Resolution 29(13) Support of Health Information Exchanges
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Resolution 29(13) Support of Health Information Exchanges
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RESOLUTION: 29(13)
SUBMITTED BY: Texas College of Emergency Physicians
SUBJECT: Support of Health Information Exchanges
PURPOSE: Support the development of well-designed Health Information Exchanges that allow rapid access to patient specific information, with minimal barriers to access, for physician use in the care of emergency patients, through development of an ACEP white paper and engagement with other stakeholders such as the AMA.
FISCAL IMPACT: Minimum of $35,000 to include committee and staff time, potential travel, conference calls, and other resources to develop a White Paper, support legislative efforts, and work with the AMA and other external stakeholders.
Resolution 29(13) Support of Health Information Exchanges
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WHEREAS, The role of electronic records and access to health information has evolved rapidly since the 1994 Institute of Medicine report on “Health Data in the Information Age”; and
WHEREAS, Health Information Exchange (HIE) is the electronic sharing of health-related information among organizations and an organization that provides services to enable the electronic sharing of health-related information; and
WHEREAS, HIE holds the potential to provide relatively easy, rapid access to prior health records including results of diagnostic laboratory testing, imaging, and recent hospitalizations; and
WHEREAS, HIE provides opportunities to promote patient safety, reduce medical errors, improve the quality of emergency care, and enhance the efficiency of emergency departments; and
WHEREAS, HIE is a means to reduce duplication of services and operational costs, resulting in lower health care costs; and
WHEREAS, Many current HIEs avoid numerous hurdles of data exchanges by allowing individual institutions control over their own institutional data and provide HIPAA privacy protection while still allowing rapid external access to individual data to qualified physicians; and
WHEREAS, Well designed HIEs potentially could allow emergency physicians relatively effective rapid access to key recent health care information for patients seen in emergency departments; and
WHEREAS, Individual physicians should not be obligated to search nor be held liable for information that is not readily provided to them or may not be available to them; and
WHEREAS, ACEP’s policy statement “Health Information Technology2” states: “Access to historical patient information, including data in Electronic Health Records and Personal Health Records, should be available for ED patients. Connectivity with external systems and participation by hospitals in health information exchanges should be encouraged.”; therefore be it
RESOLVED, That ACEP investigate and support the development of well-designed Health Information Exchanges that allow rapid access to patient specific information, with minimal barriers to access, for physician use in the care of emergency patients while not creating an obligation to access and while limiting the liability for physicians when this information is either not readily or knowingly available to a physician; and be it further
RESOLVED, That ACEP work with the American Medical Association to promote the development, implementation, and utilization of a national Health Information Exchange; and be it further
RESOLVED, That ACEP work with the American Medical Association to develop and support national legislation that encourages stakeholder participation in regional and national Health Information Exchange; and be it further
RESOLVED, That ACEP develop a white paper exploring the need for and possible implementation strategies of a national Health Information Exchange.
References
1. Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services, “Health Information Exchange,” HealthIT.gov, 2013.
2. ACEP Policy: “Health Information Technology,” approved 2008.
Resolution 29(13) Support of Health Information Exchanges
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Background
This resolution calls for ACEP to investigate and support the development of well-designed Health Information Exchanges that allow rapid access to patient specific information, with minimal barriers to access, for physician use in the care of emergency patients, through development of an ACEP white paper and engagement with other stakeholders such as the AMA.
As a nation, we are transforming health care delivery into a system that is patient-centered and value-based. Existing Medicare and Medicaid programs and initiatives, as well as new programs authorized by the Patient Protection and Affordable Care Act (Affordable Care Act), focus on new service delivery and payment models that encourage and facilitate greater coordination of care and improved quality. Critical to the success of these programs and the ultimate goal of a transformed health care system is real-time interoperable HIE among a variety of health care stakeholders: clinicians, laboratories, hospital, pharmacy, health plans, payers and patients, regardless of the application or application vendor. Greater access to person-level health information is integral to improving the quality, efficiency, and safety of health care delivery.4
Interoperability is generally accepted to mean the ability of two or more systems or components to exchange information and use the information that has been exchanged. That means that there are two steps to interoperability:
1) the ability to exchange information; and
2) the ability to use the information that has been exchanged.
