Tuesday, December 15, 2015

The Evidence Base for Health Information Exchange

One of my major projects over the last couple years has been a systematic review of the research that has been conducted on health information exchange (HIE). I wrote about this project when it first started and when our protocol for the review was posted for public comment. The report was funded by the Evidence-Based Practice Centers Program of the Agency for Healthcare Research and Quality (AHRQ). While the review itself has been done for several months, we have been finalizing the report and publications derived from it since then. I am pleased to report that both the complete report [1] plus a paper reporting on the outcomes from studies of HIE [2] have now been published. There will be some additional papers on other aspects of the report as well as a book chapter summarizing the report to be published next year [3].

This report has certainly given me the opportunity to reflect over the last couple years of the state of HIE and the interoperability required to support it. The major finding of the report echoes findings of a similar couple of systematic reviews I led on the topic of telemedicine published in 2001 [4] and 2006 [5], which is that the breadth and quality of the research are limited. There is no question that performing research on HIE is difficult. After all, HIE is not a test or a treatment, but rather a tool that facilitates other aspects of healthcare. Nonetheless, the research base for HIE is limited, and should be improved if we want to discern it benefits and optimal use. The paper provides our recommendations for improving research on HIE outcomes going forward [2].

Our report also gives us an opportunity to think about some of the larger issues around the current role and future directions of HIE. If I had to lament about HIE, I would say that it is an unfortunate requirement at this time for us to need so many different organizations (135 according to the last eHI annual survey of them [6]) devoted to HIE. In the ideal world, there would be no need for HIE organizations, but instead, there would be sufficient interoperability of systems, along with rules and regulations, to allow information to flow seamlessly between appropriate parts of the healthcare system. For example, a physician in his or her office could seamlessly transmit a consultation, receive laboratory results or a discharge summary, or notify a public health department of a reportable event without requiring an HIE entity to facilitate those activities. The information transmitted would be formatted into some standardized form and sent securely to an authenticated site, all facilitated by standard protocols used by the entire industry.

Hopefully the new emphasis of ONC on interoperability [7] and the underlying standards required [8] will facilitate more seamless HIE. While many have argued that the criteria for meaningful use should have placed more emphasis on secure and standardized information exchange rather than specific EHR functionality, such as clinical decision support or specific quality measures, that is all now proverbial water under the bridge. I am certain everyone agrees that we need to focus on seamlessly interoperable health IT going forward. I also hope in the process that robust research is carried out, not only to assess the value of HIE but also determine the best ways to implement it.

An interesting side note to this report is an episode related to another systematic review on HIE that was published in late 2014 [9]. One of our competitors for the contract that was awarded by AHRQ to our institution went out and found another source for funding to carry out a review. Not only did they perform a review that was reduced in scope from our review (it omitted public health and any type of HIE outside the US), but they were also able to bypass all of the processes that AHRQ has to insure the systematic reviews it funds have stakeholder engagement, public comment, and broad peer review. As such, the other group was able to complete their review well in advance of ours and get it published in a very high profile journal, Annals of Internal Medicine. That journal publishes a good number of AHRQ-funded systematic reviews, but understandably did not want to publish ours after they had already published another systematic review on the topic of HIE. While I have no problems with science being competitive in terms of accolades going to the first to publish, I do find it disappointing that another group basically duplicated our review and short-circuited the usual processes of AHRQ.


1. Hersh W, Totten A, Eden K, Devine B, Gorman P, Kassakian S, Woods SS, Daeges M, Pappas M, McDonagh MS. Health Information Exchange. Evidence Report/Technology Assessment No. 220. AHRQ Publication No. 15(16)-E002-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2015. http://www.effectivehealthcare.ahrq.gov/ehc/products/572/2154/health-information-exchange-report-151201.pdf.
2. Hersh, WR, Totten, AM, et al. (2015). Outcomes from health information exchange: systematic review and future research needs. JMIR Medical Informatics, 3(4):e39. http://medinform.jmir.org/2015/4/e39/.
3. Hersh, WR, Totten, AM, et al. (2016). The Evidence Base for Health Information Exchange. In Health Information Exchange: Navigating and Managing a Network of Health Information Systems. B. Dixon. Amsterdam, Netherlands, Elsevier, in press.
4. Hersh, WR, Helfand, M, et al. (2001). Clinical outcomes resulting from telemedicine interventions: a systematic review. BMC Medical Informatics and Decision Making. 1: 5. http://www.biomedcentral.com/1472-6947/1/5.
5. Hersh, WR, Hickam, DH, et al. (2006). Diagnosis, access, and outcomes: update of a systematic review on telemedicine services. Journal of Telemedicine & Telecare. 12(Supp 2): 3-31.
6. Anonymous (2014). 2014 eHI Data Exchange Survey Key Findings. Washington, DC, eHealth Initiative, http://visit.medicity.com/rs/aetnainc/images/2014%20eHI%20Data%20Exchange%20Survey%20Results.pdf.
7. Anonymous (2015). Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap version 1.0 (Roadmap). Washington, DC, Department of Health and Human Services. https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdf.
8. Anonymous (2015). Draft 2016 Interoperability Standards Advisory. Washington, DC, Department of Health and Human Services. https://www.healthit.gov/standards-advisory/2016.
9. Rudin, RS, Motala, A, et al. (2014). Usage and effect of health information exchange: a systematic review. Annals of Internal Medicine. 161: 803-811.

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