Among those are about 1,000 Advocate-employed physicians, and another 2,500 who are members of the system's physician-hospital organization. Beyond that are a group of low admitters, "the pure independents," Norenberg says.
Linking with the employed physicians is done via a connection to the ambulatory Allscripts EHR installed at those practices. Advocate has also built an interface to nearly 300 affiliated physicians in the PHO who are running eClinicalWorks (its purchase is subsidized by Advocate through the relaxed Stark rules).
But what about the rest of the physicians? Enter the health system's "private" health information exchange. Three years ago, Advocate contracted with Certify Data Systems to build an exchange that resembles the much ballyhooed statewide, "public" HIEs the federal government is supporting via grants authorized by the Health Information Technology for Economic and Clinical Health (HITECH) Act.
Through Advocate's exchange, physicians can see lab results, radiology reports, and gain access to other patient records in the Cerner, Allscripts and eClinicalWorks databases.
But there are big differences-admission to Advocate's private exchange is by invitation only, and the health system is absorbing the cost of the infrastructure. Moreover, Advocate can control what data to share, rather than relying on the collective governance of a public HIE to decide. "Public HIEs operate in a wildly diverse environment," Norenberg says. "And the first thing you do in a diverse environment is move to the lowest common denominator, a thin veneer of data everyone can initially agree on."
The emergence of the private (sometimes called enterprise) health information exchange is one of the industry's most pronounced trends: multiple health systems have recently announced ventures, and a number of information exchange vendors have shifted their focus to the private market. Like Advocate, these health systems are looking to strengthen ties with physicians and also set the stage for accountable care payment models, which will reward providers based on outcomes and which will require a high degree of coordination across care settings (see the February cover story, page 32).
But HIEs are hard to define, and "public" HIEs-namely those with open memberships-fall into several categories. However defined, private and public HIEs have their own strengths and weaknesses. And while experts concur that the sheer number of HIEs in play (around 200 are now operational, according to research from the e-Health Initiative and KLAS) spells inevitable consolidation, they say that both models will be needed as the industry struggles down the path of connectivity.
Part of the difficulty in tracking the industry is the wide number of HIE models and definitions in play. Industry veteran Ralph Wakerly, president of his own I.T. consulting firm in Downers Grove, Ill., has worked with data exchanges since the early '90s-back then they were called community health information networks, or CHINs. Wakerly estimates he worked with some three dozen of these early data exchanges, and only a few are still standing.
Wakerly now breaks HIEs into four basic types, with the first being private, or enterprise. In this model, the owner-typically a health system-bears full cost. "Large integrated health systems are making these investments to connect to physicians and other entities like long-term care organizations," he says. Second, there are regional or metropolitan health information exchanges, which might be government backed, privately funded, or a mixture of both. Third are state-level exchanges, largely funded by state funds and some federal grants through the HITECH Act. Finally, there is the national health information network (NHIN), an emerging network supported by the federal government.
The reason there's no single definition of a public HIE is that funding sources and governance models vary widely, so no one-size-fits-all definition can be used, Wakerly says.
And three definitions of a "public" HIE probably aren't enough. Doug Dietzman, executive director of Michigan Health Connect, a 49-hospital exchange that launched two years ago, is quick to distinguish the exchange from publicly funded models. "We're a private HIE," he says. "We're a community regional health information organization." Michigan Health Connect delivers more than 830,000 test results a month across its network and also processes lab orders on behalf of some 750 physician offices. It recently launched an electronic referrals service. The organization is open to any state hospital, which would seem to make it a public HIE, but it's supported entirely by hospital membership fees (physicians can join for free).
Explaining the organization's identity as a private exchange, Dietzman says Michigan Health Connect has steered clear of government funding-and remains solvent. "We have swallowed hard every time there's a grant opportunity, and decided to not take that path," he says. "The minute we take a dollar from a federal or state agency, the ability to say we're private goes away. When you take public money, you also have to do what the funder wants. That may or may not have relevance to what is important on the ground floor. If you look at grants, for example, you see nothing about referrals." Managing referrals, he adds, is a high-value service for practices frustrated with the typically phone- and fax-based process. In contrast, publicly funded data exchanges usually don't enable such transactions, at least initially, focusing instead on granting access to historical data.
Although hospital-driven HIEs share some similar characteristics, Dietzman says they're a different animal. "What is the advantage to having enterprise HIEs?" he asks. "They're no different from what we have." Indeed, some industry experts point out that the enterprise HIE is hard to track simply because the parent organization doesn't even think of itself as a data exchange. "Huge integrated delivery networks are beginning to form exchanges, but they don't call themselves an HIE," notes Jennifer Covich, CEO of the Washington, D.C.-based e-Health Initiative, which tracks data exchanges in an annual survey.