The actual exchange of health information needs to be both interoperable and electronic across myriad information systems for us to realize a patient-centered, value-driven health care system. Electronic HIE encompasses a broad array of strategies, technologies, types of exchange, and applications to share information. The use of HIE facilitates better communication and enables more coordinated and connected care across the full continuum of health delivery and payment settings. Effective communication and information sharing is essential to improving the quality of care, bettering health of communities, and lowering per capita costs. Without such exchange, providers are forced to make decisions about patient care with incomplete information, and substantial time and resources are wasted exchanging information manually. Despite agreement on the potential value, achieving broad-based electronic health information exchange (HIE) has been a major clinical and policy challenge. There is an array of barriers to widespread HIE that must be tackled before we can realize the associated benefits.5
Since the enactment of the Health Information Technology for Economic and Clinical Health Act (HITECH), as part of the American Recovery and Reinvestment Act of 2009, adoption and use of electronic health records
(EHRs) in the United States has dramatically increased.6 However, gaps and challenges still remain for the widespread use of interoperable systems and HIE across providers, settings of care, consumers and patients, and payers. Both providers and their vendors do not yet have a business imperative to electronically share person-level health information across providers and settings of care that exceeds the cost of doing so. For example, in 2011, four in ten hospitals electronically sent laboratory and radiology data to providers outside their organization; however, only 25% of hospitals could exchange medication lists and clinical summaries with outside providers.6 In addition in 2011, only 31 percent of physicians were electronically exchanging clinical summaries with other providers.8
There is even more limited HIE involving post-acute and institutional long-term and post-acute care (LTPAC), most behavioral health (BH), and laboratory providers who are not eligible for incentive payments under the Medicare and Medicaid EHR Incentive Programs (EHR Incentive Programs). Only six percent of long-term acute care hospitals, four percent of rehabilitation hospitals, and two percent of psychiatric hospitals have a basic EHR system.7 Close to 40% of Medicare beneficiaries discharged from acute care hospitals are discharged to post-acute care settings such as rehabilitation hospitals and skilled nursing facilities (SNFs), but there is little capacity in the system today to support HIE across these settings.8
To enable providers to meet the HIE-related requirements of MU, almost $600 million in HITECH funding was devoted to create the State HIE Cooperative Agreement Program (CAP). Under this program, each state received a one-time grant to expand HIE capabilities, with flexibility to do so in a way that conforms to the needs and considerations of the state. Some states are pursuing centralized approaches in which there is a single statewide exchange. More often, states are fostering local exchange efforts and then putting in place services that enable these efforts to connect to each other (i.e., a network-of-networks model). Whether the combination of HIE-related MU criteria and state funding to expand HIE will be sufficient to overcome the barriers to HIE is not yet clear. A number of barriers to robust, sustainable HIE has resulted in a high failure rate of HIE efforts over the past decade.5,9 The barriers fall into several key domains, including technical issues, legal challenges, regulatory barriers, and those that deal primarily with privacy and security; however, the most persistent and substantial barriers are financial. The majority of HIE efforts report struggling to find a sustainable business model because few providers are willing to pay for HIE and other stakeholders believed to benefit from HIE, such as payers, have yet to offer substantial financial support to these efforts.
Both the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) are working to close some of these gaps and overcome these challenges. CMS has instructed states on the use of the enhanced Medicaid Federal Medical Assistance Percentages (FMAP) at the 90/10 matching level to support HIE activities, as authorized by HITECH. This includes HIE efforts tied to EHR adoption, linking laboratory or other data sources for Medicaid eligible through HIE, and supporting hardware and software EHR/HIE linkages at the provider site that will support Medicaid providers’ meaningful use of Certified EHR Technology.
