John Norenberg, vice president of physician services for Chicago-based Advocate Health Care, faces a common industry dilemma-from the health system perspective at least. "We need to exchange data with affiliated physicians," he says. "And we need to do it in a way that's very flexible." Advocate's physician network is broad-with nearly 5,000 doctors admitting to Advocate's 12 hospitals, which run a Cerner inpatient electronic health record.

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 under the 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).

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 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.

A feature story in the March issue of Health Data Management, “Which Way for Data Exchanges?” explores challenges facing both private and public HIEs, and their need to work together.

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