The best way to gather information is to go straight to the source. This is exactly what the ONC has done to learn and assess the health of health information units, also known as health information exchange organizations (HIOs), across the country. A recent study by Dr. Julia Adler-Milstein of the University of California San Francisco (USCF) carried out the survey with the support of the ONC is the sixth national HIO survey of its kind. This instrument placed a special focus on the proposed ones Trusted Exchange Framework and Joint Agreement (TEFCA). We contacted 151 HIOs and asked questions to get a clearer picture of their state of play. (We have incorporated organizations that support operational electronic HIE into independent facilities.) Some questions we answered were: What coverage do HIOs offer and who are their participants? What services do they offer and what obstacles do they face? How closely are you networked with other HIOs? What are your current plans for participating in TEFCA?
We have published these and other findings in the latest edition of the journal Health matters.
Current status of the HIOs
The thoughts of health information organizations on TEFCA are central to building an interoperable network that enables HIOs and health organizations to securely share electronic health information not only with one another, but also with providers, individuals and health plans.
At the time the survey was conducted – May 2019 to February 2020 – a majority (56 percent) of HIOs said they were planning to participate in TEFCA, while 41 percent did not yet know whether they would still participate. Only 3 percent said they did not want to participate in TEFCA.
A striking difference between HIOs who responded that they planned to participate compared to those who said they did not was their existing degree of connectedness and the range of opportunities for exchange. Of the HIOs planning to participate in TEFCA, 64 percent said they connect to health information exchanges (HIEs) in different states, and 90 percent said they participate in at least one national network. On the flip side, HIOs who did not want to participate in TEFCA had lower levels of connectivity, with only 38 percent joining with HIEs in different states and 72 percent joining at least one national network.
Leading indicators show that HIOs are in a good position to address any changes related to the exchange landscape, including participating in TEFCA. Although the number of operational HIOs has steadily declined since 2012, the financial viability of these remaining units has doubled (from 24 percent in 2012 to 52 percent in 2019). Additionally, many HIOs have wide reach based on a number of different metrics including: the number of participants, the number of vendors who can either provide data or use the HIO, the different EHRs they are connected to, and in the work they do to facilitate exchanges for large numbers of patients.
HIOs under TEFCA
These results suggest a potential avenue for the future sustainability and growth of HIOs planning to participate in TEFCA. Survey results show that HIOs wishing to participate in TEFCA are already building robust networks to share information – both state-to-state and nationally. This experience with network-to-network connectivity will be of great benefit to HIOs as TEFCA opens up new opportunities – such as:
The outlook is also positive for HIOs who are unsure whether or not they will be attending TEFCA. According to the survey results, HIOs who are not sure about participating in TEFCA are not very different from HIOs planning to participate. This means that, given the right future conditions (e.g., viable advantages, low entry barriers, and technical assistance), these HIOs will most likely take steps to improve their ability to connect to other networks.
Changes to HIOs since 2014
Since our last survey in 2014, several upward trends have piqued our interest; in particular, we found that competition-related concerns were growing. For example, from 2014 to 2019, the number of HIOs reporting competition from healthcare IT providers with HIE networks increased from 58 percent to 63 percent, and HIOs reporting competition from other HIE efforts increased from 35 percent 42 percent.
At the same time, concerns about the technical infrastructure and standards decreased significantly. The number of HIOs reporting barriers due to the limitations of current interface standards has fallen sharply from 68 percent to 19 percent. The number of HIOs reporting technical obstacles also fell dramatically from 59 percent to just 17 percent. Eventually, the number of HIOs who said they lacked resources to implement interface standards also fell, from 63 percent to 22 percent.
One area of future growth for HIOs is related to the types of services they offer. Currently, the most common general services offered relate to the exchange and management of data at the patient level, while value-added services that go beyond these general services are offered less often. With TEFCA, HIOs will see greater opportunities to expand these services that leverage their exchange and data capabilities. This will represent a new opportunity – but also a challenge – for HIOs if they want to develop their strengths in the regions and states in which they operate.
For more details on the survey results and information about HIOs and their participation in the upcoming TEFCA, Read our last article in Health matters.
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