Monday, 8 May 2017

Benefits of an Integrated Health Information Platform #IHIP by @msharmas


We have seen the benefits of Aadhar and how a public data repository can be used for public good. Population Health based clinical data repositories too can play a similar pivotal role in providing potentially great benefits

The use of Healthcare IT in the Indian context is picking up with most of the corporate hospitals going for the #EHRs and HIMS solutions. And these are present mostly in the Tier I cities and urban areas. There is a move now to get these solutions to the Tier 2 and Tier 3 centers as well. I would be looking to review reports that highlight percentage of IT enablement in Healthcare facilities, as part of follow up articles to this one.
The Center for Healthcare Informatics has rolled out an RFI detailing the requirements of an Integrated Healthcare Information Platform (IHIP). You can also visit the dedicated website to review the details of the IHIP RFI:
In this article I would like to highlight the benefits that will accrue from implementing such a solution in India. With no historic data of past implementations of such a system in India, I have reviewed the information available in journals and public domain regarding similar implementations across the world and what are the benefits and barriers in implementing an Healthcare Information Highway of patient healthcare data.


Benefits of Implementing an HIE
  1. Benefits of Implementing HIEs:
HIEs that have been implemented in the US have conclusively shown emergency departments gaining efficiency in patient visits with the use of HIE based solutions.
HIEs have shown to reduce the length of patient stay, readmission risk, and number of doctors involved in patient visits [1].
HLNY ER Dept Infographic_HIEGains.png
  1. Discharge Planning
One of the examples of benefits of an HIE, is the ability to generate alerts 24-hour to 48-hour prior to the patient's’ discharge to Transportation services, Pharmacies at the patient’s location and alerts to help patient identify long term care and home care facilities. [2]
  1. Transfer of Radiology Images:
Currently the process of exchanging patient radiology images either does not exist or at best is time consuming with problems faced by the patients and providers treating the patients.
The ability to access and view radiology images is important for an accurate and timely patient diagnosis and treatment. Historically, the process of image exchange has happened via CDs with an understanding the receiving and reviewing physician will have the ability to view the PACS images leading to high costs and long time to diagnosis.
Enabling a Transfer to PACS capability helped in cutting these lacunae in the image sharing workflow, enabling providers to quickly share images with each other. [3]
  1. Vaccination and Immunisation details:
HIEs are now moving towards incorporating the exchange of patient immunisation details. Thereby enabling patient centered technology implementations.
  1. Disease Surveillance and Immunisation Records
IHIP will provide increased view of disease outbreaks and allow the governments at the state and national levels to deploy resources effectively and efficiently. IHIP based identification and surveillance of disasters and outbreaks is a big benefit of implementing a platform such as IHIP. And additional areas that provide a fillip to the IHIP-initiative needs to be identified and those aspects of the IHIP needs to be implemented in the initial stages.
  1. Medication Information Sharing via HIEs:
The ability for the patient to build and maintain an electronic Drug Profile is important for the continued care for the patient. Presence of a Comprehensive Patient Drug profile has direct correlation to improved patient safety. Improved medication information processing has a direct correlation to the benefits of an HIE like the IHIP since it will be able to provide a more complete clinical picture of the patient. [4]
  1. Telemedicine service enabled by HIEs:
Telemonitors will be able to provide patients a way to measure and record their vital signs daily from home using a touchscreen tablet/ mobile/ PC. The information will be then wirelessly transmitted to nurses monitoring the information for changes, giving patients with, complex disease states such as heart and respiratory conditions, a sense of empowerment around their health. Telehealth has far reaching benefits for specialists providing their services to patients in the rural, underserved and non-tier I cities. With the presence of digital payment gateways and transactions, Telemedicine is fast becoming a viable business model for certain types of visits(e.g., follow-ups, referrals). [5]
  1. New Use Cases for an HIE:
When HIEs have been implemented, new use cases can emerge that extend the usefulness of HIEs. For example, HIEs have been able to send hospitals alerts and reminders when patient transitions occur, device to device data transport, sending and receiving of claims attachments, and exchanges of documents for referrals [6]
  1. Security of Patient Information (PHI):
The greatest benefit of an IHIP-like solution is the Implementations of Security protocols for transport and transfer of patient information between healthcare facilities and between patients and hospitals. This ensures creation of “Trust” centers of patient data.
  1. Improves the Trust in sources of information
One of the reasons a physician would order for a repeat test for a patient in case of a referral, would be “Trust” on the presence of a similar/ same test result available for the patient in an earlier visit. Enabling information sharing via IHIP in a standardised and secure format will enable “Trust” between healthcare facilities as trusted sources of information. [7]
  1. Strategies to avoid Information Blocking:
Information Blocking has been known to be a major cause of hindrance to the benefits brought out by an HIE. Information Blocking is healthcare facilities not sharing patient healthcare record information causing holes in the episodes of care of a patient’s longitudinal record. To avoid this from happening, “Increasing transparency of EHR vendor business practices and product performance, stronger financial incentives for providers to share information, and making information blocking illegal were perceived as the most effective policy remedies,” wrote researchers. [8]
  1. Paradigm Shift in HIE from 1.0 to 2.0:
HIE 1.0 was characterized by a focus on “the noun,” that is trying to address perceived market failures by solving a wide variety of rich use cases through comprehensive interoperability.
By contrast, HIE 2.0 focuses on the verb that is trying to meet market needs most pressing to participating providers; HIE 2.0 has fewer legal challenges because it is trying to tackle less complex use cases and in many instances has the ability to marshal financial, technical and organizational resources. Tripathi also pointed out that HIE 2.0 comes in many shapes and sizes including point-to-patient; point-to-point; vendor-specific; transaction-specific national level; enterprise-level HIE organizations; State-level and regional collaborative HIE organizations and National level collaborative HIE organizations.
Three areas identified to spur innovation and move towards HIE2.0 were: Lab data transmission, Lightweight directed query of patient information, eCPOE and measures.

