Health information exchanges

Technically Speaking

Morris Stemp

Morris Stemp is the CEO of Stemp Systems Group, a health IT solutions provider in New York City.

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How they work, how dermatologists can connect to them and start exchanging information with other practices/hospitals

One of the key objectives of the government’s push for electronic health records (EHR) and their meaningful use (MU) is to facilitate the easy exchange of patient medical records and health information. How much more effective and less expensive might it be to care for an emergency room patient if the hospital could easily access the patient’s medical records from his primary care provider (PCP) and specialists? Would this sharing enable the hospital to more quickly respond to the patient’s symptoms or perform fewer tests? In an ambulatory setting, could a specialist focus limited appointment time caring for the patient rather than taking a patient history, recording allergies, and duplicating tests that are already recorded inside the EHR system of the patient’s PCP?

The government, in its push to encourage doctors to start using health information exchange (HIE), has mandated as part of MU Stage 2 the following requirements related to HIE. Eligible providers (EP) must “(a) conduct one or more successful electronic exchanges of a summary of care records with a recipient using technology that was designed by a different EHR developer than the sender’s, or (b) conduct one or more successful tests with the CMS-designated test EHR during the EHR reporting period.” 

(As of this writing, MU Stage 2 is set to become effective on Jan. 1, 2014. But there are various groups pushing for a delay of its implementation.) [pagebreak]

While on the topic of the electronic exchange requirements in MU Stage 2, it is important to note that exchanging information with another EHR is not the only electronic data exchange requirement mandated under Stage 2. These additional requirements include:

  • Use secure and encrypted messaging to communicate with at least 5 percent of patients.
  • Provide patients with the ability to view, download, and transmit their health information within four days of a patient visit and encourage at least 5 percent of patients to use this ability.
  • Provide a summary of care record electronically to other providers to whom patients are referred.
  • Send electronic data to immunization, cancer, and other registries.
  • Finally, as an additional motivator, in April 2013 the Department of Health and Human Services started to consider requiring electronic Health Information Exchange (HIE) as a condition of participation in Medicare.

Naturally, eligible providers, including dermatologists, are anxious to find out how they can take part in this exchange, not only to meet all the new government requirements but also to simplify the exchange of information with other providers, reduce medical errors, minimize costs, and improve the overall quality of patient care.

Getting started with health information exchange

HIE requirements can be satisfied by exchanging data through a number of exchange environments, including:

  • Exchanges set up by specific EHR vendors,
  • Private exchanges set up between providers and hospital groups, or
  • Regional health exchanges set up by a local or state government. [pagebreak]

Vendor exchange

Some vendors have integrated electronic health information exchange directly into their EHR software. eClinicalWorks (eCW), for example, has built a peer-to-peer network called P2POpen which allows secure communication between providers in their P2POpen network regardless of the EHR system used. Users of eCW invite providers into their network to collaborate with them. Providers are located using a master search list, and faxed or emailed invitations can be sent to any provider regardless of geographical location. If that provider is not already on the P2P network, the message invites him to join and includes a link to the eCW P2P Portal. According to eCW, “P2P facilitates referrals, streamlines scheduling appointments for patients with the other providers, and enables providers to transmit patient records with attachments, including progress notes, lab results, medical summaries, and scanned patient documents.”

Private exchange

A private HIE is coordinated by a health care organization such as a hospital system or ACO, through private funding, to connect constituents in the area and align to its business goals. A provider generally needs to be affiliated with the organization to participate in the private exchange, and in many cases, needs to use the EHR designated by the hospital.

One example of a private HIE is the eHealth Connection sponsored by the Inspira Health Network in New Jersey. Inspira Health Network is a community health system comprised of three hospitals with more than 5,000 employees and 800 affiliated physicians. According to Inspira’s website, the “eHealth Connection is a network that links all Inspira facilities and its physicians, allowing participating providers the ability to exchange health information.” Inspira further describes the function of the HIE as follows: “HIE allows the sharing of your health information among participating doctors’ offices, hospitals, labs, radiology centers, and other health care providers through secure, electronic means. The purpose is to provide participating caregivers the most recent health information available. This health information may include lab test results, radiology reports, medications, hospitalization summaries, allergies, and other clinical information vital to your care. Certain demographic information used to identify the individual such as name, date of birth, address, insurance may also be shared.” [pagebreak]

Public HIE

The government has loftier goals than the limited vendor or hospital networks. It seeks the exchange of information between all providers across the nation. To accomplish this public HIE, the government has funded Regional Health Information Organizations (RHIOs) and charged them with establishing HIEs for their designated regions within their states. The ultimate goal is a nationwide health information network (NHIN) which plans to connect all health care information providers, including HIEs, health plans, providers, and federal agencies through a national health exchange. (I previously addressed this topic in June 2012; see sidebar at

