HIE Requires More Research to Demonstrate Effectiveness

While studies on the electronic exchange of health information show some evidence of benefits for healthcare, the full impact of HIE on improving clinical outcomes and avoiding potential harms has been inadequately studied and needs additional research.

That’s the conclusion of a new analysis by the Agency for Healthcare Research and Quality. The 465-page assessment, prepared for AHRQ by the Pacific Northwest Evidence-based Practice Center, is the result of a systematic review of available literature on HIE, including 136 total studies.

“No studies of HIE effectiveness reported impact on primary clinical outcomes (e.g., mortality and morbidity) or identified harms,” report writers conclude. “Low-quality evidence somewhat supports the value of HIE for reducing duplicative laboratory and radiology test ordering, lowering emergency department costs, reducing hospital admissions (less so for readmissions), improving public health reporting, increasing ambulatory quality of care, and improving disability claims processing.”

Although use of HIE has increased over time—with utilization highest in hospitals (76 percent) and lowest in long-term care settings (less than 1 percent)—electronically exchanging health information remains low overall because of barriers such as lack of participation, inefficient workflows and poorly designed features, the report contends.

At the same, while studies have identified numerous facilitators and barriers to implementation and sustainability, they have failed to rank or compare their impact, researchers say.

“To advance our understanding of HIE, future studies need to address comprehensive questions, use more rigorous designs, use a standard for describing types of HIE, and be part of a coordinated, systematic approach to studying HIE,” the report recommends.

AHRQ’s findings on the sharing of electronic clinical data across healthcare organizations comes at a time when the Office of the National Coordinator for Health IT is attempting to ramp up national efforts to connect HIEs across the country.

Also See: ONC 2016 Goal to Connect HIEs Nationwide Met with Skepticism

Industry responses to AHRQ’s findings are mixed.

John Halamka, MD, CIO of Boston’s Beth Israel Deaconess Medical Center, praised the report for “nicely codifying what many in the field have experienced—HIE adoption requires better enabling technology, a tightly integrated workflow, and community leadership to bolster participation,” adding that he hopes that “reports like this further emphasize that simplistic solutions such as ‘eliminating information blocking’ are not the answer.”

However, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, was more critical of the report. “I think its main value is as a literature survey of the body of research on health information exchange, which is a great reference and a heroic undertaking,” he says. “Beyond that, I don’t think that there are any meaningful inferences that can be drawn from the analysis.”

"According to Tripathi, the problem with research to date is that it “disproportionately focuses on the activities of centrally organized state/regional HIE organizations, which represent a small and shrinking share of HIE activity in the country.” He argues that “there is too much dynamism and variety in models of health information exchange to make general conclusions based on a study of studies, and most health information exchange activity is part of B2B types of transaction that fly well under the radar of academicians.”

Acknowledging the limitations of its systematic literature review, AHRQ states that the scope of studies identified for its analysis were “limited compared with the actual uses and capabilities of HIE” with a “high degree of heterogeneity in study designs, outcomes, HIE types, and settings across the studies, limiting the ability to synthesize the evidence; no quantitative analyses were possible.” As a result, the report admits the “applicability of this evidence base is uncertain because the HIE systems studied were so diverse, and many in existence have not contributed to research in this field.”

"Nonetheless, Lee Barrett, executive director of the Electronic Healthcare Network Accreditation Commission, calls AHRQ’s report a good initial study of HIE as a “foundational enabler” to understand the value and issues that still need to be addressed. Clearly, he said, more research, case studies and initiatives are needed.

"“It is critical to ensure the privacy and security of patient data at all exchange points throughout the HIE to safeguard stakeholder trust,” according to Barrett. “This can be achieved by authenticating between entities and encryption of data using the Direct protocol, along with implementing a third-party review of HIE networks. We have come a long way in a relatively short period of time to demonstrate the value of secure HIEs, and we need to continue to collaborate between the private and governmental sectors—both federal and state—to increase acceptance and promulgation.”