From Transformation to Innovation: The Path from the EMR to the HIE

By Paul A. Testa, Acting CMIO, NYU Langone Medical Center

Paul A. Testa, Acting CMIO, NYU Langone Medical Center

Clinicians want to believe in the promise of interoperability—in the promise of the fluid flow of data and Health Information Exchange (HIE) amongst various and fragmented venues of care. They want to believe that morsels of clinical data will prevent an unneeded hospital admission, eliminate duplicate imaging and laboratory testing, and provide clinicians with a deeper understanding of the totality of their patients’ health and the care they have received. Unfortunately, accessing clinical information via an HIE is analogous to sipping water from a fire hose. Clinicians want smaller sips from the fire hose; small data at the bedside, not big. Massive structured Continuity of Care Documents do little to facilitate prioritization of information in the Electronic Medical Record (EMR), much less tell a patient’s story.

“For the promise of HIE and interoperability to be fulfilled, we need to veer from the technical and toward the clinical”

As much as patients are the stewards of their own medical history, it is the realm of the clinician to consume nuanced data and interpret the narrative of care. While there is room for pessimism, clinicians are motivated to access the HIE by perceived improvements in the quality of care they may provide and time saved. The reality is that such earnest motivation may be tempered by less than thoughtful workflows and interfaces. The benefits of HIE, at the moment and place of care, must evolve from theoretical to tangible. When it comes to providing patient care, the clinician’s question is always the same—do we know what works? This is no different with HIE.

The Rand Corporation in December published in the Annals of Internal Medicine, the first large scale, systematic review to evaluate evidence of the use and effect of HIE on clinical care. Rand researchers examined HIE literature to assess the effect on health outcomes, cost, and patient and provider attitudes. The key findings of this review were: Despite significant federal and state funding of HIEs, there is very little research about the effects of these exchanges on the quality and efficiency of health care delivery. The few evaluations that do exist suggest that the use of HIEs has some beneficial effects on emergency department costs and utilization of services such as diagnostic imaging studies. Use of HIE is low relative to the estimated potential need. Some have reported greater HIE use, with specifics of the context and implementation potentially responsible for these differences.

Barriers to acceptance and sustainability of HIEs include interface, workflow, and cost, as well as patients' concerns about privacy. Motivated clinical users of HIE believe access helps them deliver higher quality care driven by timely, relevant clinical data. Active users endorse that HIE saves them time by replacing manual outreach for requested clinical data from other physicians, hospitals, and pharmacies. Verifying medications and allergies is also faster than inputting de novo. For patients new to a clinician, information harvested through HIE facilitates the clinical interview, and reduces redundancy in the questions asked. Unfortunately, there is tremendous variation on how effectively clinicians find HIE integration into complex workflows. Many are often unsure of how to even access the HIE from their EMRs or how to import data from the HIE. Others must consciously remember to check it to find potentially omitted patient data.

Clinicians are often presented with competing sources of HIE - hospital portals, media presented by patients themselves, faxes, or other referring clinician documentation—hence, sipping from the fire hose. A notable recent development that should help to address the scarcity of information the Rand study identified is the formation of a national HIE organization called the Strategic Health Information Exchange Collaborative. The formation of this national collaborative is both a testament to the growing maturation and sustainability of HIEs and makes real the opportunity to determine and disseminate best practices amongst its members. Additionally, it is intended to undertake the much needed focus on HIE advocacy. As the distance between various points of the provision of care collapse with the often hoped for fluid and relevant information exchange, clinicians will self-reinforce the value of HIE.

As with tremendous adoption of EMRs, perceived value by clinicians comes with continued and iterative use, which can be seen as resulting in tangible benefit in the provision of care. If there is but one consensus, it is that more research and self-evaluation is needed to drive HIE usage and identification of best practices. Such will critically depend on context and commitment. EMR implementation was not presented to clinicians as just another IT project, but rather one of clinical transformation. For the promise of HIE and interoperability to be fulfilled, we need to veer from the technical and toward the clinical. As transformation has given way to innovation, the opportunity presents itself to demonstrate HIE serve as the driver of the true clinical innovation clinicians believe HIEs have the potential to be.