Health Information Exchanges May Reduce ED Use, Costs

Marcia Frellick

December 02, 2014

Health information exchanges (HIEs) may reduce emergency department (ED) use and costs in some cases, but their effects on other outcomes are unknown, new research indicates.

Robert Rudin, PhD, from RAND Health in Boston, Massachusetts, and colleagues found modest evidence of ED cost reductions in a systematic review of studies published between January 2003 and May 2014. They published their results in the December 2 issue of the Annals of Internal Medicine.

HIEs were developed so that several physicians caring for one patient could share health information. The US government has put substantial financial backing into HIEs, including nearly $600 million to support statewide HIEs, and some states have invested much more in additional funding. However, the authors found that only 30% of hospitals and 10% of ambulatory clinics participate.

They also found that only a few of the more than 100 operational HIEs in the United States have been evaluated with published results, and they called for more studies to see what works and what does not. "Until better evidence is available, all HIEs should be viewed as experiments and evaluated as such," the authors write.

C. T. Lin, MD, chief medical information officer at the University of Colorado Health in Aurora, told Medscape Medical News that signs of reduced emergency department costs are a small part of what he hopes will be overwhelming benefit once the infrastructure, primarily a switch from fee-for-service, is in place to maintain the exchanges.

"At this point, we're reaching for any positive news regarding [HIEs] to keep them alive until the big switch gets flipped," Dr Lin said. When providers are on the hook for populations and managing costs of all the care patients get, they will be highly motivated to rely on HIEs.

Until then, he said, he agrees with the authors that HIEs face significant hurdles to widespread use.

Hospitals Struggle With Business Case

Dr Rudin and colleagues found that stakeholders value HIEs but that there are significant barriers, including workflow issues, patient privacy, lack of technical interoperability, and lack of a compelling business case for adoption. However, as more payment models such as accountable care organizations (ACOs) are studied, the case may become clearer, the authors note.

Dr Lin said that at this time, physicians do not have clear financial incentives to jump in. If they know through information sharing that tests have already been done for a patient by another provider, they do fewer tests, which means less money. So at the same time hospitals are getting less money, they are being asked to pay "in the hundreds of thousands," to be part of the exchange, Dr Lin said.

"So now you've signed up to do the right thing for the patient, but you're stealing from yourself," he said.

He added that another little-talked-about barrier is distrust among physicians of findings by physicians they do not know. That may lead some to say, "I need our guy to rerun that," he said, thus negating the benefit of the shared information.

Hard to Work into Workflow

Joshua Vest, PhD, MPH, assistant professor of healthcare policy and research at Weill Cornell Medical College in New York City, told Medscape Medical News that integrating HIEs into the workflow is also a substantial challenge.

"Providers are having enough difficulty getting their [electronic health record] systems worked into their workflow, and then to add in yet another system?... It's a growing pain," he said.

What he hopes this study ignites is innovation: "The concept of [HIE], the idea of getting providers access to information they had trouble getting in the past, is sound.... Hopefully, seeing that it has promise should inspire more research and more willingness to invest in the rigorous kind of studies that the authors of this paper are calling for," Dr Vest said.

The study was funded by the US Department of Veterans Affairs. One coauthor reports receiving royalties from UptoDate, a clinical decision support resource. The other authors, Dr Lin, and Dr Vest have disclosed no relevant financial relationships.

Ann Intern Med. 2014;161:803-811. Abstract

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