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One major roadblock to widespread HIE connectivity is the lack of EHR adoption among providers. While healthcare IT has taken huge bounds forward in the last several years, many providers across the country remain totally dependent on paper-intensive processes. The EHR serves as a provider’s direct connection to structured data transfer over the HIE. As such, promoting widespread EHR adoption remains a key pursuit of stakeholders in the HIE, and particularly for states. Many states have taken an active role in encouraging adoption of electronic health records among providers by collaborating with support resources, such as Regional Extension Centers, and by offering financial incentives to organizations fostering EHR adoption in their communities. Health information exchange is facilitated by the availability of standards-based electronic health information. This section discusses the various stakeholders and existing HIT activities HIEs should consider to develop a technical integration strategy.
Hospitals and Health Systems
While many hospitals and health systems have made the transition to electronic health records, smaller practices and practices in rural areas have been slower to adopt. The entry barriers of EHRs are much more difficult to tackle for small and rural practices, particularly due to the cost of EHRs. Additionally, having to support the adoption process on one’s own can be daunting. Recognizing these prohibitive characteristics of adoption, HHS in 2006 put into action a significant exemption to the Stark law, an anti-kickback measure. Through this exemption, hospitals and health systems may subsidize up to 85% of the cost of software, training, and implementation of EHRs for smaller affiliated practices. Hardware can also be bought at group pricing through the hospital or health system. While the benefits are clear for the smaller practices receiving heavily subsidized software and services, it is important to note that the hospitals and health systems also stand to strengthen their referral networks greatly by connecting affiliated providers to their own supported EHR. Many hospitals and health systems are also developing their own HIE capabilities (often referred to as Enterprise HIEs) to support their employed and affiliated providers in meeting Meaningful Use.
Regional Extension Centers (RECs)
Many HIEs are also aligning with Regional Extension Centers to encourage adoption of EHRs among providers. Regional Extension Centers specifically target small practices and primary care providers. Technical assistance services are delivered to providers as they implement EHRs from vendor selection to go-live and optimization. RECs can also work with providers to integrate their new EHR systems with the state health information exchange. Many HIEs work collaboratively with the REC. For example, the REC can ensure that every practice they support also joins the HIE and is exchanging information.
Listing of RECs
Supporting Providers without Electronic Health Records
Despite the fact that resources are available to lessen the stresses of transitioning to EHRs, many practices and providers will determine that the time is not right for their own adoption of fully capable EHR technology. Integrating these practices into the health information exchange is critically important in the pursuit of robust interoperability between providers across the state. HIEs have a number of options for supporting these EHR-less providers.
HIE/Provider Portals
Providers without full EHR capability may be unable to send and receive structured health data through the HIE, but they can still leverage information from the exchange to improve the care they deliver. A number of HIEs are offering provider portal capabilities as part of their solutions. A provider portal offers a window into the HIE, granting access to patient data and care summaries. Providers can log in through the secure portal and pull up relevant information on a given patient, and some systems even include ePrescribing functionality and secure messaging. A portal may also include secure results delivery—push of clinical results on orders or copied results for patients to which the provider has a relationship with the patient (i.e., PCP or attending provider). This information may be able to be saved electronically, locally at the provider’s office in their ambulatory EMR/EHR of choice and/or automatically printed on a scheduled print job that supports the provider’s manual workflow.
Examples:
HIE Vendor EHRs or “EHR-Lite”
Providers and practices interested in sending and receiving structured health data but unable to make the investment in a full EHR may be interested in what has often been labeled an “EHR-Lite” solution. This is a term often associated with limited-functionality EHRs provided by vendors of integrated HIE solutions, aimed at supporting providers who are not ready to implement their own practice-specific ambulatory EHR. While not possessing the robust functionality of a complete EHR, these solutions enable physicians to use many of the basic functionalities found in the more complex systems. These capabilities may include ePrescribing and lab ordering and delivery, referral management, secure messaging, and clinical decision support, in addition to the ability to create and view clinical summaries. The EHR-Lite solution may interface with an HIE’s MPI database, and send and receive structured data through the HIE. It should be noted that in order to support providers in qualifying for Meaningful Use, the EHR-Lite solution must be certified. For more information on the certification program, click here.
Examples:
As HIEs drive for more capacity and capability, a particular menu set of services come into play, particularly those that support Meaningful Use objectives. The delivery of structured laboratory results, facilitation of ePrescribing and integration into Nationwide Health Information Network (NwHIN) are common, yet powerful offerings undertaken by numerous state HIEs. As Stage 1 Meaningful Use stipulates providers to use ePrescribing and assimilate structured lab data into the EHR, these capabilities of HIE are of specific interest to many states.
