Health information exchange is a key goal of the HITECH Act and meaningful use program, as it is designed to enable the secure transmission of data between healthcare providers. The American Health Information Management Association named HIE as one of the seven initiatives it will focus on in 2012, and the Office of the National Coordinator for Health Information Technology placed achieving HIE as one of its top goals in its 2011-2015 strategic plan. In addition, a CapSite report found that 74 percent of U.S. hospitals plan to purchase new HIE solutions. Here are seven best practices for hospitals implementing HIEs.
1. Define goals. The first step in developing an HIE, as with many projects, is to define the goals. "Determine strategic objectives, [and] how those are going to be measured. Then determine what's feasible [and identify] top priorities," says Marshall Maglothin, MHA, principal at Blue Oak Consulting, a healthcare firm specializing in electronic medical record implementation, among other areas. He says primary goals should be related to quality, such as preventing readmissions and reducing medical errors.
Other goals, however, will differ between hospitals. For example, Ralph Johnson, CIO of Franklin Memorial Hospital, a rural referral center in Farmington, Maine, says one the hospital's motivations for joining an HIE was to facilitate follow-up with patients after referrals. FMH has participated in HealthInfoNet, a statewide HIE, since 2006. "A large number of our patients will be referred out because we don't do open-heart surgery and we're not a trauma center," Mr. Johnson says. "We're constantly sending patients out of our network. [But] it's almost like a black hole — we don't get feedback on what happened to those patients. Now HealthInfoNet gives us that data."
2. Meet with physician stakeholders. Mr. Maglothin suggests forming a physician advisory board consisting of physician champions, physicians who have reservations about HIE, clinical medical directors of major departments and executives such as the COO, CMIO and CIO. Creating this board will facilitate communication between hospital leaders and physician stakeholders as well as understanding of any resistance to implementing the HIE. "Understand what the reservations and real barriers are," Mr. Maglothin says.
It is important for hospital leaders to understand the HIE initiative from a physician's point of view to be able to identify potential issues and solve them before implementation. For example, Mr. Maglothin says from a physician's standpoint, the number of log-ins required is important because it affects workflow and productivity. Multiple log-ins may take only 30 seconds for each patient; however, when considering the number of patients seen a day, log-ins could account for up to 43 hours per year of unproductive time, Mr. Maglothin says.
Mr. Johnson said minimizing log-ins was one of FMH's goals when implementing HIE technology. The hospital established a system that allows providers to pass directly from the hospital's EMR to the patient's record in HealthInfoNet without a second log-in. "We wanted to keep the patient in context going between the local EMR in the hospital and at the statewide HIE," Mr. Johnson says.
3. Encourage physician champions. "The primary point of strength of a hospital HIE is physician stakeholders," Mr. Maglothin says. A hospital can benefit from "a visionary physician who has experienced medical records and understands the potential for improving healthcare," he says. He says physician champions should drive implementation of the hospital HIE and "[tell other physicians] 'This could be an extremely significant tool to leverage our EMR investment to improve patient care across the board.'"
4. Gain physician buy-in. Gaining physician buy-in is essential to the success of an HIE because an HIE's value depends on the number of users. "Getting the enthusiasm to the end users to use the system is really [when] the benefits [occur]," Mr. Johnson says. While critical to the process, hospitals cannot rely on physician champions alone to achieve the organization's goals through HIE. "The purpose of a hospital HIE is to improve quality of patient care and reduce unnecessary costs. That can only be done if not only physician champions are using it, but also those with reservations," Mr. Maglothin says. He suggests gaining buy-in from physicians with reservations by listening to their concerns and addressing to them.
Mr. Johnson says physicians respond to HIE plans when they learn of the potential benefits, such as faster transmission of data and the reduction of duplicate tests. For example, Mr. Johnson says when he was training a hospitalist to use the HIE he pulled up a patient's chart in the system, which revealed the patient had recently been admitted to a different hospital — information the patient forgot to tell the hospitalist. This information led the hospitalist to determine the reason for the patient's back pain and immediately intervene to reduce the pain.
5. Include other practitioners. Since the benefits of HIE increase in proportion to the number of users, hospitals should include practitioners other than physicians. "When you focus solely on doctors, you're missing a tremendous opportunity for the entire care team to have information they need to take care of their patients," Mr. Johnson says. He suggests extending the HIE to nurse practitioners, nurses, physician assistants, therapists and other professionals involved in the care of a patient. FMH is roughly one-tenth the size of the largest hospital in Maine, but its HIE usage is nearly the same as the utilization of the largest hospital, Mr. Johnson says. "I think [this] is primarily because we expanded; we were not focused on just emergency department doctors using the system. We introduced it to a larger portion of the care team."
6. Work towards interoperability within the hospital. "The obstacle many are reaching now is they still have a number of significant siloed data repositories, diagnostic systems, for example, that collect extensive data, produce a report, but are not necessarily interfaced with other [systems]," Mr. Maglothin says. Hospitals can make best use of the HIE if hospital systems that collect data are interoperable and can thus create one comprehensive database. For example, Mr. Johnson said before implementing the HIE, FMH established interfaces so the HIE could normalize the hospital's data in various forms, such as radiology exams and ICD-9 codes.
