As states build exchanges, questions linger about interoperability

Introduction

As 56 U.S. states, territories and the District of Columbia inch toward a 2015 deadline for creating “exchanges” allowing health providers to share electronic medical records, those on the front lines of the effort are expressing concern about whether these systems will be able to talk to their counterparts in other regions.

A 2009 mandate from the feds actually requires states to build systems that can communicate with each other, but officials involved say questions about interoperability have largely been put on the back burner while each state or territory struggles to establish an exchange appropriate for its residents.

President Barack Obama’s 2009 economic stimulus bill provided $548 million in grants to help states establish or expand exchanges. Rather than mandate a one-size-fits-all approach, states were permitted to design their own structure, subject to the approval of the Office of the National Coordinator (ONC) for Health Information Technology.

As a result, a wide array of models are being used. Some states are building centralized state databases to house all patients’ health information. Some are building transmission systems to allow providers to securely send records to each other. And some are relying on multiple regional exchanges, tied together but operating individually.

The overall idea is to increase efficiency. By allowing providers to share information, doctors will easily be able to learn about their patients’ medical histories and exchange information.

While an iWatch News canvass of state and territorial exchanges showed virtually unanimous optimism that systems will be operating by the late 2014 or early 2015 deadlines required by grant contracts, this will only guarantee that records can be exchanged within the same state or territory.

But there’s far less optimism regarding information exchanges across jurisdictional borders. A patient living in Arlington, Va., for example, is likely to see providers in his or her Northern Virginia neighborhood, in the District of Columbia, and in the Washington suburbs in Maryland. If the exchanges for these three jurisdictions cannot communicate, the patient’s information will not catch up. The benefits of health information exchanges would therefore be lost for patients who live near state borders, who seek medical treatment while traveling, or who change their residency.

In tourism-driven Nevada, state health information technology coordinator Lynn O’Mara is concerned about ensuring interoperability. “A lot of patients who hold residency outside of the state try to access care when they are visiting,” she said.

Some state leaders have begun informally strategizing with neighboring state exchanges. New York officials, for instance, said they are talking with their New Jersey counterparts to facilitate interstate health information exchange. Ohio, which has contracted with the technology firm Medicity to build its platform, is talking to other states using the same software.

Though Puerto Rico has no bordering neighbors, it too is focusing on interoperability. Dr. José Piovanetti, the territory’s health information technology coordinator, said his agency has “already begun high-level talks with states that have a large population of Puerto Ricans” and states that send large numbers of travelers to the island, such as Florida, New York, Connecticut, Massachusetts and Texas.

Some states are further along in the setup process than others, adding another complication to collaboration. Delaware, for example, was the first state to begin establishing a model for its exchange. Dr. Jan Lee, executive director of the state’s effort, said they are starting to look across their borders. “If Maryland or Pennsylvania were ready, we would love to exchange data with them. So far, they are not.”

Other states have not yet begun to focus on interstate communications. Edward Dolly, deputy commissioner for West Virginia’s state health information technology office, said his state will “focus on interoperability with surrounding states in year two” of their efforts.

Julia Adler-Milstein, assistant professor at the University of Michigan and leading expert on health information exchanges, said a national exchange is technically possible. But federal law did not define what an ideal system should look like, in part to provide state coordinators with more flexibility so they could more easily claim more progress, she said.

A National Exchange

Dori Henry, director of communications for Maryland’s Department of Health and Mental Hygiene, noted that under rules established by the federal grant program, each state that participates must be able to connect to a Nationwide Health Information Network under development. “The national network is not yet in place and will likely not be available for states to connect to for at least another year,” she said. The requirement was spelled out in the office of the national coordinator’s 2009 funding opportunity announcement.

But the national network is already in its embryonic stage. The South Carolina Health Information Exchange, for example, is one of 20 participants already securely exchanging information in the nationwide network — ONC says it expects about 35 entities to be part of the national exchange by the end of 2011.

But much work remains to get all 56 states and territories linked into this system. Parmeeth Atwal, an ONC spokesman, describes the effort as “a challenge of a breadth and scale never attempted in any other nation.” He says the agency has collaborated with the health care community to create “a common standard enabling the electronic movement of health information,” by establishing a “simple, secure, scalable, standards-based transportation mechanism” that gives participants the ability to send encrypted health information directly to known, trusted recipients over the Web even if they are not part of the same exchange. More than 40 states are using this as part of the implementation approach, according to Atwal.

But not all observers are as confident as ONC.

Adler-Milstein of the University of Michigan says the mechanism Atwal references will be akin to secure email and will fall short of the seamless interoperability of a true national exchange, which would give the most benefit. This is “a good interim step,” she says, but there is a risk that providers get used to that and then not move beyond it.

Pam Matthews, senior director of regional affairs at the Healthcare Information and Management Systems Society (HIMSS), a nonprofit that promotes understanding and use of health information technology, said addressing this component of exchange will include significant issues — not just in technology, but other aspects of privacy, security and policy.