Laboratory Results Delivery
Community based and state HIEs have made the delivery of structured lab results over the HIE a top priority as they build up exchange infrastructure. Up to this point, practices have had to develop their own custom interfaces through their EHR to establish a direct connection to a given lab. With the proliferation and widespread use of LOINC among most major laboratories (excluding hospital laboratories), and clarification surrounding Clinical Laboratory Improvement Amendments (CLIA) privacy guidelines, HIEs have been able to act as a conduit for exchange among practices and the laboratory network. Results can be routed to providers through the HIE and delivered as structured data into electronic health records. Work continues between HIEs and national laboratories to ensure that an interface can be built to allow the entities to freely share information and results, and ultimately enable the HIE to deliver accurate and structured results to the provider. This can be a shared-service offered at the state level or even at the community or regional levels. HIEs can even act as a clearinghouse for laboratory results before they go on to public health agencies and other public entities. The fact that Stage 1 Meaningful Use requires that lab results be integrated into the EHR as structured data, has made the HIE’s role critically important as the gateway between labs and providers. See the table below2 for a list of the gaps that may exist in current lab interoperability workflows, and how an HIE might go about providing a solution.
Laboratory Results Delivery |
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Gap
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Potential Strategy
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Providers are not familiar with lab interoperability options.
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Make information about the options available through the Regional Extension Centers (RECs) and laboratory service providers.
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High degree of interstate lab transactions within the region with dissimilar state policies and regional infrastructures.
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Learn the regulations of neighboring states and work with them to promote consistency.
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Multiple data sources for identifying labs within the state.
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Enable state-wide directories or merge current disparate compendiums into common standardized ones. Both of these activities would help smaller labs participate in HIE.
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There is incompatibility between federal and state regulations or state regulations have created barriers to lab interoperability.
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Examine state regulations and statutes affecting lab interoperability.
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Electronic Prescribing
Another stipulation of Stage 1 Meaningful Use requires providers to submit 75% of all prescriptions electronically through the EHR. While many providers are already connected electronically to pharmacies through the SureScripts network, the state HIE or the community or regional HIEs can still play an important role in ensuring that smaller pharmacies and provider organizations have access to ePrescribing capabilities. States and HIEs can work to connect small and independent pharmacies and encourage these pharmacies to accept electronic prescriptions. Training and general distribution of information to providers are both effective methods of encouragement from HIEs. See the table below3 for a list of the gaps that may exist in the current ePrescribing landscape, and how states may support electronic prescribing capabilities.
Electronic Prescribing |
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Gap
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Potential Strategy
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There is incompatibility between federal and state regulations or state regulations have created barriers to ePrescribing.
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Address state regulations and statutes affecting electronic prescribing.
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Providers are not familiar with navigating e-prescribing adoption.
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Coordinate dissemination of information and training opportunities with Regional Extension Centers (RECs) and professional associations.
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Medicaid providers don’t have access to Medicaid formulary.
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Update state Medicaid systems to support ePrescribing.
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Not all providers have access to affordable e-prescribing systems that accommodate their practice environment.
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Group purchasing to reduce costs; making a certified EHR available to providers (or a certified eRx tool available to providers as a default option for those who don’t have eRx built into their EHRs).
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Current e-prescribing standards don’t support all the functionality desired within the state.
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HIE provides ePrescribing services.
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Patient Care Summaries
Under the Meaningful Use guidelines, a patient care summary includes at a minimum: diagnostic test results, problem list, medication list, and a medication allergy list. Additionally, the transfer of the care summary uses HL7 CCD or ASTM CCR standards. See the table below4 for a list of the gaps that may exist in the current workflows surrounding the exchange of a patient’s clinical care summary, and how HIEs may support these activities.
Patient Care Summaries |
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Gap
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Potential Strategy
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Clinical summaries use different terminology and coding
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- Negotiate a single set of semantic standards with stakeholders.
- Develop policy mandating a particular set of semantic standards.
- Enable conversion services between semantic coding schemes
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EHR system unable to display clinical documents
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- Enable independent document view portal for providers over the web
- Work with RECs to encourage use of certified EHR technology with this functionality
- Consider making a certified EHR system available to providers (for deployment locally or via ASP) with this functionality
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Providers have too many clinical summaries to view for each patient
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Enable additional services to extract unique information from multiple clinical documents and assemble a “summary of summaries”
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Clinical summaries may have data within them that violate our state’s current data sharing laws or policies
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- Implement and enforce appropriate policies consistent with these legal requirements
- Ensure the use of data filters within the HIE service that prevent clinical summaries (or parts of clinical summaries) containing inappropriate information from being shared.
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Reporting and Analytics
Reporting and analytics can be provided as a service by the HIE to individual providers and hospitals, not only as part of Meaningful Use, but also for ACO initiatives. A highly robust, fully functional reporting suite will enable HIEs to run system utilization and performance, user and process activity and audit reports, as well as to generate patient registries and other lists, and provide for Physician Quality Reporting System PQRS (including Meaningful Use and other quality reports). For additional information, see the Moving Forward Module.
2ONC State HIE Cooperative Agreement Technical Assistance. July 16, 2010.
3ONC State HIE Cooperative Agreement Technical Assistance. July 16, 2010.
4ONC State HIE Cooperative Agreement Technical Assistance. July 16, 2010.
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