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Exchange: What's in a Word?
February 22, 2011
 
The Health Information Exchange, (HIE) at HIMSS11 appears noticeably different than the HIE of HIMSS past. HIE will be ubiquitous. It is not just a topic for a Sunday session any more. Of the 26 sessions that listed HIE as a topic, only eight were specific to the topic. The dedicated Sunday session seemed informative but predictable. Speakers provided perspectives from the federal government, states, and stakeholders. The session also included a Town Hall Meeting, a treatment of consumer engagement, and - my favorite topic - financial sustainability.

Scratch beneath the surface of most topics, and one may find a bit of HIE. It is central to many strategies including Meaningful Use, e-Referrals, workflow management, regional performance improvement, wired BEACON communities, quality measurement, public health, and it will play a growing role as providers and health plans form new relationships.

Each of the more than 20 sessions that place great emphasis on HIE presents an informative perspective very distinct from all of the others. Each presentation is a small chapter in a book describing the far-larger elephant of health care transformation. Confusion is to be expected; the "exchange" in the term HIE has many different meanings.
 
To some, HIE is a "thing" - a regional organization providing exchange services or a state-level organization either providing similar services or fostering exchange through other means (this a bit like a "stock exchange.") To others, HIE is the act of communicating information from one point to another in hope of providing additional value to the point of decision-making or care. (This is more akin to an auto parts swap meet.) To Clayton Christensen, Jason Hwang, and others, exchange is an economic model for commerce (this model - the facilitated user network - is more like Napster.)

As a HIMSS attendee or an interested observer, it is important to keep these various models in mind when walking among the vendor exhibits or attending the scientific sessions. It is important to remember that the Electronic Health Record (EHR) is not simply a "computerized record" as much as it is a communications device operating within a vast and increasingly seamless network of commercial and clinical affairs. With or without health care reform, inevitable and consequential reimbursement changes will be taking place.
 
We are living longer; we are gaining weight; our technologic advancement is driving up costs and, as medical advances further prolong our lives our costs will rise even higher. Capitation and bundled payments based on outcomes seems inevitable. Our health plans will be armed with the capabilities to understand care delivery across often-competing providers. The integration of health plans with technologies that both foster data exchange and promote analysis will allow health plans to maintain the upper hand when negotiating with a fragmented provider base.
 
Providers, therefore, must develop similar capabilities for exchanging data with others caring for the same patients. This is essential to provide better care. Financially, it may help confer some parity in health plan negotiations. Patients - paying a growing percentage of their health care costs - will seek information from providers, health plans, or third parties. Those who are not part of the "big picture" of an individual’s care risk marginalization.

With the thought of marginalization in mind, it is helpful to return to how HIE is - and is not - like the defunct Napster. Like Napster, the act of HIE recognizes that a participant can be both a buyer and a seller. Like Napster, HIE disrupts the conventional economic model. Like Napster or any new technology, it can take several years for mature and sustainable HIE business models to emerge. But unlike Napster, HIE can be secure, consent-driven, and implemented in a way that confers positive economic gain without threatening privacy or intellectual property.

Because connectivity is central to Meaningful Use, Farzad Mostashari’s comments on the latter topic seem equally applicable to HIE. Like Meaningful Use, effective collaboration to exchange information is essential to what Mostashari said was essential to "preparing institutions to thrive in the new health care financing economy.”
 
HIE is essential to effective use of HIT which in turn is, to use Mostashari’s terms "the down payment and the kick-start of all the process changes and information changes people are going to have to make to be successful in a new transformed health care system." Meaningful use and effective communication among providers and payers may change the rhetoric to a proactive approach toward improving care and away from a reactive "jump through hoops to get paid" mind set. 

As one follows HIMSS from near or afar, the search for new models will continue. Connectivity will foster new vertical and horizontal integration strategies for supporting care delivery. Health plans may pursue vertical integration strategies by coupling claims systems, analytic systems, and connectivity solutions in an effort to tighten care integration and to reimburse through more accountable care models. Established claims clearinghouses, e-prescribing mediators, and others with robust directory structures and identity management approaches will pursue horizontal integration strategies by using their mature infrastructure to provide at a very log marginal cost a far wider array of secure messaging services.
 
Those seeking inexpensive and secure communications among providers, laboratories, public health agencies, and other groups may not have to depend on a regional health information organization. This progress is accelerated as a result of a concerted effort at the federal level to create lightweight communications protocols and standards. The security and relatively low costs of these emerging efforts suggests that over the next few years little if any excuse will be left for practitioners who choose to work in digital isolation. Consumers and privacy advocates will debate the implications of these new practices. Anti-trust experts will study how exchange-mediated communications change market forces.
 
The debates will continue as the health care technology industry tries to respond to unprecedented turbulence. And refinements and fresh ideas like the Computer Science and Telecommunications Board and President's Council of Advisors on Science and Technology  reports will keep coming.

In the final analysis, HIMSS this year - as it is every year - is a stage upon which a struggle for power is played out. Financial disputes, privacy debates, and anti-trust charges will most certainly grow in value as new models are tested and explored. But no matter what the outcome, in the unfolding drama of HIMSS11 health information exchange is a principal player on the stage.