To enable HIE and improve health care in its region, a RHIO can enable secure sharing of medical records in one of two ways. In the centralized model, the RHIO uploads and collects all the medical records from all of its participants and stores this massive amount of data on its own servers in its own infrastructure. In the federated model, the RHIO provides the infrastructure to facilitate the access requested by one provider to medical records stored in the systems maintained by other providers and supported on those other providers’ infrastructures. In this model, the HIE does not collect, hold, or maintain any medical records within the RHIO’s systems. There are pros and cons to each of these methods in terms of privacy concerns, costs, and speed of access.

RHIOs require patient consent before patient information may be shared. Some RHIOs have an opt-in format which requires that patients sign an agreement to permit their information to be shared. Others assume that patients give their consent unless a patient specifically opts-out. [pagebreak]

In order to participate in a RHIO, a provider may be required to pay one or more fees including a one-time integration fee, a one-time implementation/setup fee, an annual fee for basic services, and an implementation and/or annual fee for optional premium services. Some fees are based on the number of providers and some are charged on a per-practice basis. The actual fee may be dependent on the size of a practice or the type of health system or organization. In some cases, the fees may be subsidized by a government agency or possibly a hospital system. In order for the provider to participate electronically using his EHR, the EHR must be certified for MU Stage 2 which means that the EHR has been tested to support the interoperability standards required to share data through an HIE.

In NYC, for one to five providers, the fees can range as follows:

  • Integration fees from zero to $500 per practice
  • Implementation fees from zero to $3,500 per practice
  • Annual fee for basic services from $240 per provider to $1,000 per practice
  • Premium services fees of $1,000 for implementation plus $250 for annual support

Some of the services provided by an HIE include:

  • Patient record lookup to access the patient’s medical data.
  • Real-time notification of a patient’s medical status or update to the patient’s provider sent through a secure email or text message. For example, a provider can be alerted via a text message that a patient was admitted to the hospital.
  • Consent management.
  • Direct exchange (via secure email) of medical records for a given patient:
o To a receiving physician upon discharge from a hospital,
o To a specialist from a primary doctor, and
o To a practice from a lab.
  • Analytics across multiple sources of clinical and administrative data.
  • Quality reporting and public health reporting.
  • Patient portal (for patients to access their medical records as required by MU). [pagebreak]

How one HIE gets sharing done

To understand exactly how HIE works within a RHIO, I spoke with Jason Thaw, a senior account manager at Healthix, a RHIO located in downstate New York where I live and the largest RHIO in New York State. Healthix connects over 250 hospitals, clinician practices, nursing homes, radiology centers, diagnostic labs, and other providers with information about more than seven million patients.

When joining Healthix, providers notify their EHR vendor so that the vendor can work with the HIE to develop the interface and set up any additional services requested by the provider. Healthix offers a single sign-on which works directly within the EHR system and enables providers to access the RHIO through a tab on their EHR.

Healthix services include patient data search, consent management, secure email, and real-time event notifications. To search for patient data, providers access the patient’s record and then click on the Healthix tab to search the HIE for other medical records associated with that patient. All data is real-time and results typically display within seconds. Therefore, as soon as a lab result is available, even if the lab test was not ordered by the provider, Healthix can retrieve it, send an alert notification to the provider, and display the results the next time any provider (with consent) queries this patient.

New York is an opt-in state. When a patient goes to the doctor, she signs a consent form allowing or denying that doctor to view any of her medical records from any other facility connected to the RHIO. The consent does not relate to sharing of the medical records, but to who is permitted to access the records. [pagebreak]

Healthix follows a federated model and does not create a central repository of clinical information. Instead, it routes encrypted electronic transactions among participating institutions so that they may exchange patient clinical data which resides in systems behind the firewalls of the acquiring organizations. Healthix maintains a central registry which identifies which patients have information and where it can be found.


The function of HIE is to facilitate secure and efficient sharing of patient medical records between providers caring for the same patient. The goal is to reduce the cost of providing medical care and improve the quality of patient care by eliminating duplicate diagnostic testing and making records available when and where they are needed. But the system can only work if all the providers in a given community join the system. Once MU Stage 2 takes effect, more practices will join and, over time, membership fees are expected to drop. Start researching the HIE options and services in your communities by contacting the local regional extension center. Within the next few years, HIE participation will be a requirement. Now is the time to get onboard to be ahead of the curve.