually see lab work and emergency department visits. I then can start to build my understanding of what a patient's medical history is and, when I see (the patient), I can confirm that with the patient. The HIE provides a more robust understanding of the patient's health condition and probably a much more accurate view of it, as well."
Health Information Exchange
Willis' experience is slowly becoming the rule rather than the exception as more physician practices, hospitals and health systems move beyond the adoption and use of electronic health records to join HIEs or other integrated electronic networks to securely send and share patient data.
There now are 119 HIEs operating in the United States, and another 53 currently are in the planning stages, according to Julia Adler-Milstein, Ph.D., an assistant professor of health management and policy at the School of Information and School of Public Health at the University of Michigan.
During the past few years, the percentage of physician practices participating in HIEs has jumped from 3 percent to 10 percent, and the percentage of hospitals participating in the exchanges has climbed from 14 percent to 30 percent, according to a recent Robert Wood Johnson-funded study report, Health Information Technology in the United States: Driving Toward Delivery System Change, 2013(www.rwjf.org), that Adler-Milstein co-authored.
More than 30 percent of HIEs report supporting accountable care organizations, and 45 percent support patient-centered medical homes (PCMHs), says the study.
"When you look across the country, there are states where there is a single statewide exchange, and there are other states where there are multiple local and, sometimes, even geographically overlapping exchanges all operating within a single state," says Adler-Milstein. In addition, "A lot of the exchange efforts that are out there go beyond (just) allowing messages to go back and forth. Instead of me trying to send a message to you, I can do a search for Joe Smith, and I can see all of the information available for Joe Smith in all of the other participating hospitals or physicians' offices."
In some areas, primary care practices are transcending the PCMH concept by reaching out to subspecialists to form virtual medical neighborhoods with the help of health information technology.
For example, CMS' Center for Medicare and Medicaid Innovation recently awarded a three-year, $20.75 million Health Care Innovation Grant to TransforMED and its project affiliates(www.transformed.com) to help primary care practices in 15 communities achieve PCMH status and to then connect those practices with hospitals and subspecialists in their respective areas as part of a medical neighborhood. The goal is to improve the health care of the surrounding communities at a more affordable cost, says Bruce Bagley, M.D., interim president and CEO of TransforMED.
"Health information technology is essential for high-functioning practices to get connected to the rest of the care system in the medical neighborhood and the accountable care organization," says Bagley. "The key ingredient is to have the patient's critical clinical information available to the provider at each and every point of care so that health professionals can make the best possible recommendations for the patients they serve."
The Westminster (Colo.) Medical Clinic is a test case for the medical neighborhood. It has an ongoing partnership with 17 subspecialists in its local area. The agreements between the various practices define the responsibilities of the primary care and subspecialty practices in managing and improving patient care. Four domains of health care are outlined in the agreement:
- health care transitions,
- health care access,
- collaborative care management and
- patient communication.
"The fragmentation of health care is pervasive," says R. Scott Hammond, M.D., of the Westminster Medical Clinic, which has been a recognized level 3 PCMH for the past five years. "The relationship between primary care physicians and (sub)specialists has been splintered. You send a patient to a (sub)specialist, and you often don't know what happens to the patient and you don't get reports back."
The Westminster Medical Clinic and the subspecialists they work with rely on common definitions of care transitions that allow them to "know right off the bat who is responsible and accountable for what in regards to the patient," says Hammond. And they are able to share information electronically.
"I am responsible for transferring patient care records to the subspecialist in a timely manner," Hammond explains. "This means the subspecialist has the records, MRIs and labs before seeing the patients."
Hammond says the relationship between the primary care physicians and the subspecialists at Westminster Medical Clinic has gone past the dating stage to the marriage stage, enabling the primary care physicians to establish a strong relationship with subspecialists. This has led to dramatic improvements in care, according to Hammond.
"The only way you can truly coordinate care is by defining your roles, responsibilities and accountabilities and getting all the clinicians on the same team with your patient," he says.
Despite this type of collaboration and integration, however, the health care field still lags behind other sectors of the economy when it comes to the adoption and use of technology.
"We need to catch up with every other sector of the economy around using computers and health IT to help with all of the core business functions, all of the core clinical functions and all the core education connectivity functions that we could use for our patients," says Bagley.
Family physician Shaun Grannis, M.D., M.S., a biomedical informatics research scientist with the Regenstrief Institute, a supporting organization of Indiana University, says the "world became electronic and digital around us." He acknowledges that health IT presents certain challenges that may not exist in other industries. For example, "I often hear analogies drawn between health care and the banking industry, and that comparison seems a bit oversimplified," says Grannis. "The banking industry focuses on managing particular, well-scoped information."
Banking repeatedly adds and subtracts the same data elements, Grannis says, but "In health care, we must manage a highly diverse set of concepts ranging from medications and diagnoses to clinical assessments and text reports of DNA tests and psychiatric evaluations. The management of these information sources does not follow a simple pattern."
Lack of Participation
Even when family physicians join an HIE, however, there is no guarantee that subspecialists in the region also will participate. For example, Jen Brull, M.D., who practices as a solo physician in Plainville, Kan., joined her state's HIE two years ago, but she has been unable to exchange data with most of the subspecialists in her region. They are employed by the local hospital, which has not permitted them to turn on individual physician messaging for the HIE. This has greatly limited the effectiveness of the exchange.
"It has been the status quo for so long. We have always had to fax or mail," says Brull. "We would love to be able to communicate with the (subspecialists) directly through the exchange."
In contrast, the ophthalmologists in the region participate in the HIE and have what Brull describes as "tremendous uptake." They regularly send her consultant reports and pictures of eye exams, and they allow Brull to send them clinical information, as well. "I get information on my diabetic patients about what their eye exams look like, and that is very helpful," says Brull. "But we don't have an exchange yet with the cardiologists, urologists, oncologists and orthopedists. We hope it will get there."
Seamless interoperability is more a journey than any actual destination, and any hopes of complete interoperability are unlikely to be realized, according to Grannis. Unlike other industries, health IT will never be fully interoperable because of the constant introduction of new tests and procedures that cannot be immediately reflected in the data itself.
Physicians and other health care professionals also tend to label the same tests and procedures by different names. As a result, "the identical test, diagnosis or clinical scenario may be listed under different codes among different systems," says Grannis.
However, Bagley says too much emphasis is being placed on interoperability, which is defined as the ability of computers to talk to each other in real time. "The missing piece is the continuity-of-care record," Bagley says. "Think about that as a transportable, readable, computable packet of information on a thumb drive that follows patients wherever they go.
"That would be the holy grail," he adds.
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