Health Information Exchange or “HIE” is the name of the game these days in the world of healthcare. You’ve got information in your electronic health record that I want, and I’ve got information in my EHR that you want. So, how can we share that information in a way that’s useful and makes sense? Turns out it’s not as simple as you might think.
While most would believe the biggest barrier to using HIE is the technology, I would argue that it’s more about how you manage change in your organization. The technology part, believe it or not, is fairly simple. Can your system do what you want it or need it to do, or not?
The bigger challenge comes when we start diving down into the details of how to operationalize HIE and implement new workflows when the processes you have in place now with faxing works “just fine.” Sound familiar? Faxing face sheets, referrals, hospital discharge summaries, test results, etc. back and forth is easy…because we’ve been doing it for 30+ years…we know what to expect. So, how do we get our staff, our leaders, ourselves on board with HIE so that when push comes to shove and we are required to use it, we can overcome the barriers that keep us from embracing the technology.
I’ve had the privilege of working with several mental health centers in the states of Massachusetts and New Hampshire as they work to understand health information exchange and to implement systems that support improved care transitions. The barriers discussed below are ones in which they faced in their facilities along with some solutions that seem to be working so far.
1. Limited demand – “People aren’t asking for it”, “No one wants to receive it”. Remember Meaningful Use? MU required providers to send Transition of Care Summaries, or CCDs, to those providers to whom they were referring a patient. So, EHR vendors developed their products to send. They did not spend a whole heck of a lot of time developing their systems to receive, which is unfortunate, because receiving the information is so much more useful to a healthcare provider! And, let’s be frank, a lot of people aren’t asking for it and don’t want to receive it because there’s not much that can be done with the information in a CCD. (See Barrier #2 for more information on the value of the content).
- Talk it up. Start talking about HIE. With your peers, with your staff, with your vendors. The more you talk about it, the more you’ll begin to understand it.
- Make HIE a standing item on your monthly staff meeting agendas and your weekly EHR vendor calls.
- Reach out to providers you share clinical information with to start a discussion on how you can improve care transitions electronically.
2. Content of a CCD is not valuable – or consistent. The content of the CCD is not always valuable…and it varies by EHR vendor. Some CCDs will show you every single medication a patient has been on, while others will show you medications the patient is currently taking. Some EHRs will let you use the information that comes in on the CCD by consuming it into your record (like med and allergy lists), while others will not. To further complicate the matter, what if you need to send or receive information outside of that CCD, like a lab result or PDF copy of a patients Advanced Directives? And what if your system can’t handle that?
- Designate a clinical champion within your organization to look at the content of a CCD from a clinical perspective.
- Dive into the content of your CCD. Where does the information pull from and what exactly does the information signify?
- Get together with the senders of the CCD. Give them feedback so they can improve their patient hand-off to your clinical team.
- Conduct a thorough analysis of your systems technical capabilities on sending and receiving information. Can you send/receive documents other than a CCD?
- Ask your EHR vendors what their timelines are on developing greater flexibility around information that can be added to a CCD or documents that can be sent alongside a CCD to improve the clinical value in the exchange.
3. Lack of buy in from leadership. Let’s face it, healthcare organizations are stretched thin, and with changes in regulations and payment reform, leadership may have other priorities. Starting a new project is a lot of work and there are limited internal resources available to pull in. The culture of an organization is driven from the top down. Others can’t be expected to buy into the change if leadership doesn’t.
- Develop a communication plan and provide regular communication around HIE activities up, down, and sideways.
- Set timelines for when paper processes will end and build a culture of accountability toward that goal.
- Determine your goals and how you want to monitor progress.
- Conduct really simple time and productivity studies to help clarify the value for senior leadership in terms of better, faster, and cheaper.
4. What’s in it for me? Barriers 3 and go hand in hand, in that most people will not buy-in to going through the stress of a new change if they don’t see value in it. For some, that value might be clinical in nature, for example, maybe a discharge summary comes over from a hospital now within 12 hours of discharge instead of 48 hours. For others, it maybe that their work is streamlined, for example, since they are able to pull in medications from the CCD sent by the Primary Care physician, and no longer have to hand key 8 medications with dosage information. This value statement is relevant both internally and externally as you begin to discuss HIE with other healthcare providers in the community.
- Develop internal value statements, describing benefits to using HIE which can be shared or used in training with staff. “Using HIE, we no longer hand key in 104 medications per day, heading off our potential medication errors and giving us back 25 minutes each day.”
- Develop external value statements, designed to help others understand the value in exchanging information via HIE. “When you send us timely and complete hospital discharge summaries, we can give higher quality follow up care that keeps our shared patients from re-admitting to the hospital.”
- Ask a lot of questions. If you don’t understand what drives the people you’re talking with to hop on board with your plans for HIE, ask them what they think.
5. Changing workflow is complicated Change management is not easy. Asking others to change a process that works and is comfortable for them is not a simple feat. If you’ve done a good job at understanding the content of the CCD, your systems capabilities and what information you need to send/receive in order for the information being exchanged to have value and relevance, then it’s time to get to work on re-designing workflow to manage the information coming in and going out.
- Start small with a pilot. See what works and doesn’t work and then re-assess to add value and expand.
- Document Inbound workflow and Outbound workflow and develop training guides for staff with pictures.
- Determine the Who, What, When, and Where pieces to the workflow to get started. For example, who receives the incoming message (Medical Records), what information is coming in (a CCD), when does it come in (when a PCP in the community refers a patient for SSRI medication management), where does the message show up (Inbox). Then, think about the intent of the information and document HOW the information is to be processed, step-by-step.
- Don’t forget to Quality Check
- Ask for end-user feedback. Check in several times after implementation to determine if any tweaks need to be made to the process.
Bottom Line – It’s time to expand the conversation out from IT, add clinicians to the discussion, and do the hard work of change management.