Journal of AHIMA - May 2011

The industry requires more leadership on HIE. Sharing information across
enterprises is not instinctive—other priorities will prevail. —Bill Bernstein

But because state-level HIEs are using different models and offering different services, it would be difficult to require providers to use state-level HIEs as a part of meeting meaningful use, Williams says.

“Saying, ‘You must use the HIE’—what does that mean when
the [state-level HIE] model in Vermont and the model in Ten-
nessee and the model in Wyoming are totally different?” Wil-
liams says. “So I think that we just have to be a little more passive
in using these.”
Though she would not recommend requiring use of the state-
level HIEs, Williams says that all state HIEs should provide ser-
vices that are useful in meeting meaningful use for both large
and small, urban and rural providers. This requirement has
been considered when ONC approves state-level HIE models
and plans.

Many of the stage 1 meaningful use requirements that involve health information exchange can be done using Direct or other electronic specifications. While many HIEs may choose to include Direct in their offerings, providers may have other options through which to use the service, such as a local hospital. But Direct could serve as a launching pad that shows providers the benefits of exchange and convinces them to use the more complex HIE, Torzewski says.

Meaningful use is moving faster than the state HIE program, which causes some disconnect in the ability of the two programs to meet. It is understandable why ONC has been hesitant to aggressively push HIE on providers—both the providers and the HIEs are not fully ready.

“ONC recognized that if they incorporated too many HIE requirements in stage 1 meaningful use, and they may be right about this, that the market just couldn’t handle those requirements,” Frohlich says. “There just wasn’t enough capacity in the market to deal with 100 percent e-prescribing and lab results delivery and patient visit summary delivery in two or three years.” The lack of HIE promotion by ONC can be corrected in the stage 2 meaningful use requirements, Frohlich says.

“I think they need that, and they recognize that, and they are now trying to catch up,” he says.

Because meaningful use funding steps down significantly over the years, now is the time to better tie HIE to the program if the government hopes to entice HIE participation through the promise of incentive payments. This will help get the critical mass of HIE participants that is needed for HIE to provide valuable services to providers.

A Better Link between Meaningful Use and HIE Better linking the meaningful use criteria to the state-level HIEs would greatly increase the chance for HIE success, Bernstein

says. The healthcare community cannot afford to just let the market figure out how the various HIE pieces fit together.

“Sharing of information across institutional and enterprise
lines is not something that people do instinctively, because they
have lots of other priorities,” Bernstein says. “I think you have
to be more directive if you want that to take place. And I don’t
think that sort of direction has come forward to date.”
Providers should be able to meet meaningful use require-
ments in multiple ways, but state-level HIEs should be in a posi-
tion to help them.

“The debate right now is it’s very, very important in the next
stage of meaningful use that these federal investments [in HIE]
are actually connected in a real way to the receipt of meaning-
ful use dollars,” Bernstein says. “That is probably the single most
important policy change, given the construct of where we are
right now, that needs to happen.”
The PCAST recommendations on changing ONC’s HIE strat-
egy are currently being evaluated by ONC’s Health I T Policy and
Standards Advisory Committees, which are also in charge of
drafting criteria for stages 2 and 3 of meaningful use.

The group is working on ways to incorporate PCAST’s recommendations into meaningful use and other ONC initiatives, Fridsma says.

Final recommendations on stage 2 meaningful use will be announced this summer, but in a preview of stage 2 issued earlier this year, some of the HIE measures had increased.

For example, in stage 1 providers merely had to perform a test
of HIE in order to meet the criterion. The proposed stage 2 rec-
ommendation for that same measure, which would take effect
in 2013, states providers must “connect to at least three external
providers in their primary referral network (but outside their
delivery system that uses the same EHR) or establish an ongo-
ing bidirectional connection to at least one health information
exchange.”
Much of the upcoming health reform agenda, including bol-
stered quality reporting and pay-for-performance initiatives,
will rely on organizations adopting EHRs and participating in
HIEs.

Bernstein believes that ONC is up to the challenge of better aligning its efforts around HIE and in turn improving healthcare. But time is running low.

“They realize that they have had to move very fast, and they are taking a breath and are going to recalibrate and hopefully come out with some improved thinking on how to make the pieces all fit,” he says. ¢