Contexture, the largest health information organisation in the western US, recently announced plans to transition to unified health information exchange (HIE) platforms in Colorado and Arizona. Contexture claims the upgraded HIEs will improve system performance and functionality, and will give HIE participants information to make critical decisions that can improve care quality and outcomes.
The Signify View
The planned HIE upgrades in Colorado and Arizona, which will begin this year and are scheduled for completion in 2025, mark another step in the long-overdue upgrade to HIE infrastructure across the US that is currently underway and will continue over the next few years. Health Catalyst, the technology provider for the existing Colorado HIE, will be responsible for the Contexture upgrades.
State-wide HIEs have existed for around 20 years, their primary role being to connect with and pull data from multiple EHRs in their vicinity to give health providers a longitudinal view of a patient’s healthcare record.
Their track record in doing this is chequered, however, and first and second-generation HIEs have never really reached their true potential. Issues around interoperability, the ability to integrate HIE data back into a provider-specific EHR, the depth of information exchange, level of provider participation and information latency have held them back and restricted their usefulness, despite legislation over the years like the Affordable Care Act.
There are also several ways that an HIE can be deployed and used. This insight specifically focuses on State-wide HIEs, but the below summarised these in the context of other HIE deployments.
State-wide HIEs can play a critical role in supplying out-of-network patient data. Alongside claims data, provider system-wide HIEs and local EHRs they also offer a vital tool for providers operating in value-based care (VBC) reimbursement models in terms of obtaining longitudinal health records for the populations they manage. Each of these data sources has their pros and cons and typically only in combination can they provide the tools providers seek.
For example, anecdotally, IDNs and ACOs say that, while the quality of claims data is comprehensive across the whole patient journey, it lacks clinical depth and takes three to five months to show up on data feeds (see diagram below). ACOs/IDNs also say that EHR and ADT (Admission, Discharge, Transfer IT) data is the most clinically in-depth, but complain that, across a health system or a local region, there are many EHRs and so data is siloed.
State-wide HIEs have been unable to gain a foothold in large areas of the US due to some of their own shortcomings, particularly in States where multiple state-wide HIEs compete, which adds to fragmentation. Health system participation in HIEs has been inconsistent, with some choosing to only participate in HIEs where other participants are using the same vendor for their EHR, or only participating in systems with allied groups. Data latency, while nowhere near as long as claims data, has also been a barrier to wider adoption.
Patient Data Sources for IDNs/VBCs
The Path Forward
Next generation State-wide HIEs do, however, offer a blueprint for greater data sharing, and promise to meet growing demand for more co-ordinated healthcare responses and better management of patient flows through the health system (inpatient and outpatient, long-term care, social care and primary care). Faster, more reliable data exchange between healthcare providers should, in theory at least, improve patient care quality, boost efficiencies and reduce healthcare system costs, all central elements of VBC.
Perhaps inevitably, COVID substantially re-lit the fading embers of first and second-generation HIEs. During the pandemic they played a vital role in co-ordinating patient monitoring and vaccination programmes, providing an aggregated single source of data for testing and hospitalisation in states where there was a State-wide HIE, and supporting state decision-making. This ignited fresh interest in the development of more sophisticated HIEs based on real-time standards. New legislation which came into force at the end of last year has continued the forward momentum.
The 21st Century Cures Act includes provisions for greater EHR interoperability and data sharing. Promoting the creation of a ‘trusted’ nationwide information exchange framework connecting all different EHRs in a state, it legally requires hospital IT vendors to share data. This will be unusual territory for some vendors, most notably Epic, which has never shown any enthusiasm to share. But the law is a much-needed step forward for the industry as a whole.
The expected upcoming wave of state-wide HIE upgrades across the US will pique the interest of an array of vendors. Health Catalyst looks like a done deal in Colorado and Arizona, while EHR and data aggregation vendors like InterSystems, Innovaccer, Orion Health, Lyniate (which has had success with its Rhapsody solution and has just announced it will be renamed after Rhapsody), all have good track records in providing summary EHR overlays that offer the population and clinicians a longitudinal patient health history. They will be confident about winning new contracts, as will the likes of AWS, Google, Redox and Epic.
Oracle Cerner will almost certainly have a say in the future of HIEs, too. Almost a year ago Signify Research wrote in this Insight of Oracle Cerner’s ambitions to develop a national EHR database solution for the US. Any large-scale programme to upgrade State-wide HIE infrastructure could, therefore, be a conduit for Oracle Cerner and its broader national EHR plans.
InterSystems already has some experience doing this at a national level in the US, providing its underlying HealthShare technology for the eHealth Exchange. Connecting healthcare providers to five federal agencies, over three-quarters of all US hospitals and 61 regional or state HIEs and 85% of dialysis clinics running on more than 30 EHRs, the eHealth Exchange is one of the largest health information networks in the country. It currently processes around 33M information requests every month.
Although it is more of a national system for exchanging patient data rather than a national EHR, the eHealth Exchange is still a real-world example of a solution aimed at addressing the siloed nature of EHRs and patient data at national level.
Oracle Cerner has strong credentials here, given its large installed base (second only to Epic) of US hospital customers already using its EHR, and its installed base of ambulatory and primary care EHR customers (although its share is much smaller here compared to the hospital market).
It also has experience in deploying solutions to connect providers’ individual EHR instances, having deployed HealtheIntent (its current population health management platform to support system-wide summary care records) to more than 200 customers across the US.
Oracle Cerner has not confirmed whether HealtheIntent would be the foundation technology for any national EHR database, but it would be an obvious candidate given its current main use-case is integrating data from disparate EHRs, vendors and settings; exactly what the company says it wants to do at a national level. However, scaling to this extent would be a significant step beyond its original design.
Crux of the Matter
The success of next generation State-wide HIE solutions will ultimately depend on how far beyond simple information transfer they can go. The crux of the matter here is using real-time data to improve population health outcomes. But HIEs will also need to scale if they are to evolve, and this is now happening and slowly accelerating.
After nearly two decades of underachieving, State-wide HIEs are making a comeback, and occupy a key role as gatekeepers of value-based care.