Imagine the year is 450 B.C., and you live in one of the thousand Greek city-states, an appealing model of infrastructure for its time. In this city/castle-like microcosm, everything is local. The people you interact with, the food you eat, the water you drink, the business you conduct—all conveniently located safely within the towering stone walls. You may live your entire life without leaving.
However, occasionally someone new shows up at the gates. Weary traveling merchants braved the perils of life outside the walls to make the trek from city to city in order to exchange goods. Their successful journeys gained traction, as one merchant told another merchant the best routes to take. This led to the development of roads, ultimately leading us to the culture of exchange we have today.
We currently live in a society where people are no longer bound by stone perimeters. Globalism is alive and well. In fact, I cross state lines for work every day. The same is true for many people when they receive healthcare treatment as some organizations provide better treatment than others. Depending on means and types of treatment, an individual might end up in Minnesota, then Texas, and then California in order to receive sufficient or appropriate care. Even more locally, my primary care provider is in Kansas near my office, whereas if I needed urgent care, I would likely go to a provider in Missouri where I live.
Unfortunately, there is no state-run health information exchange (HIE) that allows my providers to share information outside of their four walls. Although we have the ability to seek multiple providers throughout the country, the information gathered during those services is often isolated to each care setting. This is most true of individuals living with both a physical and behavioral health issue.
Researchers found that 27.3% of individuals with depression and 27.7% of individuals with bipolar disorder lacked a diagnosis of their mental illness in their primary care EHRs. In addition, data about mental health client-provider encounters occurring in non-primary care settings were often nowhere to be found in the primary care record. Furthermore, nearly 90% of acute psychiatric services at hospital facilities—often representing the most severe treatment of mental illness—were not present in the EHR whatsoever.
Why, after more than 2,000 years, are our HIE mechanisms still set up like ancient city-states: old, walled-off and disconnected?
Traditional answers to this question point to a lack of funding outside the acute care market, regulatory restrictions in behavioral health with 42 CFR Part 2, and the lack of adoption of certified EHRs outside the acute space.
Beyond the lack of adoption and funding of IT needs in non-acute settings, health IT infrastructure is specifically lacking at behavioral health care settings. In an ONC report, it was found only 2% of psychiatric hospitals had adopted sufficient EHR technology as of 2012. “While 20 percent of community mental health centers had EHRs in all of their clinic sites in 2012, only 2 percent of community mental health centers reported that they could meet the requirements of the EHR Incentive Programs,” stated the federal agency.
However, even in the acute care space, where certified EHR adoption is standard across the board, 32% of individuals who presented at a hospital still experienced a gap in care. Fortunately, this is changing.
If the old HIE models are the city-states connected by dirt roads, then nationwide interoperability frameworks, such as Carequality and Commonwell Health Alliance, are the interconnected super highways of the future.
When Carequality implementers first went live, we boasted a monthly document exchange rate of 2.4 million. Now, with robust implementation across all healthcare markets and with the usage of industry standards, 80 million documents are exchanged every month. That number is only growing.
There has been considerable success in achieving true interoperability with these frameworks, prompting some HIEs to join Carequality as an implementer or to implement through the eHealthExchange initiative. These frameworks allow HIEs to experience the value of standardized document exchange that is not bound by regional, geographic borders. We are seeing more and more providers and HIEs capitalize on the good work being done in the industry to support a consumer’s positive treatment experience and reduce gaps in care.
Source: Sequoia Project
These industry initiatives are not just opening up lanes for providers to exchange data, but also rapidly changing the types of data exchanged. In the days of the city-states, merchants would usually show up with one type of ware to sell. The concept of the general store had not been invented, so people would specialize in what they exchanged. The same goes for HIEs. Usually it’s demographic data or a Continuity of Care Document (CCD) that’s exchanged. The CCD is a container that can only hold a finite data set. However, vendors and framework-led workgroups are quickly adopting new standards such as FHIR® in order to eliminate the element of scarcity held by the CCD so that an unlimited data set can be exchanged across providers, payers, social service organizations and more.
The walls of the old models are crumbling, affording us the opportunity to move into the 21st century. Data exchange is not only mandated, it’s expected. Whether a person presents in New York or Florida, Alaska or Hawaii, data should be available to providers nationally to support better transitions of care, more cognizant conversations and more informed care delivery.
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