Problems Implementing HIE: A review of Global HIE Experiences

  1. Unspecified Interoperability Standards:
Barriers to HIE relate to incomplete and unspecific interoperability standards and the cost of interfacing the EHR with the HIE.  The lack of mature, agreed standards around interfaces, patient consent and patient identification are significant barriers to success.
  1. Accurate patient identification is not only a data management and data quality issue, it’s also a patient safety issue
  2. Clinical Information Generator and Vendor relations
In the India context, healthcare facilities like hospitals, laboratories, pharmacies deploy systems that are proprietary in nature and not necessarily standards based. In the event of strained relations between healthcare facilities and respective vendors, there is a need to consider addressing the need to have the patient related information to be relayed to the patient in a HIE readeable format. This information can then be uploaded by the patient thereby ensuring the continuity of care records are maintained in the IHIP, specific to the patient.
In this scenario, there could be a loss of updates to the public health based registries and the hospital based registries and it should be incumbant on the hospital to ensure the data is transmitted before the changeover of systems happens.
  1. Identifying ROI for various Stakeholders
A study needs to be enabled by the government at the national and state levels that will study the benefits of implementing interfaces that will share information between the Healthcare facilities and the IHIP. Potential savings can be quantified based on cost and projected savings in improved efficiencies enabled by the implementation IHIP towards patient safety and care coordination for the stakeholders.
Additionally, its important to quantify the cost of implementing HIE-based interfaces by the various healthcare entities (like Hospitals, Laboratories, Diagnostic centers, pharmacies, etc). It will be important to identify the Revenue Streams to sustain IHIP data sharing, and how can it be sustained by the stakeholders.
  1. Breach of Security of Data contained in IHIP or connected interfaces
We have seen various types of hacks that have breached the security of patient records stored in hospital systems. Enabling security at various levels needs to be ensured before any of the Stakeholders connect with the IHIP. Security guidelines will have to be defined and adhered to and reported on a regular basis as a regulatory requirement.
Security is also necessary at the IHIP level which has been defined as a main requirement for developing the IHIP infrastructure.
In the US Architecturally, RHIOs employ either the CHMIS approach of a centralized database, the CHIN model of federated independent databases, or some combination of the two, hybrid model.
  1. Usability & Access to Information Ok, so the data about a patient has been stored in the Data Repository for all to access and review at the time of emergencies, for enabling a continuity of care record for the patient and for generating population health management analysis. But, what if the data is not easily accessible, the functionality to access the care information of the patient, requires multiple access requests and clicks and permissions. What if, the data has now been stored in the public data repository, who can access it? Who can view it? Can there be an unauthorised data access by persons not connected to the health care of the patient? [25]
  2. Information Blocking:
For-profit EHR vendors have a natural vested interest in increasing revenue by limiting the flow of data.
“The specific forms of and perceived motivations for information blocking were harder to predict a priori,” Adler-Milstein & Pfeifer explain. “What we found in relation to specific forms is that EHR vendors appear to most often engage in information-blocking behaviors that directly maximize short-term revenue. Our respondents reported that EHR vendors deploy products with limited interoperability and charge providers high fees unrelated to the actual cost to deliver those capabilities or refuse to support information exchange with specific EHRs and HIEs.”
Hospitals and health systems likewise utilize information blocking as a means to prevent clients from seeking services elsewhere to keep from losing out to the competition.
“In our results, the most commonly reported forms of information blocking among hospitals and health systems point to their interest in strengthening their competitive position in the market by controlling patient flow, which has been reported in other studies,” they wrote.

