Health information exchanges (HIEs) promise to improve patient care and trim costs by providing access to patient data across organizations ... if they can achieve sustainability. Yet, integrating a key component of patient data—images—into the HIE has proven to be problematic and plagued by technical and privacy hurdles.
“There are some estimates that inappropriate utilization, which covers a gamut of things, may be as high as 20 percent of the imaging that’s done in the U.S.,” said David S. Mendelson, MD, chief of clinical informatics at The Mount Sinai Hospital in New York City during an educational session at the Radiological Society of North America’s (RSNA) 97th Scientific Assembly and Annual Meeting in November 2011 in Chicago.
“If that statement is even close to true, inappropriate utilization is a very expensive part of the healthcare system and … as a profession, we should be doing everything we can to bring ourselves back to using imaging when it’s appropriate,” Mendelson said.
Indeed, as he peered into the future of image sharing, Mendelson underscored the importance of image communication, not just to the workflow of physicians or care of the patient, but to the functioning of the healthcare system. Better communication, including access to a patient’s medical history and prior imaging studies, is a boon for everyone.
While most organizations still live in the era of image communication via CDs, the last half-decade has been marked by the emergence of the HIE, regional or statewide systems where information is shared electronically among a group of healthcare providers. The eHealth Initiative, a Washington, D.C.-based nonprofit, conducts an annual survey of HIEs. In 2008, the survey identified 42 HIEs across the U.S.; by 2011, that number had risen to 255.
Mendelson noted, though, that most HIEs do not allow image sharing, instead only allow for the exchange of text-based patient data with radiology represented by the exchange of transcribed reports. To bring images into the HIE, a number of issues must first be addressed—some organizational and some technical.
The list of hurdles that must be cleared before there’s a wider integration of images in HIEs include financial sustainability, connectivity and storage issues and the development of an efficient process for providers to access the images.
The bottom line
The most significant challenge facing HIEs is sustainability, Mendelson noted at RSNA. Very few models can demonstrate financial sustainability, surviving instead on the lifeblood of federal or state grants. This point is reinforced by the eHealth Initiative’s 2011 survey, which also determined that of the 196 HIEs responding to the survey, only 12 percent were self-sustaining.
HIEs can attain financial independence when they are funded through transaction fees for the information exchanged or through some other source attributable to the advantages of the HIE, but getting providers to sign on for this investment can be tricky. While the general benefits of electronic information exchange are obvious and well-documented—access to more complete patient information, reduced duplication of exams, easier transition of patient care between facilities, more accurate prescriptions—it’s difficult to determine a specific return on investment for HIE membership.
“There is absolute concern about sustainability, because if you truly have established a community-wide benefit such as this with an intangible return on investment and make it so that it is accessible to all without significant costs, where’s the revenue?” asks Judy Smith, MD, medical director at Roswell Park Cancer Institute in Buffalo, N.Y. The institute participates in the HEALTHeLINK HIE.
Smith, who serves on the HEALTHeLINK board, says sustainability is the focus of extraordinarily difficult discussions taking place in many regional exchanges. There’s not a good model of sustainability that’s been put forward that works for every exchange. The payors reap many of the benefits. Providers’ efficiency gains aren’t as measurable, and aren’t of the magnitude that staffing can be reduced, which is a major cost for any facility, says Smith.
Currently, Roswell Park and the six other founding providers of HEALTHeLINK contribute to the support of the system knowing that there are benefits, however hard to measure, from the arrangement, says Smith.
While there’s no one-size-fits-all model of sustainability, some HIEs have found a way