7. Don't limit the organization to one HIE. "Hospitals won't [use] one or the other," Mr. Maglothin says. "Large health systems will have possibly their own internal HIE as an internal resource, and also exchange data with a state or regional HIE." Mr. Johnson says when examining a patient, FMH usually begins with the hospital's EMR and then references the HIE to include statewide data. Participating in both an internal and external HIE can enable the hospital to better organize data within the organization and be able to share that information via the regional or statewide system.
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1. Define goals. The first step in developing an HIE, as with many projects, is to define the goals. "Determine strategic objectives, [and] how those are going to be measured. Then determine what's feasible [and identify] top priorities," says Marshall Maglothin, MHA, principal at Blue Oak Consulting, a healthcare firm specializing in electronic medical record implementation, among other areas. He says primary goals should be related to quality, such as preventing readmissions and reducing medical errors.
Other goals, however, will differ between hospitals. For example, Ralph Johnson, CIO of Franklin Memorial Hospital, a rural referral center in Farmington, Maine, says one the hospital's motivations for joining an HIE was to facilitate follow-up with patients after referrals. FMH has participated in HealthInfoNet, a statewide HIE, since 2006. "A large number of our patients will be referred out because we don't do open-heart surgery and we're not a trauma center," Mr. Johnson says. "We're constantly sending patients out of our network. [But] it's almost like a black hole — we don't get feedback on what happened to those patients. Now HealthInfoNet gives us that data."
2. Meet with physician stakeholders. Mr. Maglothin suggests forming a physician advisory board consisting of physician champions, physicians who have reservations about HIE, clinical medical directors of major departments and executives such as the COO, CMIO and CIO. Creating this board will facilitate communication between hospital leaders and physician stakeholders as well as understanding of any resistance to implementing the HIE. "Understand what the reservations and real barriers are," Mr. Maglothin says.
It is important for hospital leaders to understand the HIE initiative from a physician's point of view to be able to identify potential issues and solve them before implementation. For example, Mr. Maglothin says from a physician's standpoint, the number of log-ins required is important because it affects workflow and productivity. Multiple log-ins may take only 30 seconds for each patient; however, when considering the number of patients seen a day, log-ins could account for up to 43 hours per year of unproductive time, Mr. Maglothin says.
Mr. Johnson said minimizing log-ins was one of FMH's goals when implementing HIE technology. The hospital established a system that allows providers to pass directly from the hospital's EMR to the patient's record in HealthInfoNet without a second log-in. "We wanted to keep the patient in context going between the local EMR in the hospital and at the statewide HIE," Mr. Johnson says.
3. Encourage physician champions. "The primary point of strength of a hospital HIE is physician stakeholders," Mr. Maglothin says. A hospital can benefit from "a visionary physician who has experienced medical records and understands the potential for improving healthcare," he says. He says physician champions should drive implementation of the hospital HIE and "[tell other physicians] 'This could be an extremely significant tool to leverage our EMR investment to improve patient care across the board.'"
4. Gain physician buy-in. Gaining physician buy-in is essential to the success of an HIE because an HIE's value depends on the number of users. "Getting the enthusiasm to the end users to use the system is really [when] the benefits [occur]," Mr. Johnson says. While critical to the process, hospitals cannot rely on physician champions alone to achieve the organization's goals through HIE. "The purpose of a hospital HIE is to improve quality of patient care and reduce unnecessary costs. That can only be done if not only physician champions are using it, but also those with reservations," Mr. Maglothin says. He suggests gaining buy-in from physicians with reservations by listening to their concerns and addressing to them.
Mr. Johnson says physicians respond to HIE plans when they learn of the potential benefits, such as faster transmission of data and the reduction of duplicate tests. For example, Mr. Johnson says when he was training a hospitalist to use the HIE he pulled up a patient's chart in the system, which revealed the patient had recently been admitted to a different hospital — information the patient forgot to tell the hospitalist. This information led the hospitalist to determine the reason for the patient's back pain and immediately intervene to reduce the pain.
5. Include other practitioners. Since the benefits of HIE increase in proportion to the number of users, hospitals should include practitioners other than physicians. "When you focus solely on doctors, you're missing a tremendous opportunity for the entire care team to have information they need to take care of their patients," Mr. Johnson says. He suggests extending the HIE to nurse practitioners, nurses, physician assistants, therapists and other professionals involved in the care of a patient. FMH is roughly one-tenth the size of the largest hospital in Maine, but its HIE usage is nearly the same as the utilization of the largest hospital, Mr. Johnson says. "I think [this] is primarily because we expanded; we were not focused on just emergency department doctors using the system. We introduced it to a larger portion of the care team."
6. Work towards interoperability within the hospital. "The obstacle many are reaching now is they still have a number of significant siloed data repositories, diagnostic systems, for example, that collect extensive data, produce a report, but are not necessarily interfaced with other [systems]," Mr. Maglothin says. Hospitals can make best use of the HIE if hospital systems that collect data are interoperable and can thus create one comprehensive database. For example, Mr. Johnson said before implementing the HIE, FMH established interfaces so the HIE could normalize the hospital's data in various forms, such as radiology exams and ICD-9 codes.
7. Don't limit the organization to one HIE. "Hospitals won't [use] one or the other," Mr. Maglothin says. "Large health systems will have possibly their own internal HIE as an internal resource, and also exchange data with a state or regional HIE." Mr. Johnson says when examining a patient, FMH usually begins with the hospital's EMR and then references the HIE to include statewide data. Participating in both an internal and external HIE can enable the hospital to better organize data within the organization and be able to share that information via the regional or statewide system.
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