Interoperability in Healthcare: Some thoughts to share

Having followed the implementations in India for sometime now, I always wonder why interoperability is not a top priority or not implemented in most systems. They are HL7 compliant, but are they really interoperable? And I dont mean the part from HIMS to Lab or Rad equipment, that part is fairly well defined and documented. 

- But from the Patient to Hospital to Patient
- Patient to Insurance to Patient
- Patient to app to hospital to Patient

Take for instance most systems are able to share the discharge summaries as emails to patients, and a print out, even today. But on discharge can the patient "share" her discharge summary from an app or application to another practitioner who takes care of the patient rehab? Are for instance, the systems involved in the above use case, interoperable? 

Another point, how many Healthcare Apps (the production versions) have any data sharing via standards? They can however email PDFs of the recorded data. So what can be done to enable out-of-the-box interoperability in the Healthcare Apps? With the growing number of mHealth Apps, we will soon find ourselves in another new set of "Data-Silos" being created on a daily basis.

Recently we moved from Cash to Cashless to Less Cash scenarios ... so is it right to say, in healthcare context, we are working from a Paper to Paperless to Less Paper scenario in Healthcare before going totally paperless? 

And if so: 

1. What will be the business case for interoperability and for sharing the discharge summary/ medications in a format that is easily exchangeable?

2. Can a Healthcare IT think tank, work on defining the standards of "workflow" of the data being generated in healthcare today? Starting from the Patient through the healthcare ecosystem and back to the Patient?


3. Can the Healthcare IT vendors form a group of HIMS, LIMS, Pharma Apps, HomeCare solutions that enable a "Patient Data Workflow" exchange group (a mini-IHIP) that actually enables the "Interoperability" of patient data as a great showcase. It could perhaps be tied to the IHIP effort or NDHA. It adds onto the work that is being planned in the Phase 1 of the IHIP project, by being able to provide feedback on issues, solutions, recommendations, pain points etc.

Its important to note, that a system like IHIP has a potential to solve the accessibility of patient care problem in India. My view is that there is a need to see interoperability from a Patient's point of view rather than from the point of view of "Systems". There is a need to map the flow of data from the Patient and back to the Patient, and this can help in enabling a radically different approach to interoperability in Indian Healthcare.

With Aadhar based solutions allowing for the consumer information to be securely transmitted and verified, it only behoves well if we were to adopt an "HIE of Patient" approach to IHIP wherein the Information is exchanged between various stakeholders in the Patient's Care Continuum and that information finally rests with the Patient's Electronic Health Record (PEHR). With the EHR standards mandating the Healthcare Information belongs to the patient, it will be extending that mandate to IHIP.

And here is a review by Mr. Rajendra Pratap Gupta, Policy Maker, Researcher, Author, TED Speaker, Economic & Political Strategies, Innovation, Healthcare) on how "India aims to be a Global Leader in Digital Health, https://www.linkedin.com/pulse/india-aims-global-leader-digital-health-rajendra-pratap-gupta


References

  1. Cancer Care set for Digital Leap with the National Cancer Grid in India: http://health.economictimes.indiatimes.com/news/health-it/cancer-care-set-for-digital-leap/58758858
  2. NY Health Information Exchange Improves ED Quality, Efficiency
  1. HIE Partnership to improve Health Data Exchange of Imaging
  1. Health information exchange and patient safety
  1. Vermont HIE adds telehealth component
  1. DirectTrust HIE growth shows priority of Interoperability
  1. Health information exchange: persistent challenges and new strategies
  1. Health Information Exchanges report Information Blocking
  1. Maine Rural Veterans Health Access HIT Strategies
  1. The Value Of Health Care Information Exchange And Interoperability (a must read paper on how the costing for HIEs can be done)
  1. Health information exchange: persistent challenges and new strategies
  1. Information Blocking: Is It Occurring and What Policy Strategies Can Address It?:
  1. What is HIE?:
  1. Health Information Exchange?:
  1. HIE Benefits?:
  1. Guide to Evaluating Health Information Exchange Projects
  1. HIMSS Library for Information on HIEs
  1. Health Information Exchange - Overview
  1. 10 things to know about health information exchanges
  1. Selecting & Using a Health Information Exchange | AMA
  1. The Sequoia Project eHealth Exchange
  1. What is Health Information Exchange? | HIMSS
  1. IHIP, India
  1. Are Data repositories set to become data dumps? https://www.digitalhealth.net/2017/04/another-view-neil-paul-21/
  2. Powering the Patient Relationship with Blockchains: https://www.healthit.gov/sites/default/files/7-29-poweringthephysician-patientrelationshipwithblockchainhealthit.pdf
  3. Lessons from the UK | Healthcare IT News

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Manish Sharma
Founder HCITExpert.com, Digital Health Entrepreneur

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