As part of Stage 2 of the EHR Incentive Programs, CMS introduced many concepts of HIE that eligible professionals and hospitals must meet as part of the “meaningful use” requirements. CMS and ONC expect Stage 3 of the EHR Incentive Programs will also include requirements for advanced HIE. CMS’ implementation of e-health standards and services aligns the requirements of HIPAA transaction standards and operating rules and HIPAA Administrative Simplification including ICD-10, the EHR Incentive Programs, electronic quality reporting, and privacy/information security across its existing and innovative payment programs. CMS’ administration and enforcement of HIPAA Administrative Simplification regulations also promote interoperable data exchange via standards and operating rules.
As the overall HIT ecosystem evolves and matures, its components are becoming more modular and distributed. Increasingly, EHRs themselves are modular and can include data services from multiple sources. There is a clear need to ensure standardization of data structure and format and interfaces through HIE standards and policies that are understood by vendors, providers, CMS, ONC, private payers, and other users. This will enable the use of a diverse and distributed set of interoperable technology solutions.
Where feasible, agencies need to leverage available authorities to go beyond HITECH implementation to accelerate interoperability and electronic exchange of health information across the health care system. Incremental steps to accelerate HIE will stem from Affordable Care Act delivery reform programs, and Medicare and Medicaid payment. The program-specific changes needed to accelerate HIE must target expanded sharing of health information between multiple stakeholders, such as: hospitals and physicians; primary care physicians and specialists; and hospitals and nursing homes, home health providers, and other post-acute care and community-based providers. However, many existing program and policy levers remain specific to a setting of care, and it is not apparent how they will be used to collectively achieve system-wide HIE to ensure health information always follows a patient regardless of where and when they receive health care services. A critical part of enabling the secure flow of information across the system is advancing the adoption of HIT standards through voluntary certification of HIT and HIE products and services. CMS will consider various ways in which the voluntary certification of HIT and HIE products and services under the ONC HIT Certification Program could be aligned with Medicare and Medicaid payment policy, to the extent feasible and within the scope of applicable law.
Background References
3. Office of the National Coordinator for Health IT/Centers for Medicare and Medicaid Services. Strategy and Principles to Accelerate HIE. August 7, 2013
4. Rosenbaum, R., “Data Governance and Stewardship: Designing Data Stewardship Entities and Advancing Data Access,” Health Services Research 2010 45:5, Part II.
5. Adler-Milstein J, Bates DW, Jha AK. “A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use.” Annals of Internal Medicine. 2011;154(10):666–71
6. Health Information Technology in the United States: Better Information Systems for Better Care, 2013, report by Robert Wood Johnson®, Mathematica Policy Research and the Harvard School of Public Health.
7. ONC analysis of data from the 2011 American Hospital Association Survey Information Technology Supplement.
8. ONC analysis of data from the 2011 National Ambulatory Medical Care Survey Electronic Health Record Supplement.
9. Adler-Milstein J, Bates DW, Jha AK. “U.S. Regional Health Information Organizations: Progress And Challenges.” Health Affairs. 2009;28(2):483–92.
ACEP Strategic Plan Reference
Goal 1 – Reform and Improve the Delivery System for Emergency Care
Objective A – Develop and promote delivery models that provide effective and efficient emergency medical care in different environments.
Tactic 4 – Promote legislative initiatives and best practices for access to board-certified emergency physicians, via real-time, interactive telecommunications systems from rural and remote areas.
Fiscal Impact
Minimum of $35,000 to include committee and staff time, potential travel, conference calls, and other resources to develop a White Paper, support legislative efforts, and work with the AMA and other external stakeholders.
Prior Council Action
Resolution 22(07) Information Systems for Emergency Care – ACEP Policy adopted. Directed ACEP to update and establish policies regarding the need and utility of information systems for emergency care and produce a paper on the issue.
Prior Board Action
June 2013, approved the policy statement, “EMS Regionalization of Care.”
January 2010, approved revised policy statement, Health Information Standards.” Originally approved June 2003 with the title, “Health Care Data Standards and Interoperable Systems.”
April 2009, approved the “Emergency Department Information Systems White Paper.” The paper was written as a primer for emergency physicians, nurses, and IT professionals.